Pes Cavus – Flashcard
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What is pes cavus?
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Fixed equinus deformity of the forefoot in relation to the hindfoot --> Abnormal elevation of the medial longitudinal arch --> Either a flexible or rigid varus hindfoot deformity dorsiflexion of the rearfoot on the forefoot
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What are the causes of pes cavus?
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neuromuscular -muscle disease -afflictions of the peripheral nerves -anterior horn cell disease of the spinal cord -long tract and central disease congenital traumatic idiopathic
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What are the considerations for pes cavus classification?
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Apex of deformity Flexibility Classification based on associated deformities Classification based on cause
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What is charcot marie tooth?
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Most common inherited neurological disorder 1:125,000 affected yearly Defects in myelin sheath proteins of peripheral nerves Slows sensory and motor nerve conduction velocities Distal muscular atrophy of the upper and lower extremities
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What happens if CMT causes the AT become weak?
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plantarflexion of the 1st ray, hallux claw toe, and equinus because of the stronger EHL, PL, and achilles
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What happens if CMT causes the PB to become weak?
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forefoot adduction and hindfoot varus due to stronger PT
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What happens if CMT causes weak intrinsics?
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Stronger EDL and FDL will lead to digital claw toes, depressed MT heads, and raised arches
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What are the symptoms associated with pes cavus foot type?
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Arch elevation Calluses Metatarsalgia Ankle instability Unsteady gait Foot drop Hammertoes Plantar fasciitis Peroneal tendon pain/injury Calf atrophy Shoe gear difficulty
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What are the components of the msk exam for pes cavus foot type?
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Individual testing of each muscle group and muscle Anterior compartment EHL, EDL, TA Lateral Compartment Peroneus Brevis/Longus Posterior compartment TP, FDL, FHL, Triceps surae
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What is pseudoequinus?
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Functional limitation of ankle dorsiflexion secondary to compensation from plantarflexed forefoot
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What biomechanical exam is done for pes cavus foot type?
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Gait analysis Wide with short steps neurological High stepping weak ankle joint dorsiflexion Kelikian push-up test Flexible vs rigid digital deformities Coleman Block Test 1st ray influence on the RF
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How is the coleman block test conducted?
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The test is performed by first observing the position of the hindfoot when weigthbearing on level ground (A). Next, a 1-2 inch block is placed under the lateral column of the foot, allowing the first MT to drop off. If heel varus is secondary to a PF 1st ray, it will correct to neutral or even valgus (B). Rearfoot procedures a typically not needed. If varus persists, the deformity is rigid (meaning the STJ is partially compensated or uncompensated) and rearfoot procedures are required.
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What additional tests can be done for pes cavus to rule out CMT?
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Electromyography (EMG) Nerve Conduction Velocity (NCV) Muscle Biopsy Nerve Biopsy
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What radiograph findings are done for pes cavus?
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Increased calcaneal inclination Decreased talar declination Increased Meary's angle Increased Hibb's angle Bullet-hole sinus tarsi Posterior cyma line Stacked lesser MTs Hindfoot or midfoot DJD
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What radiographic measurements need to be focused on?
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The calcaneal pitch, on average is 24.5 degrees. >30 degrees is a moderate pes cavus and >40 degrees should be considered a severe pes cavus. If calcaneal inclination is increased, then by default talar declination is decreased. Meary's angle (talar declination-1st met), normally 0, will be increased. The lines forming this angle will intersect at the apex of the deformity. Hibbs angle (calcaneal axis-1st met), which is normally less than 45 degrees, can approach 90 degrees in severe cases. This also intersects at the apex of the deformity. Other findings on the lateral radiograph can include a bullet-hole sinus tarsi, posterior cyma line, stacked lesser mets, and hindfoot or midfoot DJD.
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What are the symptoms of type 1 mild pes cavus that is flexible?
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Forefoot symptoms: Metatarsalgia Forefoot calluses Hammertoe deformities
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What are the biomechanics of pes cavus?
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Static hammertoe deformities Physical abnormality of the digit Ex: mallet toe Dynamic Hammertoe deformities Extensor substitution hammertoes Flexor substitution Neuromuscular imbalance
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How does extensor substitution lead to pes cavus deformity forming?
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Weak anterior group recruitment of EDL which overpower lumbricales Leads to dorsiflexion at MPJ in swing phase of gait
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What are the signs of type 2 pes cavus?
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More rigid deformity Increased frontal plane deformity Plantarflexed 1st ray Rearfoot Varus
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What is the biomechanics that leads to type 2 pes cavus foot type?
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Rigid Plantarflexed 1st ray or FF valgus subtalar supination leads to rearfoot varus Coleman Block test Rearfoot varus leads to lateral ankle instability
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What are the findings associated with stage 3 pes cavus that makes it a candidate for surgery?
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Appreciable clinical and radiographic deformity Multiplanar forefoot and hindfoot pathologies Requires osteotomies and arthrodesis for correction
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What are the considerations for the approach of treatment for pes cavus?
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Underlying etiology MUST be addressed Static vs Progressive Flexible vs Rigid? Arthrosis? Plane of deformity? Muscle weakness? Apex of deformity?
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What are the non-operative treatments for pes cavus?
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Shoe modifications Orthotics or AFO Physical therapy Shoes should be high-tops for greater stability at the ankle. An orthotic is designed to unload pressure at the heel and metatarsal heads. Orthotics typically have a minimum cast fill, metatarsal pads, and forefoot valgus posting.
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For flexible or early deformity, what surgical treatments are used for pes cavus foot type?
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Soft tissue releases Tendon transfers
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What are the rigid or late deformities used for pes cavus?
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Osteotomy Arthrodesis
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What tendon transfers are done for pes cavus?
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Jones Hibbs Girdlestone-Taylor
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What rigid deformity surgical treatments are done for anterior cavus?
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PIPJ arthrodesis Pan-metatarsal base dorsiflexory osteotomies
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What surgeries are done for midfoot cavus if the apex of deformity is posterior to the metatarsals, but not in the calcaneus?
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cole japas
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What surgical treatment is done for pes cavus when there is an increased calcaneal inclination and varus rotation?
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Dwyer lateral calcaneal closing wedge Triple arthrodesis
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What soft tissue procedures are done for contracted medial and plantar soft tissue?
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Plantar fascia release Medial band of PF Steindler stripping PF, abductor hallucis, FDB, abductor digiti minimi, quadratus plantae Incise transversely at calcaneal insertion Protect plantar arteries!
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Why is laxity of lateral soft tissue important?
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Brostrom Autograft or allograft reconstruction
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How is Jones forefoot tendon procedure done?
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Transfer EHL from the hallux to 1st MT neck IPJ fusion to prevent clawing done for patients with overactive EHL
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How is the Hibbs tendon procedure for the forefoot done?
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Transfer EDL from digits 2-5 to the lateral cuneiform PIPJ fusion, MTPJ capsulotomy
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How is the girdlestone-taylor tendon procedure done for the forefoot?
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Transfer FDL to dorsum to digit
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Review the rearfoot procedures
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STATT posterior tibial tendon transfer PL to PB
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How is the PIPJ arthrodesis of the forefoot done?
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Stable lever arm for extensor and flexor to function Restores MTPJ alignment
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How is the DFWO osseous procedure of the forefoot done?
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Usually combined with PF release, calcaneal osteotomy, +/- Jones Secondary effect by Cole or Japas, but MPJ's still may be buried into the walking surface
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What kind of deformities are best surgically managed by PIPJ arthrodesis?
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hammertoes
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What is the PIPJ arthrodesis done with?
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release of the extensor contracture at the MPJ
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What is the DFWO procedure done with?
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PF release, Dwyer osteotomy, Jones
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What is a Cole procedure of the midfoot?
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removal of dorsal based wedge from the NC joints and the cuboid Caution: shortens the foot
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What is the Japas procedure of the midfoot?
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V-osteotomy with the apex in the navicular and arms extending through cuboid and medial cuneiform Technically more difficult Trauma to lesser tarsal joints May need: Tendon transfer with digital fusions Plantar fascia release TAL
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What are the indications for the Dwyer lateral closing wedge calcaneal osteotomy?
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calcaneal varus posterior cavus rigid deformity
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What are the contraindications of dwyer rearfoot?
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reducible calcaneal varus secondary to PF 1st ray
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What is the triple arthrodesis used for and what is it used to correct?
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Historical standard Indicated for severe, rigid, and/or recurrent hindfoot deformities Corrects all planal deformities if properly planned
