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1

HAV Sujective

CC: “Bump pain,” “Big toe is moving over,” Typical patient is female although it is unclear whether there is a higher
incidence among females, or if there is a higher complaint incidence among females.
HPI: -Nature: Throbbing, aching-type pain
-Location: Dorsomedial 1
st
MPJ is most typical presentation. Pain could also be more medial (suggesting
underlying transverse plane deformity such as met adductus) or dorsal (suggesting OA of 1
st
MPJ).
-Course: Gradual and progressive
-Aggravating Factors: Shoe wear, WB
PMH: -Inflammatory conditions (SLE, RA, Gout, etc.)
-Ligamentous Laxity (Ehlers-Danlos, Marfan’s, Downs syndrome)
-Spastic conditions (40% incidence of HAV among those with CP)
PSH: -Previous F&A surgery
FH: -Hereditary component (63-68% family incidence among general population, 94% with juvenile HAV)
-Johnston reports an autosomal dominant component with incomplete penetrance
Meds/All: Usually non-contributory
ROS: Usually non-contributory

2

HAV OBJ

Derm: -Dorsomedial erythema +/- burs
-Submet 2 lesion
-Nail bed rotational changes
-Pinch callus

Vasc/Neuro: Usually non-contributory

Ortho:
-Dorsomedial eminence
-Pes plano valgus
-Varus compensation
-Equinus
-Underlying met adductus
-Hypermobile 1stray
-PROM 1stMPJ
-LLD
-Tracking vs. Track-bound 1stMPJ

3

Plain film radiographs vHAV

-Increased soft tissue density
-In first met head: subchondral bone cysts, osteophytes, hypertrophy of medial eminence
-Overall metatarsal parabola
-1stMPJ joint space: ~2mm of clear space; Congruent vs. Deviated vs. Subluxed

4

angles for bunions on radiograph

-Met Adductus (<2mm) -Kite’s Angle

5

HAV Dissection and capsule procedures

anatomic dissection
lateral release
Medial capsulotomies

6

HAV anatomic dissection

-1st incision is through epidermis and dermis
-Incision is planned along the dorsomedial aspect of the 1st MPJ, just medial to EHL and lateral to the medial dorsal
cutaneous nerve.
-From midshaft of 1st
metatarsal to just proximal to the hallux IPJ
-Subcutaneous tissue is dissected to deep fascia/capsular layer
-NV structures: Superficial venous network, medial dorsal cutaneous nerve
-Be wary of the anterior resident’s nerve (Extensor capsularis)!

7

HAV lateral release

-Release of adductor hallucis tendon from base of proximal phalanx and fibular sesamoid
-Release of fibular metatarsal-fibular sesamoid ligament and lateral capsule
-Tenotomy of the lateral head of the FHB between the fibular sesamoid and the proximal phalanx
-Optional excision of the fibular sesamoid

8

Medial capsulotomies for HAV

-Linear
-Washington Monument: Strongest medial capsulotomy allowing for both transverse and frontal plane correction
-Lenticular (Elliptical): Allows for transverse and frontal plane correction with removal of redundant capsule
-Inverted L: Transverse plane correction with removal of redundant capsule
-Medial T: Transverse plane correction with removal of redundant capsule
-Medial H: Transverse plane correction with removal of redundant capsule

9

HAV Distal phalanx procedures

Distal Phalanx
1. Medial Nail Bed Rotation: Corrects soft tissue mal-alignment

10

Hallux IPJ HAV procedures

Hallux IPJ
2. Amputation of the distal phalanx: Permanent correction of abnormal Hallux Interphalangeus Angle (HIA)
3. IPJ Fusion: Corrects abnormal HAI

11

HAV Proximal Phalanx procedures

4. Distal Akin: Corrects abnormal HAI with a medially-based wedge osteotomy at distal proximal phalanx
5. Central Akin: Corrects for long proximal phalanx seen with concurrent HL/HR
6. Oblique Akin: Corrects for distal articular set angle (DASA) midshaft proximal phalanx
7. Proximal Akin: Corrects for DASA of the proximal phalanx
8. Keller Arthroplasty: Corrects for abnormal Hallux Abductus Angle (HAA) and with concurrent HL/HR
9. Keller-Brandis Arthroplasty: Same as the Keller, but with removal of 2/3 of the proximal phalanx
10. Bonney-Kessel: Dorsiflexory osteotomy with concurrent HL/HR with modified forms correcting for abnormal DASA
11. Distal Hemi-Implant: Corrects for abnormal HAA or DASA with concurrent HL/HR
12. Regnauld: Allows for correction of DASA and abnormal proximal phalanx length in presence of HL/HR
13. Sagittal Z: Corrects for DASA and abnormal proximal phalanx length in presence of HL/HR

12

HAV MPJ procedres

14. Total Implant: Correction of HAA in presence of HL/HR
15. McKeever arthrodesis: Allows for permanent correction of DASA, PASA and HAA
16. McBride: Soft tissue reconstruction for correction of HAA
17. Modified McBride: Bone and soft tissue reconstruction for correction of HAA and medial eminence
18. Silver: Correction of medial eminence
19. Hiss: Modified McBride with Abductor hallucis advancement
20. External Fixation: Double Taylor frame for gradual soft tissue realignment
21. Hallux Amputation: Permanent correction of abnormal HAA

13

Distal 1st Met procedures HAV

22. Proximal Hemi-Implant: Correction of PASA and HAA with concurrent HL/HR
23. Mayo: First met head resection for correction of HAA with HL/HR
24. Stone: Mayo with sesamoid articulation left intact
25. Reverdin: Correction of PASA. Incomplete osteotomy.
26. Reverdin-Green: Correction of PASA with incomplete osteotomy and plantar shelf
27. Reverdin-Laird: Correction of PASA and IMA with complete osteotomy and plantar shelf
28. Reverdin-Todd: Correction of PASA, IMA and sagittal plane deformity (elevatus)
29. Youngswick: Correction of IMA and elevatus
30. Austin: Correction of IMA
31. Bicorrectional Austin: Correction of IMA and PASA
32. Tricorrectional Austin: Correction of IMA, PASA and elevatus
33. Mitchell: Rectangular osteotomy with lateral spicule to correct for IMA, elevatus and metatarsal length. Perpendicular to first met axis.
34. Roux: Wedged Mitchell to also correct for PASA
35. Miller: Mitchell with osteotomy oblique to first met axis for further correction of IM and length
36. Hohmann: Transverse through and through cut to correct for IMA and sagittal plane
37. Wilson: Oblique through and through osteotomy to correct for IMA and metatarsal length
38. Distal L: Similar to a Reverdin-Green without correction of PASA
39. Kalish: Austin with a long dorsal arm to allow for screw internal fixation
40. Mygind: Mexican hat procedure of distal first metatarsal for correction of IM and length
41. Off-set V/Vogler: Proximal Kalish
42. Peabody: Proximal Reverdin
43. Short-arm Scarf: Correction of IMA
44. Percutaneous DMO: Percutaneous Hohmann
45. DRATO (Derotational Abductory Transpositional Osteotomy): Can be used to correct frontal plane, IMA, sagittal plane and wedged for PASA
46. Distal Crescentic: Correction of IMA
47. Distal Crescentic with a shelf: Correction of IMA with greater stabilit

14

HAV Shaft Procedures

48. Scarf: Correction of IMA
49. Ludloff: Correction of IMA. Dorsal-proximal to distal-plantar cut.
50. Mau: Correction of IMA. Distal-dorsal to proximal-plantar cut.

15

HAV Proximal first met procedures

51. Cresentic: Correction of IMA
52. Cresentic Shelf: Correction of IMA with greater stability
53. OBWO: Correction of IMA
54. Trethowan: OBWO using medial eminence for graft
55. CBWO (Loison-Balacescu): Closing base wedge proximal osteotomy. Corrects IMA.
56. Logroscino: CBWO with Reverdin. Corrects IMA and PASA.
57. Juvara: Oblique CBWO
58. Proximal Austin: Correction of IMA
59. Lambrinudi: Plantar CBWO to correct for sagittal plane

16

HAV 1st Met cuneiform proc

60. Lapidus with internal fixation
61. Lapidus with external fixation
62. Westman: OBWO of the cuneiform to correct for transverse plane
63. Cotton: OBWO of the cuneiform to correct for sagittal plane
64. Cotton-Westman: OBWO of the cuneiform to correct for transverse and frontal plan

17

HAV complicatios

Recurrence
Hallux Varus
Malunion/Delayed union/Non union

18

HAV recurrence

-Early (1 year)
-Usually due to an unrecognized underlying deformity (such as met adductus, Ehlers-Danlos, equinus, 1st met hypermobility, etc.)
-Symptoms usually worse than initial presentation
-Treatment: Distal soft tissue procedures or a proximal osteotomy usually indicated

19

Hallux varus with extension at MPJ with flexion at IPJ

Hallux malleus

20

etiology of hallux vrus

-Underlying causes: -Long 1stmetatarsal
-Round 1stmetatarsal head
-1stMPJ hypermobility

-Iatrogenic causes: -Staking of the 1st
metatarsal head
-Overcorrection of the IM angle
-Overzealous medial capsulorraphy
-Fibular sesamoidectomy
-Over extensive lateral release
-Overcorrection of the PASA
-Overzealous bandaging

21

Hallux Varus treatment

-Soft tissue rebalancing (medial releases and lateral tightenings)
-EHB tendon transfer
-Reverse distal osteotomies
-Ludloff/Mau
-Resection arthroplasty, implant, arthrodesis

22

HAV Malunion

-Malunion
-Consolidated osteotomy with an angular or rotational deformity
-Most common is sagittal plane abnormality (“dorsal tilting”)
-Must be corrected with an osteotomy

23

Classficaionof non union

Weber and cech

24

Weber and Cech classification

-Hypertrophic/Hypervascular (represents ~90% of non-unions)
-These types of non-unions have adequate biology, but they usually require increased
stabilization in order to heal.
-Elephant Foot
-Horse Hoof
-Oligotrophic

-Atrophic/Avascular (represents ~10% of non-unions)
-These types of non-unions have bad biology and require aggressive debridement, usually
with some type of orthobiologic product.
-Torsion wedge -Defect
-Comminuted -Atrophic

25

HL/HR work up subjective

CC: Pt will generally complain of a “painful big toe.”
HPI: -Nature: Aching, Dull, Throbbing
-Location: Dorsal 1st
MTPJ and within the joint
-Course: Usually gradual and progressive. May follow an acute traumatic event.
-Aggravating Factors: Shoe gear, WB
-Alleviating Factors: Ice, NSAIDs, Rest
PMH: -Inflammatory Condition: RA, SLE, Gout
PSH: -Past 1st MTPJ surgery
Meds/Allergies/SH/FH: Non-contributory
ROS: Non-contributory

26

HL/HR Objective

Derm:
-Hyperkeratotic lesions: Plantar hallux IPJ, Medial pinch callus hallux IPJ, Submet 2
-Erythema, Calor, Dorsal 1st
MTPJ bursa

Vasc/Neuro: Non-contributory

Gait: -Early Heel-off
-Apropulsive Gait
-Abductory Twist

Ortho:
-Decreased PROM 1st
MTPJ
-Varus Deformity
-Dorsal eminence 1st
MTPJ
-Plantar Contracture
-Dorsal eminence 1st
Met-Cun
-Equinus
-Hypermobile 1st ray

27

Plain film findings in HL/HR

-Osteophytes at 1st MTPJ
-Long 1st met
-Irregular Joint Space Narrowing
-Long hallux proximal phalanx
-Lateral view: dorsal flag sign, dorsal lipping -Elevated 1st met
-Loose bodies (joint mice)
-Osteophytes at hallux IPJ, 1st met-cun
-Square-shaped 1st met head

28

HL vs HR

-This is a progressive deformity, so what defines rigidus from limitus? Bony ankylosis and sesamoid immobilization

29

define functional HL

-Functional HL is defined as a decreased PROM with the foot loading and in a neutral position, and normal PROM when the foot is unloaded.
Dannanberg first defined functional HL.

30

flexor stabilization of hallux

Essentially a hammertoe of the hallux with extension at the MTPJ and plantarflexion at the IPJ

31

axi rotation of 1st MTPJ

Normally found in the center of the metatarsal head allowing for a gliding motion of the hallux up and over
the first metatarsal head. In a HL/HR deformity the axis of rotation moves distally and plantarly leading to dorsal jamming of the join

32

define met primus elevates both primary ad secondary

-Met Primus Elevatus: Dorsiflexed position of the 1st metatarsal.
-Primary: Structural. Distal segment is dorsiflexed compared to proximal segment.
-Secondary: Global. Due to some extrinsic variable. This can be measured by Meary’s Angle on a lateral plain film radiograph or
using the Seiberg technique comparing the 1st
and 2nd metatarsal positions

33

what stimulates osteophyte production around joint in HL/HR

loss of functional cartilage

34

1st MTPJ ROM for HL/HR

-Normal PROM of the 1st
MTPJ is classically described as 65-75 degrees of dorsiflexion of the hallux referenced to the weight-bearing surface
(same as 85-95 degrees of dorsiflexion referenced to the 1st met shaft). Plantarflexion is 30 degrees to the weight-bearing surface.
-Hetherington contradicts this somewhat by finding an average ROM of 31degrees of dorsiflexion during pain-free gait in asymptomatic patients.

35

Compensation patterns forlack of motion in HL/HR

-Distal: Hallux IPJ leading to OA and plantar hyperkeratotic lesions
-Lateral: Lesser metatarsalgia
-Proximal: 1
st
met-medial cuneiform joint increased motion and OA
-Gait patterns: Abductory twist with roll-off; early heel-off; apropulsive gait

36

HL/HR etiology

-Many people have reported potential causes of HL/HR including Root, Lapidus and Nilsonne:
-Acute Trauma
-Chronic degenerative trauma
-Pes planus with 1st
met hypermobility
-Long first metatarsal
-Short first metatarsal with hallux gripping
-Long hallux proximal phalanx
-Iatrogenic
-Compensated varus deformity
-Neuromuscular imbalance
-Plantar contracture
-Spastic conditions
-Square first metatarsal head shape
-Met primus elevatus
-No single characteristic has been shown to reliably lead to HL/HR except acute trauma
-Coughlin (FAI 2003) performed a retrospective analysis and seemed to demonstrate that there are no reliable underlying indicators for
development of HL/HR

37

Classificatio for HL/HR

-Numerous exist; usually in the mild, moderate, severe format:
-Mild: Mild pain; Normal PROM; Radiographic evidence of osteophytes
-Moderate: Increasing pain; Decreasing PROM; Osteophytes and irregular joint space narrowing on radiograph
-Severe: Increasing pain; Decreasing PROM; Osteophytes, irregular joint space narrowing, subchondral sclerosis on radiograph.
-Rigidus: Increasing pain; Absent PROM; Sesamoid immobility
-Examples of classifications include the Regnauld, Hanft and KLL.

38

HL/HR consev tx

-Do nothing
-Activity modification
-Orthotics: First ray cut-out, Morton’s extension, rocker-bottom sole
-Meds: PO NSAIDs, Intra-articular corticosteroid injections

39

2 kinds of surgical proc for HL/HR

joint sparing
joint destructive

40

Joint sparing proc fo HL/HR

Proximal Phalanx
-Bonney-Kessell
-Regnauld
-Vanore
-Sagittal “Z”
-Central Akin

1stMTPJ
-Cheilectomy

1stMetatarsal
-Youngswick
-Watermann
-Watermann-Green
-Jacoby
-Hohmann
-Derner
-Dorsal OBWO
-Lambrinudi
-Westman

41

flatfoot subjective

-Wide range of presenting ages and complaints.
-Always think about posterior tibialis tendon dysfunction when someone complains of “medial ankle pain.”

42

Underlying orthopedic etiology of flatfoot

-Compensated forefoot varus
-Forefoot valgus
-Rearfoot valgus
-Equinus
-Compensated and uncompensated ab/adduction deformities
-Muscle imbalances (PTTD)
-Ligamentous laxity
-Tarsal coalitions
-Planal dominance
-Normal STJ axis: 42° from transverse/16° from sagittal
-Normal MTJ-O: 52° from transverse/57°from sagittal
-Normal MTJ-L: 15° from transverse/9° from sagittal

43

flat foot clinic findings

-“Too many toes” sign (forefoot abduction)
-Hubscher maneuver
-Evaluation for flexible versus rigid deformity
-RCSP
-Single and double heel raise
-Subjective gait analysis

44

Flatfoot xrays Lateral finings

-Decreased calcaneal inclination angle
-Increased talar declination angle
-Increased first metatarsal declination angle
-Calcaneal-cuboid “break”
-Anterior break in Cyma line
-Meary’s Angle
-Midfoot “breaks” or “incongruity”

45

AP xrays findings

-Increased talo-calcaneal angle
-Talar-first metatarsal axis
-Cuboid-abduction angle
-Intermetatarsal angle
-Talar head coverage
-Forefoot adduction angle or Engle’s Angle
-Look for “skew foot” deformity

46

viw to evaluate tarsal coaliions

harris beath

47

Evaluation of structural rearfoot deformities

long leg calcanea axial views

48

Classifications for flatfoo

Johnson an strom
Funk
Jahss or Janis

49

Johnson and stom

-Later modified by Myerson who added Stage IV (he does that a lot):
-[Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. JBJS-Am. 1996;
78: 780-92.]
-[Bluman EM, et al. Posterior tibial tendon rupture: a refined classification system. Foot Ankle Clin. 2007 Jun; 12(2):
233-49.]
-Stage I: Tenosynovitis with mild tendon degeneration; flexible rearfoot; Mild weakness of single heel raise and
negative “too many toes” sign
-Stage II: Elongated tendon with tendon degeneration; flexible rearfoot; Marked weakness of single heel raise and
positive “too many toes” sign
-Stage III: Elongated and ruptured tendon; Rigid valgus rearfoot; Marked weakness of single heel raise and positive
“too many toes” sign
-Stage IV: Same as Stage III with a rigid ankle valgus

50

Funk classification

-Funk: Classification based on gross intra-operative appearance
-[Funk DA, et al. Acquired adult flatfoot secondary to posterior tibial tendon pathology. JBJS-Am. 1986; 68: 95-102.]
-Type I: Tendon Avulsions
-Type II: Complete midsubstance rupture
-Type III: In-continuity tears
-Type IV: Tenosynovitis

51

Jahss or Janis

There are several MRI classifications generally along the lines of:
-[Conti S, Michelson J, Jahss M. Clinical significance of MRI in preoperative planning for reconstruction of posterior tibial tendon ruptures.
Foot Ankle. 1192; 13(4): 208-214.]
-[Janis LR, et al. Posterior tibial tendon rupture: classification, modified surgical repair, and retrospective study. JFAS. 1993; 31(1): 2-13.]
-Type I: Tenosynovitis, increased tendon width, mild longitudinal splits
-Type II: Long longitudinal splits with attenuated tendon
-Type III: Complete rupture

52

Johnson/strom Myerson classifiatin treatmen

-In addition to describing the deformity, this classification system (discussed on a previous sheet) also makes general
treatment recommendations:
-Stage I: Conservative treatment; Tenosynovectomy; Tendon Debridement
-Stage II: Tendon transfer; Rearfoot arthrodesis
-Stage III: Isolated rearfoot arthrodesis; Triple arthrodesis
-Stage IV: TTC arthrodesis; Pantalar arthrodesis

53

soft tissue procedure for flafoot

-FDL Tendon Transfer: FDL is sectioned as distal as possible (consider anastomosis of stump to FHL) and either
attach proximal FDL to the PT, within the PT sheath or into the navicular under tension.
-Cobb: Split TA tendon, transfer to the PT or into the navicular
-Young’s Tenosuspension: TA rerouted through navicular
-Anastomosis of PB and PL: Removes PB as deforming force
-STJ implant (arthroeresis)
-TAL
-Gastroc recession

54

Rearoot osseous proc

-Evans Osteotomy (1975): opening wedge calcaneal osteotomy
-Silver (1967) is a more proximal (and less common) Evans-type opening wedge
-Medial Calcaneal Slide (Koutsogiannis - 1971): medial translation of posterior calcaneus
-Double Calcaneal Osteotomy: Evans with a medial calcaneal slide
-STJ arthrodesis
-Triple arthrodesis
-Tibiotalocalcaneal arthrodesis
-Pantalar arthrodesis
-Closing wedge of the medial calcaneus: Essentially the opposite of an Evans but with more NV structures
-Dwyer (1960)
-Slakovich: opening wedge behind the sus tali
-Baker-Hill: opening wedge osteotomy with graft horizontally under the posterior calcaneal facet

55

flatfoot midfoot and forefoot osseous procedures

-Cotton: opening wedge osteotomy with graft in medial cuneiform
-Kidner: advancement and reattachment of PT tendon (+/- resection of portion of navicular)
-TN arthrodesis: called a Lowman when wedged and combined with TAL

Medial column arthrodeses
-Miller: NC and 1st
met-cun arthrodesis
-Lapidus (1931/1960): 1st
met-cun arthrodesis
-Hoke: arthrodesis of navicular with 1st/2nd
cuneiforms

56

Standardized systems for cavus foot work up

-Underlying Etiology of the Deformity (Spastic vs. Progressive vs. Stable)
-Forefoot vs. Rearfoot driven deformity (Anterior Cavus vs. Posterior Cavus)
-Plane of the Deformity (Sagittal vs. Frontal vs. Transverse vs. Combination)
-Rigid vs. Flexible

decide treatment based on that

57

underlying etiology of cavus foot

spastic vs progressive vs stable

-Obtained through a good PMH and physical exam
-Brewerton of the Royal Hospital in London identified 75% of 77 patients seen at his pes cavus clinic to have an underlying
neuromuscular disorder.
-Common Congenital Conditions leading to neuromuscular dysfunction:
-Spina bifida
-Charcot-Marie-Tooth
-Myelodysplasia
-Friedreich’s Ataxia
-Cerebral Palsy
-Roussy-Levy syndrome
-Muscular Dystrophy
-Dejerine-Sottas
-Poliomyelitis

-Also consider MMT, clonus, deep tendon reflexes, EMG studies and nerve conduction studies during your physical exam.

58

cavus foot
define different kinds

anterior
metatarsus
lesser tarsus
forefoot
combined

-Anterior Cavus: plantar declination of the forefoot in relation to the rearfoot. Subdivided based on apex of deformity:
-Metatarsus Cavus: Apex at Lisfranc’s joint. Generally more rigid.
-Lesser Tarsus Cavus: Apex in the lesser tarsus area
-Forefoot Cavus: Apex at Chopart’s joint
-Combined Cavus: Combination of any of the above

59

cavus foot how to find the apex

-Intersection of Meary’s lines (longitudinal axes of talus and first met)
-Intersection of Hibb’s Angle (longitudinal axes of calcaneus and first met)
-Dorsal boney prominences
-Joint space gapping

60

define posterior cavus

-Posterior Cavus: Dorsiflexion of the rearfoot in relation to the forefoot
-Generally defined as an increased calcaneal inclination angle (>30 degrees) and a varus positioning.
-Usually the result of an anterior cavus; rarely presents as separate entity.

61

how to define anterior and a posterior cavus

-An anterior cavus and a posterior cavus can be defined based on radiographic evidence and a physical exam measure called the
Coleman Block Test. In this test the forefoot, or the medial and lateral portions of the forefoot, are suspended off of a block. If
the calcaneus returns from a varus to a normal position, the deformity is forefoot driven. A deformity is rearfoot driven only if
the varus positioning of the calcaneus remains after all forefoot elements are removed

62

biomechanical compensation for a sagittal plane cavuse deformity

-Digital retraction: HT deformity where EDL gains mechanical advantage and uses a passive pull.
-MPJ Retrograde buckling: As per above
-Lesser Tarsal Sagittal Plane Flexibility: The lesser tarsus “absorbs” some of the dorsiflexion. They can be clearly
seen when comparing NWB and WB lateral views of an anterior cavus foot.
-Pseudoequinus: Occurs when the ankle joint must dorsiflex because the lesser tarsus cannot “absorb” all of the
dorsiflexion. Limits the amount of “free” dorsiflexion available during gait.

63

Cavus foot plane of deformity

sagittal
transverse
frontal plane

-Sagittal Plane:
-Anterior Cavus (Global, Medial Column, or Lateral Column)
-Posterior Cavus
-Muscular Cavus (Gastroc Equinus, Gastroc-Soleus Equinus)
-Osseous Equinus (Tibiotalar exostosis)

-Transverse Plane:
-Met adductus (measured via met adductus angle or Engle’s angle)
-Met abductus (measured via met adductus angle)

-Frontal Plane:
-Forefoot Varus
-Forefoot Valgus
-Rearfoot Varus
-Rearfoot Valgus

64

How to differ a flexible cavus foot to a rigid

-Flexible deformities can be manipulated out during the physical exam and are obvious comparing NWB and WB lateral
radiographs.
-Rigid deformities show no compensation with manipulation of weight-bearing.
-Defining each of these variables during your work-up will give you a clear enough understanding of the deformity to
recommend a treatment option.

65

basic priniciples for cavus foot treatment

underlying etiology
forefoot vs rearfoot
plane of deformity
rigid vs flexible

-Underlying Etiology:
-Progressive/Spastic conditions are generally treated with osteotomies and arthrodeses.
-Stable conditions are generally treated with soft tissue procedures and osteotomies.
-Forefoot vs. Rearfoot Driven:
-Forefoot driven conditions are treated with manipulation of the bones and soft tissue of the forefoot.
-Rearfoot driven conditions require rearfoot osteotomies and arthrodeses.
-Plane of the Deformity:
-Procedures are chosen by which plane you want correction in.
-Rigid vs. Flexible:
-Rigid deformities are generally treated with osteotomies and arthrodeses.
-Flexible deformities can usually be managed with soft tissue procedures and tendon transfers

66

Cavus foot soft tissue releases

reduces contracture of the plantar fascia seen with longstanding disease

-Subcutaneous Fasciotomy: Cuts the plantar fascia at its insertion.
-Steindler Stripping: Removes all soft tissue from the plantar surface of the calcaneus.
-Plantar Medial Release: Releases plantar musculature and ligaments from the plantar-medial foo

67

tendon transfers for cavus feet

flexible

-Jones Suspension: Transfer of EHL through the first metatarsal head.
-Heyman Procedure: Transfer of EHL and EDL tendons through each of the respective metatarsal heads.
-Hibbs Procedure: Transfer of EDL into lateral cuneiform; EHL into first metatarsal; EDB into sectioned tendons.
-STATT: Tibialis anterior is split and sutured into peroneus tertius.
-Peroneus Longus Transfer: Peroneus longus is split and anastomosed to the TA and peroneus tertius tendons.
-Peroneal Anastomosis: Increases the eversion power of the foot.
-PL/PT transfer to calcaneus: Tendons are attached into the calcaneus via bone anchors to aid weak Achilles
tendon

68

Cavus foot osseous procedures

reduction of rigid deformities. can be used to correct multi-planar deformites

-Cole Procedure: Dorsiflexory wedge is removed from Chopart’s joint.
-Japas Procedure: “V” shaped osteotomy through the midfoot (apex proximal) to dorsiflex forefoot.
-Jahss Procedure: Essentially a Cole procedure performed at Lisfranc’s joint.
-Dorsiflexory Metatarsal Osteotomies
-Dwyer Osteotomy: Closing wedge osteotomy out of lateral calcaneus to reduce rigid rearfoot varus.
-Dorsiflexory Calcaneal Osteotomy: Must be used with caution

69

Arthrodesis procedures for cavus foot

Used as last resort to correct rigid deformities in the face of progressive disease.
-Hoke: STJ and TNJ arthrodesis
-Ryerson (1923): Triple arthrodesis

70

deformities you can correctfor equinus

-Charcot arthropathy
-Digital deformities
-Pes plano valgus
-Met primus elevatus
-HAV
-Plantar fasciitis
-Medial column hypermobility
-Diabetic foot ulcerations

71

equinus history

-First TAL: Paris on Achilles in the “Iliad”
-First medically documented procedure: Stromeyer on Dr. Charles Little. Dr. Little was a prominent physician suffering from
cerebral palsy (CP) who then became an advocate for surgical correction of equinus.

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equinus anatomy

-Review the origins/insertions/course/action/NV supply of the gastroc and soleus.
-Review the concept of the “twisting” fibers within the Achilles tendo

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definitions for equinus

muscular
osseous
pseudoequinus
combo

-Muscular Equinus
-Spastic vs. Non-Spastic
-Gastroc Equinus
-Gastroc-Soleal Equinus
-Osseous Equinus
-Tibio-talar exostosis
-Pseudoequinus
-Combination equinus

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biomechinic compensation for equinus

-Lumbar lordosis
-STJ pronation
-Hip flexion
-MTJ pronation
-Genu recurvatum
-Forefoot abduction
-No compensation (toe walking)
-Medial column hypermobility

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testing for equinus

-Silfverskiold test
-Stress dorsiflexion plain film radiographs
-WB wall tes

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conservative treatment for equinus

stretching
PT
heel lifts
casting
NM blockage injections (Botox)

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Surgical correction for gastroc equinus

-Neurectomy of motor branches of tibial nerve
-Proximal recession (Silfverskiold procedure)
-Release of muscular heads of gastroc +/- reattachment to tibia +/- neurectomy
-Distal aponeurotic recession
-Vulpius&Stoffel (1913): Inverted “V” shaped incision without suture reapproximation
-Strayer (1950): Transverse incision with proximal dissection and suturing (absorbable)
-Baker (1956): Tongue and groove with suturing (two incisions distal)
-Fulp&McGlamry: Inverted tongue and groove with suturing (two incisions proximal)
-Endoscopic recession

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surgical treatment for gastrosoleal equinus

-Sagittal plane “Z” lengthening: equal medial and lateral portions
-Frontal plane “Z” lengthening: equal anterior and posterior portions
-Hoke Triple Hemisection (1931): 2 medial cuts/1 lateral cut
-White slide technique

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Percutaneous equinus correction

-Similar to the Hoke procedure
-1cm Æ 3cm Æ 3 cm