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Cavovarus Foot in Pediatrics & Adults

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Topic updated on 06/20/16 8:50pm
Introduction
  • A foot deformity characterized by an elevated longitudinal arch
    • caused by fixed plantar flexion of the forefoot
    • may be seen in both pediatric and adult populations
  • Epidemiology
    • may be seen in both pediatric and adult populations
    • 2/3 of patients have neurologic condition mentioned below 
    • when bilateral, often hereditary
  • Pathophysiology
    • deformity caused by
      • contracted plantar fascia
      • weak tibialis anterior being over-powered by peroneous longus
    • table of foot deformity muscle imbalances 
  • Genetics
    • no specific genetic predilection but associated with conditions mentioned below
  • Associated conditions
    • orthopaedic
      • Charcot-Marie-Tooth 
      • Freidreich's ataxia 
      • Cerebral palsy
      • Polio
      • spinal cord lesions
  • Prognosis
    • depends on severity and etiology
    • full neurologic workup is mandatory
Presentation
  • Symptoms
    • painful calluses under head of 1st metatarsal, 5th metatarsal, and medial heel due to plantar flexed first ray
  • Physical exam
    • Coleman block test 
      • helps guide treatment
      • evaluates flexibility of hindfoot
      • by putting block under lateral foot you eliminate the contribution by the first ray
        • a first ray that is overly flexed can contribute to a varus deformity
      • flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of foot 
      • a rigid hindfoot will not correct into neutral
    • always remove shirt and look for spinal dysraphism 
Treatment
  • Nonoperative
    • full-length semi-rigid insole orthotic with a depression for the first ray and a lateral wedge 
      • indications
        • mild cavus foot deformities in adults
        • nonoperative management usually not effective in treatment of more severe pediatric cavus deformities
  • Operative
    • plantar fascia release, posterior tibial tendon transfer, tendoachilles lengthening (TAL), and +/- 1st metatarsal dorsiflexion osteotomy
      • indications
        • flexible hindfoot cavus deformities (normal Coleman block test) 
        • surgical intervention should be delayed until progression of the deformity begins to cause symptoms and/or weakness of the muscular units resulting in contractures of the antagonistic muscle units.
      • technique
        • +/- transfer posterior tibialis to dorsum of foot to improve foot drop (augment weak tibialis anterior)
        • +/- transfer of peroneus longus to brevis
        • +/- lateral ankle ligament reconstruction (e.g. Broström ligament reconstruction) 
        • dorsiflexion 1st metatarsal osteotomy sometimes performed 
          • 1st metatarsal osteotomy and transfer of EHL to neck of 1st MT when hallux clawing combined with cavus foot  
    • calcaneal valgus producing osteotomy
      • indications
        • rigid hindfoot cavus deformities (abnormal Coleman block test)
      • technique
        • combine with soft tissue procedure discussed above, and dorsiflexion 1st metatarsal osteotomy
    • triple arthrodesis
      • indications
        • severe rigid deformities
        • may be helpful in select cases but is falling out of favor

 

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Qbank (4 Questions)

TAG
(OBQ09.32) What is the preferred orthotic device for a symptomatic adult foot deformity that is shown in Figure A, has no arthritis on radiographs, and responds to Coleman block testing as shown in Figure B? Topic Review Topic
FIGURES: A   B        

1. Short walker boot
2. Accommodative custom orthotics
3. Lace up soft ankle brace
4. Medial hindfoot posting with arch support
5. Lateral hindfoot posting with recessed first ray

PREFERRED RESPONSE ▶
TAG
(OBQ04.90) An 18-year-old male presents with recurrent ankle sprains of the left ankle and painful callus underneath the 5th metatarsal. Standing examination is shown in Figures A and B. During Coleman block testing the hindfoot is positioned in 3 degrees of valgus. The peroneus brevis and anterior tibialis have 4/5 strength compared to 5/5 strength in peroneal longus, gastrocsoleus complex, and posterior tibialis. Using a semi-ridged orthotic with a recess for the head of the first ray and lateral hindfoot posting has failed to improve symptoms. Which of the following is most appropriate as one part of the surgical plan?? Topic Review Topic
FIGURES: A   B        

1. Peroneus brevis to longus transfer with medial calcaneal slide osteotomy
2. Triple arthrodesis
3. First ray dorsiflexion osteotomy with plantar fascia release
4. Subtalar arthrodesis
5. First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release

PREFERRED RESPONSE ▶
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