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Podiatric Surgery II > 3) Pes Cavus Procedures > Flashcards

3) Pes Cavus Procedures Flashcards

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1
Q

Pes cavus simple definition

A
  • Primarily a sagittal plane deformity
  • Forefoot is plantarflexed on the rearfoot
  • With or without plantarflexed 1st metatarsal
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2
Q

Pes cavus etiology

A
  • Idiopathic
  • Congenital
  • Neuromuscular* (mostly CMT)
  • Acquired
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3
Q

Goals of pes cavus tx

A
  • Look at function requirements and goals of patient
  • Consider conservative options first
  • Most effective with mild flexible deformities
  • Often limited / provide symptomatic relief
  • Accommodative orthotics
  • Bracing (AFO)
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4
Q

Pes cavus surgical tx goals

A
  • Plantigrade, stable foot
  • Resist deforming forces
  • Long lasting
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5
Q

Preoperative assessment

A
  • Thorough family history
  • Growth Milestones
  • Patients progression of deformity
  • Rule out paralytic disease (neurological consult)
  • Type of cavus
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6
Q

Neurological consult for pes cavus procedures

A
  • Myelodysplasias or Spinal Dysraphisms (spinal bifida occulta)
  • Hereditary motor and sensory neuropathies (CMT)
  • Hereditary Degeneration of spinocerebellar tracts
  • Nerve conduction and EMG studies
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7
Q

Type of cavus determination

A
  • Locate apex of deformity

- Position of hindfoot

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8
Q

JAPAS classification

A
  • Anterior cavus
  • Posterior cavus
  • Combined
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9
Q

Local anterior cavus

A
  • First metatarsal is plantar flexed lower than the weightbearing area of the heel
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10
Q

Global anterior cavus

A
  • Metatarsals I through V lie lower than the weightbearing of the heel and providing the main deforming force
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11
Q

Posterior cavus

A
  • Vertical heel – High calcaneal inclination angle

- Calcaneal varus

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12
Q

Combined cavus

A
  • Frontal

- Saggital

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13
Q

Flexible versus rigid deformity

A
  • Coleman block test
  • Posterior block for evaluation of ankle component
  • Does heel evert past inverted or neutral position
  • Can forefoot be reduced with rearfoot
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14
Q

Weightbearing AP radiographic evaluation

A
  • Decreased Talocalcaneal angle
  • Normal or decreased Cuboid Abduction angle
  • Increased forefoot Adductus angle
  • Increased TN joint “congruency”
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15
Q

Weightbearing lateral radiographic evaluation

A
  • Increased calcaneal inclination
  • Normal Cyma line to POSTERIOR break
  • Accentuated “bullet hole” sinus tarsi
  • Decreased talar declination
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16
Q

Calcaneal axial view to rule out

A
  • Structural varus
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17
Q

Meary’s angle

A
  • Formed between lines drawn through the longitudinal axis of the talus and its reference to the bisection of the first metatarsal
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18
Q

Hibb’s angle

A
  • Bisection of the longitudinal axis of the calcaneus in reference to the first metatarsal
  • Overall angle number determines the degree of cavus deformity
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19
Q

Cavus deformity utilizing the Hibb’s angle is determined by

A
  • Anything that is < 130°
  • Posterior cavus, this angle will approach 90°
  • Anterior cavus, it will approach 130°
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20
Q

Coleman Block Test

A
  • Build up the lateral column, suspending 1st ray
  • Removing influence of the 1st metatarsal
  • “Stress pronation x-ray of the STJ” (evaluating the position of the lateral process of the talus)
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21
Q

Coleman Block Test flexible vs. rigid

A
  • Lateral process of the talus hits the floor of the sinus tarsi = Flexible Cavus
  • DF wedge of the 1st metatarsal indicated, allowing STJ pronation
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22
Q

Cavus procedure categories

A
  • Soft tissus
  • Corrective Osteotomies
  • Fusions (IPJ)
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23
Q

Soft tissue cavus procedures

A
  • ST releases
  • Tendon Transfers
  • Tendon lengthening
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24
Q

Corrective osteotomy cavus procedures

A
  • Hindfoot (Dwyer)
  • Midfoot (Cole)
  • Forefoot (Metatarsal bases)
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25
IPJ fusion
- Malleous correction - IPJ release – allowing 1st met dorsiflexion - Strengthen flexor power
26
Stage II cavus deformity clinical presentation
- Calcaneus - Rigid - MTP - Flexible - First Ray - Rigid
27
Stage II cavus deformity surgical approach
- Calcaneus – Dwyer - No MTP Release - First Ray - DFWO
28
Osseous procedures
- Midtarsal osteotomies - Metatarsal osteotomies - Tarsal osteotomies - Tarsal arthrodesis
29
Soft tissue releases
- Fasciotomies (Pediatric or adolescent patient, adjunctive procedure) - Subcutaneous fasciotomy - Steindler Stripping
30
Steindler Stripping
- Plantar fascia - Abductor hallucis - Flexor digitorum brevis - Abductor digiti quinti - Long plantar ligament is released - Casted 3 weeks subsequent to correction - Walking cast 2-3 weeks
31
Cavus foot tendon transfers
- Reduce supination - Increase pronation - Reduce dropfoot - Increase dorsiflexion
32
Tendon transfer considerations
- >10-11 years of age - Rarely effect permanent correction - Removal of deforming force in controlling progressive deformity
33
Types of tendon transfers
- Extensor Tendon Transfers (Jones Suspension, Heyman Prodedure, Hibbs) - Split Tibialis Anterior Tendon Transfer - Peroneus Longus Tendon Transfer - Tibialis Posterior Tendon Transfer - Peroneus Anastomosis
34
Jones Suspension indications
- Flexible cavus | - Flexible plantarflexed 1st ray
35
Jones Suspension
- EHL transected at IPJ of Hallux, rerouted through hole in 1st Met head - Sutured back to itself, proximally - Distal stump sutured to EHB - IPJ fusion - prevents hammering
36
Jones Suspension mechanics
- Compensates for overpowering peroneus longus and flexor hallucis longus - Retrograde plantar buckling of 1st MPJ is released - Adjunct to transfers
37
Hibbs Tenosuspension indications
- Flexible Forefoot or metatarsal equinus | - Flexible Cavus with Extensor Substitution
38
Hibbs tenosuspension
- EDL (2,3,4,&5) detached from insertion - Tenodesed as group into dorsal foot - Distal stumps sutured to corresponding Brevis tendon (4&5 go to 4th Brevis)
39
Hibbs procedure components
- Extensors transfer to the lateral cuneiform - Plantar fascia and plantar muscle release - TAL
40
Heyman procedure
- Transfer of all five long extensor tendons to respective metatarsal heads - of distal stumps of long extensor tendons to short - 4th and 5th to short extensor of 4th
41
Heyman procedure complications
- Technically difficult - Flexion or abduction deformity of digitis - Metatarsal fractures - Dehiscence of skin
42
STATT
- Effective adjunctive procedure with flexible cavus | - Pronatory influence across the ST and Midtarsal joints
43
STATT procedure steps
- Tendon split to its insertion site - Lateral fibers drawn up through proximal incision - Rerouted down peroneus tertius sheath - Sutured to peroneus tertius tendon, peroneus brevis, or tenodesed to cuboid
44
STATT incisions (3)
- Near TA insertion site - Anterior surface of leg above cruciate ligament - Over peroneus tertius, 1 inch proximal to insertion
45
Peroneus Longus tendon transfer
- Detached near cuboid - Retrograded proximally, rerouted through lateral intermuscular septum to the anterior compartment, through extensor tendon sheath - Inserted into the lesser tarsal area
46
Peroneus longus tendon transfer mechanics
- Increases ankle joint DF power - Decreased associated dropfoot deformity - Removes deforming force - Increases ankle DF and eversion - Posterior Tibial tendon transferred through interosseous membrane to dorsal midfoot
47
Posterior tibial tendon transfer attachment points
- Anastomosis to P. Brevis | - 3rd cuneiform / cuboid (interference screw or anchor)
48
Posterior tibial tendon transfer indications
- Anterior group weakness leading to drop foot
49
Posterior tibial tendon transfer complications
- Progressive pes valgus | - Triple arthrodesis or Talocalcaneal fusion
50
Peroneal anastomosis
- Peroneus longus to peroneus brevis at the level of the lateral ankle or at the base of 5th metatarsal - Decrease plantarflexory force on the first ray - Increasing eversion
51
Midtarsal osteotomies
- Cole - Japas - McElvenny-Caldwell
52
Metatarsal osteotomies
- DFWO | - Pan metatarsal osteotomies
53
Tarsal osteotomies
- Dwyer | - Samilson
54
Cole procedure
- Dorsal tarsal wedge to reduce fixed anterior cavus - Extends from cuboid to navicularcuneiform - Wider at medial aspect - Subtalar and midtarsal joint motion preserved
55
Cole procedure fixation
- Forefoot manipulated into dorsiflexion - Fixated (pins or screws) - Non-WB cast immobilization 8 weeks - WB cast for additional 4-6 weeks
56
Cole procedure complications
- Delayed union - Poor cosmesis and function - Results in a shorter, wider, thicker foot
57
JAPAS procedure
- Midtarsal V osteotomy at the apex of the deformity ( navicular ) - No bone is excised - Forefoot shifted dorsally on rearfoot
58
Mcelvenny-Caldwell Procedure
- 1st Metatarsal-cuneiform arthrodesis | - Elevation of 1st metatarsal correcting anterior cavus
59
DFWO
- Dorsiflexory Wedge Osteotomy | - Preserves function of major joints
60
Dwyer Osteotomy
- Lateral closing wedge of the body of the calcaneus - Indicated with a rigid calcaneovarus deformtiy - Caution with tibial varus - Goal is perpendicular calcaneus - Sural nerve - Staple/Screw fixation - Drain
61
Samilson
- Dorsiflexory calcaneal osteotomy | - Dorsal displacement of posterior calcaneus
62
Tarsal Arthrodesis
- Before or after tendon transfers - Medial double (STJ and TN fusion) - CC arthroplasty vs. fusion - Triple arthrodesis
63
Stage II cavus deformity clinical --> surgical decision
- Calcaneus, Flexible --> No Dwyer - MTP, Rigid --> MTP release - First Ray, Flexible --> No DFWO
64
Forefoot driven cavus
- DFW 1st Metatarsal osteotomy (1st TMT fusion, Jones tenosuspension / IPJ fusion) - Plantar fascial release - Steindler stripping - Peroneal anastomosis vs. tendon transfer
65
Digital – Anterior global/local Flexible deformity and procedure selection
- IPJ – Flexion contracture --> IPJ fusion - MPJ – Extension --> Extensor hood release, EHL and EDL lengthening - MET – Retrograde plantarflexion --> Jones, Hibbs

Podiatric Surgery II (6 decks)

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