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Equinovalgus Foot

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Topic updated on 04/13/16 11:16am
Introduction
  • Epidemiology
    • incidence
      • common foot deformity seen with 
        • cerebral palsy (spastic diplegic and quadriplegic)
        • fibular hemimelia
    • body location
      • typically bilateral
  • Pathophysiology
    • deformities
      • midfoot abduction 
      • hindfoot valgus
      • equinus contracture
    • muscle imbalances 
      • spasticity of
        • peroneals
        • gastoc-soleus complex
      • weakness of
        • ligamentous laxity
        • posterior tibialis
        • anterior tibialis
    • pathomechanics
      • creates lever arm dysfunction during gait and ankle rocker function
      • patient is bearing weight on the medial border of the foot and talar head
      • external rotation of the foot creates instability during push off
Presentation
  • Symptoms
    • painful callus over talar head secondary to weightbearing
    • shoe wear problems
  • Physical exam
    • inspection
      • typically seen bilaterally
      • valgus heel deformity seen when viewing feet from posterior
      • prominent talar head appreciated in the arch
      • compensatory midfoot supination is typically seen
        • midfoot break occurs in attempt to keep foot plantigrade 
      • hallux valgus typically develops over time
    • motion
      • the hindfoot valgus deformity must be manually corrected first before testing for achilles contracture
        • a valgus heel can mask an equinus contracture by allowing a shortened path for the achilles
Imaging
  • Radiographs 
    • recommended views
      • weight-bearing AP radiographs of the ankles must be obtained to rule out ankle valgus as cause of deformity
    • findings 
      • collapse of the medial longitudinal arch as seen by a decrease in the calcaneal pitch.
      • talus tilted inferiorly
Treatment
  • Nonoperative
    • bracing and physical therapy
      • indications
        • flexible deformities
      • technique
        • ankle foot orthosis or supramalleolar orthosis
    • botox injections
      • indications
        • flexible deformities with mild spasticity
        • delays need for surgery
  • Operative
    • calcaneal osteotomy with soft tissue procedure
      • indications
        • rigid deformities
    • subtalar arthroereisis
      • indications
        • marked rigid deformity or ligamentous laxity
      • technique 
        • stabilizes subtalar joint in correct alignment without fusion
        • implant or spacer is placed laterally in the subtalar joint to prop open
Techniques
  • Calcaneal osteotomy with soft tissue procedure
    • soft tissue procedures
      • TAL
      • peroneus brevis lengthening
    • bony procedures
      • calcaneal osteotomy  
        • medial slide osteotomy or calcaneal lengthening osteotomy
      • lateral column lengthening procedure
        • performed through calcaneus or cuboid
      • Grice procedure 
        • extra-articular subtalar arthrodesis via a lateral approach
        • place ICBG in lateral subtalar joint to block valgus
        • does not interfere with tarsal bone growth
      • subtalar arthroereisis 
        • stabilizes subtalar joint in correct alignment without fusion
        • implant or spacer is placed laterally in the subtalar joint to prop open
Complications
  • Overcorrection (resultant varus deformity)
    • most common complication
  • Sural nerve injury
    • at risk during calcaneal osteotomy procedures
  • Overlengthening of lateral column
    • results in a painful lateral forefoot secondary to overload

 

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