CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS

ARMEN S KELIKIAN MD

CONFLICTS

INTRODUCTION/SUMMARY

Level IV- H&P Rx soft tissue disorders Realign osseous deformities Ubiquitous locked foot & cavus is

more of a musculoskeletal problem than PTD!

Questions?

Cavus foot incidence? 10,16, 23,43% If the hindfoot remains in varus with

the Coleman block test it should not be corrected? True/false

Cavovarus causes > anteromedial joint pressure in vitro at 15 degrees? True/false

Bilateral cavovarus in peds population regardless of FHx is most likely HSMN?Y/N

Cavus & sports mannifestations

23% all feet Most idiopathic not neurogenic Locked foot is ubiquitous ‘Peek a boo” heel-Manoli 1st metatarsal fat bulge Address underlying pathology Otherwise recurrence likely

Sports manifestations

Jones & Torg Fx- 5th metatarsal Stress Fx’s tibia/fibula Medial knee pain Varus ankle with arthritis Peroneal tendon tears & dislocation Anterolateral ankle instability

NORMAL ANATOMY OF PERONEAL TENDONS &

RETINACULUM

PERONEAL SUBLUXATION USN 100,85,90% (s/s/a)JBJS-

A 8/05

Complex peroneus brevis tear Rx tubularize

42% unable return

sports(Syeel-Deorio FAI 1/07)

Tears seen at groove,tubercle, or os in cuboid tunnel

Pl tears > cavovarus

Can excise peripheral tears <50%

Retinacular flap & groove deepening

PB repair & retinacular reefing

PL III Rx Pulvertaft weave

Peroneus longus overpull

Inability to raise lesser mt level with 1st

With forced pf 1st ray pf > lesser mts If TA weak transfer EHL to TA or M-1 Tenodese PL to PB

Dislocation-subluxation

2004 world series “bloody sock”

Acute-cast 4-6wks-seldom successful

Provocative stress-DF/EVERSION

USN-subtle cases Superior

retinaculum

Chronic Ankle Instability ANKLE SPRAINS

– COMMON INJURY

LATERAL COLLATERAL LIGAMENTS OF ANKLE Ant.

Talofibular Lig. Calcaneofibula

r Lig.

Calcaneal deformity-varus-Biomechanics

McEllvany-reciprocal relationship HF & FF

Coleman block test Carroll test Sarrafian twisted

plate

Twisted plate – rigid lamina pedis

Lamina pedis

Loose pack Ext rot load column Hindfoot varus Forefoot pronation Pf loose

Tight pack Int rot load column Hindfoot valgus Forefoot supination Pf taut

Cavovarus-Mosca 2014

Acquired sometimes progressive pronation deformity of the HF on FF

FF pronated,MF adducted, HF endorotaion

Ankle apparent equinus in child-more FF

Tibia ET Motor PL >> TA;Recruited EHL >FHL Flexibility HF vs FF flexible vs stiff

CLINICAL EVALUATION Wt. bearing exam Prone biomechanical exam ROM GSC strength Heel width & height Coleman block test Neurologic

PRINCIPLES Assume proper osseous realignments Identify motor deficits:

agonist/antagonist Access soft tissue contractures Rules of tendon

transfers:length,strength, in phase, rom, tension

Underlying pathologies Functional deficits

CLINICAL EVALUATION Wt. bearing exam Prone

biomechanical exam

ROM GSC strength &

contracture Coleman/Chestnut

block test Manoli “peek-a-

boo” H Kelikian “push-up

test” Neurologic

No correction w Carroll/Coleman

RADIOGRAPHS

AP/Lateral wt. bearing foot Broden’s Axial Weight bearing axial -Cosby

Coleman block Xray w Saltzman view

Considerations

Age Unilateral vs bilateral Progressive or static ? Idiopathic,traumatic,hereditary Rigid or flexible?-rom Agonist vs antagonist:PB/PT,PL/TA,E/F Hindfoot varus reciprocal to forefoot

pron.

Nonsurgical options

Cavovarus orthotic device Unload 1st mtp head Lateral heel sole wedge

CMT 30 TYPES-HSMN

Type I a-c 50% all case AD IA 80% of I ncvs are

10-30ms IB point mutation

severe demyelinating IC-? Defect rare

Others II, X,IV II-20%,AD,ncv

normal,indolent course

X-linked females clinically, male carriers,10-20%=defect conexin protein # 32

IV-AR,rare,absent myelin proteins

JM-HSMN

IMR

60 mo f/u

Bilateral TTC fusions

5th metatarsal banana

23 yo football 100kg

Removal 4mm retap insert 6.5mm & 1st ray DCWO

Calcaneal deformity-varus

Varus hinfoot Pronated 1st ray McEllvenny CO:1958; reciprical

relation Coleman block test Carroll test Hind foot alignment view

Cavovarus :Surgical Options

Dwyer osteotomy:1cm lateral closing wedge

Lateral displacement osteotomy <5mm Scarf triplane osteotomy 45 degree osteotomy Transfix with axial screw or staple Keep screw in lateral 1/3 of heel 2 incision technique 5cm bridge:Anderson/ Davis (AOFAS 8/04) for lat recon. Sx

1cm lateral cw osteotomy

Skin bridge 5cm

41yo ankle pain

Allograft ligament failed Brostrom with cavovarus

mobilization

1st MT & Z osteotomy

12mo post

AAAA @ 3mo

MA HF driven cavus Rx Dwyer/1st MTO

Cavovarus: Surgical Options

If 1st ray pronated Or Coleman block shows correction Modified Lapidus Dorsal closing wedge 1st TMT joint Cross screw,plate or staple fixation

1st MT DCW Osteotomy

1st ray Rx via dorsal cwo

Bibliography Kelikian AS.:Calcaneal

Osteotomies.Ch;#23.Operative Rx of the Foot & Ankle,Appleton & Lange,Stamford,Conn;417-32,1999.

Mosca, VS; Principle and management of pediatric foot & ankle deformities & malformations. Wolters Klumar,2014

Rodrigues RP.:Medial displacment calcaneal osteotomy in the Rx of PTD. Foot & Ankle Clinics.#3,545-67,2001.

Sammarco GJ, Taylor R.:Combined calcaneal & metatarsal osteotomies for the Rx of the cavus foot.Foot & Ankle Clinics.#3:533-43.2001