SURGICAL MANAGEMENT

Preoperative Planning

 

Imaging studies are reviewed.

 

 

 

Physical examination should be done to test for rigidity or flexibility of the foot.

 

Plain radiographs should be examined for arthritic changes, with triple arthrodesis reserved for severe, rigid deformity.6

 

Computed tomography (CT) scanning can aid in determining arthritis when plain radiographs are unclear, but suspicion is high.

 

A tight Achilles tendon should be addressed during the same procedure (gastrocnemius recession, percutaneous, or open Achilles lengthening).

 

Coleman block testing confirms forefoot-driven hindfoot varus or primary hindfoot varus.

 

Concurrent problems, such as lateral ankle instability, should be addressed during the same procedure.

 

Positioning

 

The patient is positioned supine on the table with the heel resting at the end of the bed (FIG 1).

 

 

 

FIG 1 • Positioning for cavovarus reconstruction. The patient is supine with a bump under the ipsilateral hip. The foot is placed perpendicular to the floor to facilitate medial and lateral foot access.

 

 

Thigh tourniquets are used and well padded.

 

A bump is placed beneath the ipsilateral hip until the foot is perpendicular to the table to facilitate medial and lateral exposures if needed.

 

The leg is prepared to the knee.

 

Approach

 

Achilles tendon pathology is addressed first, so this will minimize the deforming force on the heel when shifted.

 

Either a lateral displacement or Dwyer-type osteotomy is performed, depending on the surgeon's preference, if rigid heel varus is present.

 

 

The lateral displacement osteotomy is used for most adult cases, as the Dwyer weakens the moment arm of the Achilles and often cannot achieve the desired correction.7

 

Through the same incision, a peroneus longus to brevis transfer is done if appropriate.

 

Attention is then turned toward the first metatarsal, where a dorsiflexion osteotomy of the first ray is performed until the first ray is out of plantarflexion.

 

 

This is the most common location needing osteotomy in our practice.

 

 

For more severe cases, multiple metatarsal dorsiflexion osteotomies may be required in a similar fashion.5

 

More advanced cases with extensive cavus through the midfoot and forefoot may require dorsal wedge osteotomies at more proximal levels, as described by multiple authors.2,3

 

Adequate preoperative planning should alert the surgeon to the need for these more advanced procedures.

 

A plantar fascia release is useful as an adjunct when midfoot flexion is severe and prevents adequate reduction of the forefoot after osteotomy.

 

 

This can also be done first in deformities associated with increased calcaneal pitch, where a proximal slide of the calcaneus is being done to lower the arch.

 

A Jones procedure can be used to correct residual claw hallux with Girdlestone and Taylor hammer toe procedures for the lesser toes if required.

 

Transfer of the tibialis posterior to the lateral cuneiform is a useful adjunct in cases of Charcot-Marie-Tooth associated with dorsiflexion weakness of the ankle.4

 

84

 

 

 

TECHNIQUES

• Gastrocnemius Recession

  Isolate the gastrocnemius fascia through a longitudinal incision just distal to the musculotendinous junction of the gastrocnemius on the medial side of the leg (TECH FIG 1).

  Identify the deep fascia of the leg and incise it in line with the incision, revealing the muscle and tendon structures beneath.

  The plantaris tendon will be visible along the medial border of the tendons and may be cut.

  Using blunt dissection, the separation of the deep soleus and the more superficial gastrocnemius can be recognized.

   

  TECH FIG 1 • A. Location of incision along medial leg. B. Deep fascia has been incised, revealing division

  of gastrocnemius and soleus fascias. C. Gastrocnemius fascia is isolated and cut from medial to lateral using tenotomy scissors. This protects the overlying sural nerve and saphenous vein.

   

   

  The gastrocnemius fascia is easily isolated using a pediatric vaginal speculum, but various retraction techniques may be employed.

   

  Retraction helps protect the sural nerve, which lies adjacent to the gastrocnemius at this level near the midline.

   

  Once isolated, cut the entire fascia transversely using tenotomy scissors.

   

   

  Fifteen to 20 degrees of increased ankle dorsiflexion with the knee extended can usually be obtained. Reapproximate the deep fascia using 3-0 absorbable sutures.

• Lateral Displacement Calcaneal Osteotomy and Peroneus Longus to Brevis Transfer

   

  The incision to accomplish both of these procedures is made inferior to but parallel to the peroneus longus tendon (TECH FIG 2).

   

  Deepen the dissection from the original incision until the peroneal tendons are identified.

   

  Enter the sheaths for the length of the incision, making sure to preserve the superior peroneal retinaculum (SPR).

   

  The SPR may be taken down directly off the posterior fibula and reattached with a suture anchor if tendon pathology exists such as tears or instability, such as in our example.

   

  Otherwise, the tendons can be sutured together, preserving this structure.

   

  Remove a section of the peroneus longus with a knife.

   

   

  85

   

   

   

  TECH FIG 2 • Lateral displacement calcaneal osteotomy and peroneus longus to brevis transfer. A. Lateral incision over hindfoot just posterior to peroneal tendons. B. Dissection carried down to the peroneal tendons, with the SPR still intact. C. With the SPR flap taken posterior, a section of the peroneus longus is removed. D. The peroneus longus has been sutured to the brevis, making sure the knot does not impinge under the SPR through range of motion of the tendon. E. Sural nerve is identified as dissection is carried inferior. F. A saw is used to cut across the calcaneus, perpendicular to its long axis, protecting the Achilles and plantar fascia. G. An assistant holds the lateral shift while two 6.5-mm partially threaded cancellous screws are placed across the osteotomy. H. Final screw positioning as seen from lateral and superior views.

   

   

  86

   

  Reapproximate the longus and brevis tendons proximally and hold them together with figure-8 no. 0 nonabsorbable suture, making sure the knot does not impinge below the SPR.

   

   

  Carry dissection inferior to the sural nerve, taking care to identify and protect it. Once the calcaneus is reached, carry the subperiosteal dissection inferior.

   

  Place small Hohmann retractors superior and anterior to the calcaneal tuberosity, protecting the insertion

  of the Achilles tendon and the origin of the plantar fascia, respectively.

   

  With soft tissues protected, use a sagittal saw to make the osteotomy perpendicular to the axis of the calcaneus.

   

  Shift the free tuberosity piece lateral until a physiologic valgus position of 5 degrees is obtained (usually 8 to 10 mm).

   

   

  Make a midline longitudinal incision just off the posterior plantar heel pad. Carry dissection straight through subcutaneous fat to bone.

   

  An assistant or Kirschner wire holds the heel shift in the corrected position while two 6.5-mm partially threaded cancellous screws are placed in lag fashion.

   

  The screws should be off the posterior weight-bearing surface of the heel and should not penetrate the subtalar joint.

   

  Use a rasp to smooth down the prominent lateral bone after the heel shift.

• Dwyer Lateral Closing Wedge Calcaneal Osteotomy

   

  Use the approach outlined earlier for the lateral sliding calcaneal osteotomy.

   

  Instead of a transverse cut with a shift, remove a wedge of bone, based laterally, using a sagittal saw (TECH FIG 3).

   

  The size of the wedge depends on the desired correction but should bring the heel to a physiologic valgus position.

   

  Once the bone is removed, dorsiflex the foot to close the wedge and proceed with fixation as described previously.1

   

   

   

  TECH FIG 3 • Dwyer calcaneal osteotomy. Instead of a straight cut through bone, a lateral-based wedge is removed.

• First Metatarsal Dorsiflexion Osteotomy

   

  Make a dorsal incision over the proximal first metatarsal and carry dissection down to the extensor tendons (TECH FIG 4).

   

  Retract them lateral so dissection can be carried down to bone.

   

   

   

  TECH FIG 4 • First metatarsal dorsiflexion osteotomy. A. Plantarflexed first ray. B. Incision over first metatarsal. (continued)

   

   

  Subperiosteal dissection allows exposure of the proximal metatarsal to the first tarsometatarsal joint. Mark a line transversely on the bone 1 cm from the joint for the bone cut.

   

  Place small Hohmann retractors around the bone to protect the soft tissues and perform a dorsal closing wedge osteotomy using a sagittal saw.

   

  87

   

   

   

  TECH FIG 4 • (continued) C. Measuring 1 cm from first tarsometatarsal joint. D. A small dorsally based wedge is removed. E. The wedge is closed and held with a screw recessed in the first metatarsal. F. Final first ray position.

   

   

  The first cut is through 90% of the bone and perpendicular to the diaphysis.

   

  The second cut is 2 to 3 mm distal and angled back toward the plantar end point of the first cut.

   

  Complete the first cut and remove the bone wedge. Take enough bone to restore anatomic alignment of the talus and first metatarsal on the lateral radiograph (about 0 degree).

   

  Use a small burr to make a shallow hole in the dorsal bone to recess the screw head.

   

  Reduce the first metatarsal and place a 3.5-mm lag screw from the burr hole across the osteotomy, taking care not to enter the first tarsometatarsal joint.

• Partial Plantar Fasciotomy

   

   

  Make an incision just distal and parallel to the plantar heel pad (TECH FIG 5). Dissection through subcutaneous fat exposes the plantar fascia.

   

  When the medial and lateral borders of the fascia are identified, partial or complete release may be undertaken.

   

   

  Begin transection 1 cm from the origin on the calcaneus and proceed medial to lateral. More severe deformities may require more of a release.

   

   

   

  TECH FIG 5 • Partial plantar fasciotomy. Incision is made over medial hindfoot, off the weight-bearing surface, making sure not to disturb nerves. The plantar fascia is cut transversely until desired correction is achieved.

   

   

   

• Jones Procedure

  88

   

  The interphalangeal (IP) fusion of the great toe begins with a transverse incision over the IP joint dorsally (TECH FIG 6).

   

  Cut the extensor hallucis and make an arthrotomy in the joint, freeing up the collateral ligaments.

   

  Use curettes to remove the articular cartilage and use a 2-mm drill bit to fenestrate both sides of the joint.

   

  Place a Kirschner wire from proximal to distal through the distal phalanx and out the tip of the toe just under the nail, leaving minimal wire within the joint.

   

   

  Place the wire retrograde across the IP joint while holding it reduced. Make a transverse incision at the toe tip to allow drilling over the wire.

   

   

   

  TECH FIG 6 • Jones procedure of first toe. A. Incision is made transversely over the IP joint to remove cartilage and harvest EHL tendon. B. Incision is made longitudinally over the first metatarsal, transferring the tendon to the neck, and a screw is placed across the IP joint in lag mode.

   

   

   

   

  Measure the length of screw so it does not penetrate the metatarsophalangeal joint. Place a 4.0-mm partially threaded cannulated screw over the wire for compression. Confirm the position on fluoroscopy and remove the wire.

   

  Center a dorsal midline incision over the first metatarsal neck.

   

  Identify the extensor hallucis longus (EHL) and bring its distal end into the wound.

   

  Make 4.0-mm drill holes on the medial and lateral aspects of the metatarsal neck and connect them using a curette.

   

  Pass the tendon from lateral to medial through the hole and suture it back on to itself using nonabsorbable suture while holding the ankle in a neutral to slightly dorsiflexed position.

• Example Case (Courtesy of Mark E. Easley, MD)

Background, Physical Examination, and Imaging

 

 

A 36-year-old man with progressive hereditary sensory motor neuropathy Left cavovarus foot symptomatic despite bracing

 

Flexible hindfoot deformity: nearly fully passively correctable

 

Some fixed plantarflexion of the first ray

 

 

Some clawing of the toes, including the hallux Cavovarus foot alignment with weight bearing

 

 

Overload of lateral border of the foot (TECH FIG 7A) High arch (TECH FIG 7B)

 

Heel varus: Be sure to observe patient weight bearing (TECH FIG 7C).

 

Fixed or flexible

 

If deformity is flexible, joint-sparing realignment is feasible.

 

If deformity is fixed, hindfoot arthrodesis should be considered.

 

 

Motor function deficits Sagittal plane motion

 

Limited ankle dorsiflexion

 

Lack of tibialis anterior muscle function

 

Compensation with toe extensors and peroneus tertius

 

 

Typically associated with an equinus contracture: intact gastrocnemius-soleus function Coronal plane motion (hindfoot motion)

 

 

Limited eversion/forefoot abduction: lack of peroneus brevis tendon function Hindfoot varus/forefoot adduction due to unopposed intact posterior tibialis function

 

Often associated with clawing of the toes

 

Evaluate the ankle radiographically because there may be associated talar tilt.

 

In this case, the ankle is congruent, but hindfoot is obviously in varus through the subtalar and transverse tarsal joints (TECH FIG 7D).

 

89

 

 

 

TECH FIG 7 • A 36-year-old man with a progressive hereditary sensory motor neuropathy and right cavovarus foot deformity. A. Note peek-a-boo heel on visualization from anterior perspective and clawing of the hallux. B. High arch and clawed hallux on lateral perspective. C. Heel varus on posterior perspective.

D. Weight-bearing AP ankle view suggests that mortise is congruent and varus deformity is in the hindfoot.

E. Weight-bearing lateral view does not give full appreciation of cavovarus noted clinically; however, plantarflexed first ray is evident.

 

 

90

 

Evaluate the foot.

 

Anteroposterior (AP) foot radiograph: forefoot abduction with stacking of the lesser metatarsals

 

Lateral foot radiograph: cavus alignment with stacking of the lesser metatarsals and plantarflexed first ray (TECH FIG 7E); clawing of toes often observed

Tendo Achilles Lengthening

 

Favor lengthening the Achilles tendon over gastrocnemiussoleus recession.

 

The gastrocsoleus complex is unopposed not only the gastrocnemius-soleus muscles.

 

Triple cut hemisection (TECH FIG 8)

 

 

Goal is to lengthen and not completely release Three percutaneous hemisections

 

Two toward the medial side

 

 

One toward the lateral side between the two toward the medial side Hemisections spaced approximately 2.5 to 3 cm apart

 

Gentle dorsiflexion force to lengthen the tendon but maintain its continuity.

Plantar Fascia Release

 

Unlike the partial release (rarely) performed for recalcitrant plantar fasciitis, the release performed for symptomatic cavus foot malalignment is complete.

 

Make a longitudinal 3- to 4-cm incision immediately medial to the tight plantar fascia.

 

Dorsiflex the toes to activate the windlass mechanism, putting the plantar fascia on stretch, making it easier to palpate.

 

 

 

TECH FIG 8 • Tendo Achilles lengthening via percutaneous hemisection technique.

 

 

 

Careful dissection to expose and isolate the plantar fascia completely on its dorsal and plantar aspects Perform a complete plantar fascia release with a scalpel blade (TECH FIG 9).

Posterior Tibial Tendon Transfer

 

 

Make a longitudinal 5-cm incision directly over the posterior tibial tendon (PTT) insertion at the navicular. Incise the PTT sheath to expose the tendon.

 

Release the tendon from the insertion on the navicular, including as much distal tendon as possible to optimize the tendon length for the planned transfer (TECH FIG 10A).

 

Place a suture in the distal (released) tendon to facilitate in tendon transfer.

 

While protecting the plantar medial venous plexus and the spring ligament, release as distal as possible the portion of the PTT that courses plantar to the foot.

 

Mobilize the released tendon for transfer.

 

 

Make an incision over the posteromedial tibial cortex 10 to 12 cm proximal to the medial malleolus. Release the retinaculum from the posteromedial tibia.

 

Expose the PTT.

 

Typically, the first tendon encountered is the flexor digitorum longus tendon; this tendon needs to be retracted to access the PTT.

 

With the distal PTT released, pull the PTT through the more proximal medial wound (TECH FIG 10B).

 

It may bind where the tendon passes posterior to the medial malleolus.

 

This is typically mitigated by spreading within the PTT sheath at the distal medial malleolus with a blunt scissor from the distal incision.

 

Pass the PTT posterior to the tibia, from the medial wound, immediately adjacent to the posterior tibia, through the interosseous membrane, and through a lateral wound created anterior to fibula (TECH FIG 10C,D).

 

 

The interosseous membrane should be carefully spread to create enough space to avoid tendon binding. Alternatively, the tendon may be passed anterior to the tibia.

 

 

 

TECH FIG 9 • Plantar fascia release. As opposed to the partial release recommended for plantar fasciitis, in cavovarus foot deformity, the plantar fascia is completely released through an incision more distal than the one used for traditional plantar fascia release.

 

 

91

 

 

 

TECH FIG 10 • PTT release. A. Release of the PTT from the medial navicular and plantar arch. B. Identifying

the PTT through a medial incision 10 to 12 cm proximal to the medial malleolus. C. Delivering the PTT to the proximal medial wound and preparing for anterior transfer through interosseous membrane. D. The clamp is passed from the anterolateral wound, immediately posterior to the tibia.

Peroneal Tendon Transfer

 

Transfer the peroneus longus to the peroneus brevis tendon.

 

Make a standard utilitarian lateral curvilinear incision over the peroneal tendons.

 

Protect the sural nerve.

 

 

Open the peroneal tendon sheaths for both peroneal tendons. Release the more inferior peroneus longus tendon (TECH FIG 11A).

 

 

 

TECH FIG 11 • Peroneus longus to brevis tendon transfer. A. Through approach on lateral aspect of foot, peroneus longus is transected. B. Weave the peroneus longus into the peroneus brevis.

 

 

Transfer the peroneus longus tendon to the peroneus brevis tendon.

 

Side-to-side repair

 

Tendon weave (TECH FIG 11B)

 

Calcaneal Osteotomy

 

Use the same utilitarian lateral incision.

 

Retract the peroneal tendons anteriorly and protect soft tissues.

 

 

92

 

 

 

 

TECH FIG 12 • Lateralizing/lateral closing calcaneal osteotomy. A. Through the same utilitarian lateral approach, with the peroneal tendons elevated, carefully expose the lateral calcaneus to perform the osteotomy. B. Intraoperative fluoroscopy confirming satisfactory bony apposition of the osteotomy and

proper position of hardware.

 

 

 

Calcaneal osteotomy pattern (surgeon preference) Lateral closing wedge (Dwyer)

 

Lateral calcaneal tuberosity translation

 

 

Combination (TECH FIG 12A) Z-osteotomy

 

Fixation is with one or two axial screws from the posterior calcaneus perpendicular to the osteotomy without violating the subtalar joint

 

Obtain fluoroscopic confirmation (TECH FIG 12B).

 

 

Transfer of Posterior Tibial Tendon to the Dorsum of the Midfoot Make a 2- to 3-cm dorsolateral midfoot incision over the lateral cuneiform. Protect the superficial peroneal nerve.

 

Create a subcutaneous tunnel with a long clamp, carefully spreading to limit binding of tendon (TECH FIG

13A).

 

Pull the distal end of tendon to be transferred through subcutaneous tunnel and have it ready to be secured to the lateral cuneiform.

 

 

 

TECH FIG 13 • Transfer the PTT from the anterolateral wound to the dorsum of the foot. A. Through a dorsolateral incision over the lateral cuneiform, a clamp is passed subcutaneously to the anterolateral ankle wound to capture the suture in the distal PTT. B. Pass the PTT through the subcutaneous tunnel. (continued)

 

 

Drill a hole in the lateral cuneiform.

 

Use careful soft tissue dissection to protect superficial peroneal nerve, extensor tendons, and neurovascular structures.

 

Place a guide pin in the lateral cuneiform and confirm its appropriate orientation and position fluoroscopically.

 

Overdrill the guide pin to gradually enlarge to tunnel so that it may accommodate the tendon (TECH FIG 13B).

 

Use fluoroscopy to confirm appropriate tunnel (TECH FIG 13C).

 

Pass the tendon into the tunnel.

 

Attach the suture to a long needle.

 

Pass the needle through the bone tunnel in the lateral cuneiform and carefully pass it through the arch (TECH FIG 13D).

 

Pull the suture on the plantar foot and advance the tendon into the tunnel to confirm that it will easily fit into the tunnel without binding (TECH FIG 13E).

 

Delay PTT fixation to cuneiform until end of procedure.

 

Securing it at this point risks weakening the fixation prior to closure and casting.

 

 

93

 

 

 

TECH FIG 13 • (continued) C. Create a drill hole in the lateral cuneiform under fluoroscopic guidance. D. Use a long suture needle to pass the suture attached to the distal PTT through the cuneiform tunnel to the plantar foot. E. Tension on the plantar suture allows tensions the PTT into the tunnel.

First Metatarsal Elevation and Correction of Clawed Hallux (Jones Procedure)

 

Make a dorsal longitudinal incision over the first ray.

 

Over the hallux IP joint, the incision may be continued as a Z in order to improve access to the joint.

 

 

Release the EHL tendon from the hallux distal phalanx. Place a tagging suture in the EHL tendon (TECH FIG 14).

Dorsiflexion Osteotomy of the First Metatarsal

 

Limit periosteal stripping of the first metatarsal.

 

Identify optimal position for dorsiflexion osteotomy of first metatarsal (TECH FIG 15A).

 

Dorsal wedge resection in the proximal metatarsal can be either vertical or oblique, depending on surgeon preference.

 

 

Maintain plantar cortex to create a stable closing wedge osteotomy (TECH FIG 15B). Stabilize the osteotomy with a low-profile dorsal compression plate (TECH FIG 15C).

Correction of Clawed Hallux (Jones Procedure)

 

Create tunnel in first metatarsal head-shaft junction from medial to lateral (TECH FIG 16A,B).

 

Delay EHL tendon transfer (and the PTT transfer) to the first metatarsal until the completion of the surgery.

 

Complete all bony correction.

 

Perform tendon transfers as last step to obtain proper tension and balance and to protect tendon fixation to bone.

 

94

 

 

 

TECH FIG 14 • Through a longitudinal incision over the first ray, release the EHL tendon from its insertion on the distal phalanx.

 

 

Prepare the hallux IP joint for arthrodesis.

 

Remove cartilage surfaces and prepare subchondral bone.

 

Maintain slight plantarflexion of the IP joint and avoid removing too much dorsal bone that may create hyperextension.

 

Secure the hallux IP joint arthrodesis with a longitudinal compression screw placed from the tip of the toe through a transverse stab incision 2 mm plantar to the hallux nail (TECH FIG 16C,D).

 

 

 

TECH FIG 15 • First metatarsal dorsiflexion osteotomy. A. Fluoroscopic confirmation of proper position for osteotomy, leaving adequate space for proximal fixation in the metatarsal without violating the tarsometatarsal joint. B. Dorsal wedge resection osteotomy, with minimal periosteal stripping and leaving the plantar cortex intact. C. Osteotomy fixation with a dorsal compression plate.

Complete the Tendon Transfers

 

Delay EHL tendon transfer (and the PTT transfer) to the first metatarsal until the completion of the surgery.

 

Complete all bony correction.

 

Perform tendon transfers as last step to obtain proper tension and balance and to protect tendon fixation to bone.

 

With the ankle in slight dorsiflexion, secure the PTT tendon to the lateral cuneiform.

 

 

Suture anchors can be used, even within the tunnel created in the cuneiform. Currently available interference screws offer satisfactory stability.

 

If concern for fixation, consideration may be given to using a combination of the interference screw and suture anchors.

 

Pass the EHL tendon through the metatarsal neck tunnel and secure it to itself after passing through the tunnel.

 

The EHL transfer, if functional, will add dynamic elevation to the first ray rather than promote clawing of the hallux.

Closure and Casting

 

Routine closure (sutures or staples)

 

With the ankle in slight dorsiflexion, place a well-padded shortleg cast that extends beyond the toes.

Postoperative Care

 

 

Three weeks of non-weight-bearing short-leg cast, then suture/stable removal Four more weeks of new short-leg cast partial weight bearing permitted

 

At 7 weeks, surgeon decision is based on stability of tendon fixation and osteotomies and evaluation of follow-up radiographs.

 

If stable fixation and satisfactory healing on radiographs, consider cam boot and gradually advance weight bearing.

 

Patient should maintain dorsiflexion when boot is removed to clean leg/foot and should sleep in boot.

 

 

95

 

 

 

TECH FIG 16 • Drill hole in metatarsal neck for Jones procedure. A. Identifying optimal position for drill hole in metatarsal neck to transfer the EHL tendon. B. Drill hole in first metatarsal created. C. After preparation of hallux IP joint for arthrodesis, axial screw is placed, with toe in proper rotation. D. Intraoperative fluoroscopic image demonstrating metatarsal and hallux IP joint fixation and satisfactory bony apposition.

 

 

 

If more healing deemed necessary, then new short-leg cast and gradually advance weight bearing At 10 to 11 weeks

 

Fit for hinged ankle-foot orthosis (AFO) that has a plantarflexion stop at neutral

 

Initiate physical therapy (PT) program for training for PTT to dorsiflex the ankle, generalized conditioning and gait training.

 

 

Gradually transfer from cam boot to hinged AFO. Continue PT and hinged AFO for 8 weeks.

 

At 18 to 20 weeks, after satisfactory progression with PT program, transition to regular shoe (see FIG 2).

 

 

 

96

Preoperative

assessment

• A neurologic workup is indicated if no identifiable neurologic cause for deformity is

known, as a progressive muscle imbalance may cause recurrence.

Heel screw

placement

• With a lateral heel shift, the tendency is to place screws too far lateral.

• The drill should be angled slightly medial to ensure entering the remaining calcaneus.

First

metatarsal osteotomy

• The tendency is to take too little of a dorsal wedge, leaving the first metatarsal

plantarflexed and making the patient susceptible to recurrence.

Plantar

fascia release

• The medial calcaneal branch of the tibial nerve and the intrinsic musculature of

the foot are at risk, so careful dissection is warranted.

PEARLS AND PITFALLS

 

 

POSTOPERATIVE CARE

 

 

Posterior sugar-tong splinting is used immediately postoperatively with the ankle in neutral dorsiflexion. Skin staples are removed at 2 weeks.

 

Patients are kept immobilized and non-weight bearing for a total of 8 weeks, and weight bearing is begun when bony healing has occurred.

 

FIG 2 shows 6-month follow-up of the patient in the Example Case.

 

FIG 2 • Six-month follow-up of the patient in TECH FIGS 7, 8, 9, 10, 11, 12, 13, 14, 15, 16. A. Anterior perspective. The “peek-a-boo” heel is no longer present. B. Lateral perspective demonstrates more physiologic arch and correction of the hallux claw toe deformity. C. Posterior perspective demonstrates correction of heel varus. Lateral ( D) and AP ( E) weight-bearing follow-up radiographs.

 

OUTCOMES

Long-term studies of cavovarus correction in adults are lacking, likely given the varied presentation and multiple modes of treatment for the disorder.

Early treatment while feet are flexible is advised to prevent more extensive procedures required for rigid deformities and complications from progressive arthrosis.

 

 

97

 

COMPLICATIONS

Painful hardware Infection

Recurrence of deformity Wound dehiscence Nonunion

 

 

 

REFERENCES

1. Dwyer FC. The present status of the problem of pes cavus. Clin Orthop Relat Res 1975;(106):254-275.

    

    

2. Jahss MH. Tarsometatarsal truncated-wedge arthrodesis for pes cavus and equinovarus deformity of the fore part of the foot. J Bone Joint Surg Am 1980;62(5):713-722.

    

    

3. Japas LM. Surgical treatment of pes cavus by tarsal V-osteotomy. Preliminary report. J Bone Joint Surg Am 1968;50(5):927-944.

    

    

4. McCluskey WP, Lovell WW, Cummings RJ. The cavovarus foot deformity: etiology and management. Clin Orthop Relat Res 1989; (247):27-37.

    

    

5. Sammarco GJ, Taylor R. Cavovarus foot treated with combined calcaneus and metatarsal osteotomies. Foot Ankle Int 2001;22:19-30.

    

    

6. Wetmore RS, Drennan JC. Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 1989;71(3): 417-422.

    

    

7. Younger AE, Hansen ST Jr. Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315.