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Adult Cavovarus Foot
Abstract
Cavovarus foot deformity, which often results from an imbalance of muscle forces, is commonly caused by hereditary motor sensory neuropathies. Other causes are cerebral palsy, cerebral injury (stroke), anterior horn cell disease (spinal root injury), talar neck injury, and residual clubfoot. In cavovarus foot deformity, the relatively strong peroneus longus and tibialis posterior muscles cause a hindfoot varus and forefoot valgus (pronated) position. Hindfoot varus causes overload of the lateral border of the foot, resulting in ankle instability, peroneal tendinitis, and stress fracture. Degenerative arthritic changes can develop in overloaded joints. Gait examination allows appropriate planning of tendon transfers to correct stance and swing-phase deficits. Inspection of the forefoot and hindfoot positions determines the need for soft-tissue release and osteotomy. The Coleman block test is invaluable for assessing the cause of hindfoot varus. Prolonged use of orthoses or supportive footwear can result in muscle imbalance, causing increasing deformity and irreversible damage to tendons and joints. Rebalancing tendons is an early priority to prevent unsalvageable deterioration of the foot. Muscle imbalance can be corrected by tendon transfer, corrective osteotomy, and fusion. Fixed bony deformity can be addressed by fusion and osteotomy.
... Первая плюсневая кость не несёт нагрузки, поскольку свешивается с блока, соответственно её влияние на положение остальных частей стопы исключается. Если варусное положение пяточной кости меняется на физиологический вальгус при выполнении данного теста, это значит, что деформация эластичная и обусловлена передним отделом стопы [31] (рис. 3). ...
... При наличии у пациента идиопатической полой стопы угол Meary может принимать отрицательные значения и указывать на плантарное смещение первого луча стопы. В редких случаях на рентгенограммах могут быть выявлены признаки стрессового перелома пятой плюсневой кости или остеофиты в области латерального отдела голеностопного сустава [31][32][33][34]. ...
Relevance . The subtle cavovarus foot is a mild malalignment caused by either primary hindfoot varus or a plantarflexed first ray, resulting in a typical constellation of symptoms because of altered foot mechanics. The etiology of idiopathic cavus foot is usually unknown and is not associated with neurological pathology, it is believed that about 25% of the population have a mild grade of cavus foot deformity.
Aim : review the Russian and international scientific literature on the treatment of idiopathic cavus foot and to integrate the collected material.
Materials and methods : analysis of modern scientific literature on the topic of treatment of idiopathic cavus foot, the research base was the Pubmed website.
Results . It was found that there is a lack of sufficient understanding of the etiology, diagnostic methods and treatment guidelines for idiopathic cavus foot.
Conclusions : Idiopathic cavus foot is often the cause of such pathologies as lateral ankle instability, stress fracture of the fifth metatarsal, peroneal tendinopathy. Understanding the biomechanics of this deformity, which determines the course of other foot diseases, can improve the results of conservative and surgical treatment of patients.
... Adult hindfoot-driven cavovarus foot deformity is a painful condition with a variety of etiologies including neurologic, traumatic, congenital, and idiopathic causes. 11,12,24 Patients present with a spectrum of symptoms such as lateral column pain, ankle instability, peroneal tendinopathy, and eventually hindfoot arthritis. These manifestations of the underlying deformity often become debilitating and frequently necessitate operative intervention despite appropriate nonoperative treatment. ...
... However, this is largely unavoidable as a successful cavovarus correction usually necessitates the use of multiple bony and soft tissue procedures. 12,17,21,24 Hence, outcome scores are descriptive of overall changes in patient function and cannot be used to describe a certain combination of procedures as significantly superior or inferior to others. In addition, we were unable to include data on 6 of 18 patients who underwent this procedure within our date range because of inability to contact them or patient refusal to participate. ...
Background
The Malerba calcaneal Z-osteotomy is an operative procedure to treat the hindfoot varus component of adult cavovarus deformity. Basic science studies support the corrective ability of this osteotomy. However, there have been no published midterm clinical and radiographic results. The purpose of this article is to describe the radiographic and clinical improvement in a series of patients treated with this osteotomy.
Methods
A retrospective chart review identified 14 feet in 12 patients from January 2013 to August 2018 who met minimal follow-up criteria. Preoperative visual analog scale (VAS) scores, Foot Function Index (FFI) scores, and American Orthopaedic Foot & Ankle Society (AOFAS) scores were compared with postoperative scores. Preoperative Meary angle, calcaneal pitch, and hindfoot alignment were also compared with postoperative measurements. Complications and radiographic union were recorded.
Results
At a mean of 80 months, VAS, FFI, and AOFAS scores improved from 7.86 to 1.64, 57.78% to 18.11%, and 39.57 to 80.71, respectively (all P < .001). At a mean of 15 months, Meary angle, calcaneal pitch, and hindfoot alignment improved from 11.14 to 6.64 degrees ( P < .001), 30.93 to 27.43 degrees ( P = .005), and 19.83 degrees varus to 8.50 degrees varus ( P < .001). There was 1 nonunion and 1 postoperative sural nerve neuralgia, but both patients ultimately did well clinically. There were no instances of postoperative tarsal tunnel syndrome. All patients stated that they would have the procedure done again.
Conclusion
The calcaneal Z-osteotomy is an effective method to treat adult hindfoot cavovarus deformity. All patients had good clinical outcomes with minimal complications.
Level of Evidence
Level IV, case series.
... Therefore, we focused on correcting the bony alignment without repairing the ligaments. Dwyer osteotomy has been the method most widely for the correction of hindfoot varus [16], and a lateralizing calcaneal osteotomy is also frequently used nowadays [17]. The lateralizing calcaneal osteotomy has the advantages of being a simple surgical technique with adjustable movement and less reduction in tension on the Achilles tendon because there is no shortening of calcaneal length [17]. ...
... Dwyer osteotomy has been the method most widely for the correction of hindfoot varus [16], and a lateralizing calcaneal osteotomy is also frequently used nowadays [17]. The lateralizing calcaneal osteotomy has the advantages of being a simple surgical technique with adjustable movement and less reduction in tension on the Achilles tendon because there is no shortening of calcaneal length [17]. Furthermore, there is no evidence that osteotomies that are focused on the correction of valgus, such as the Dwyer osteotomy, are superior to lateralizing calcaneal osteotomy [18]. ...
A 47-year-old male presented with an eight-year history of pain in the posterior inferior part of the lateral malleolus, ankle instability, and repeated right-sided ankle sprains. He had pes cavus and hind-foot varus in his right foot, which is an unknown congenital entity or acquired with tenderness in the inferior peroneal retinaculum. There is no deformity in his left foot. The pain was elicited by the movement of the subtalar joint. Imaging revealed a high medial longitudinal arch, an enlarged peroneal tubercle, thinning of the peroneus brevis tendon, and hypertrophy of the peroneus longus tendon. We diagnosed peroneal tendinopathy with cavovarus foot in a chronic ankle sprain. The supination generated by pes cavus was thought to be aggravating the peroneal tendinopathy and causing the ankle sprains. Incision of the peroneal tendon sheath, repair of the peroneus brevis tendon, lateralizing calcaneal osteotomy, and first metatarsal dorsiflexion osteotomy were performed. At the one-year follow-up, Meary's angle was corrected to 0°, the calcaneal pitch was corrected to 20°, and the hindfoot varus was improved. He was pain-free and reported no further instability when walking. His Japanese Society of Surgery of the Foot ankle-hindfoot scale score improved from 59 preoperatively to a maximum of 100 and the Self-Administered Foot Evaluation Questionnaire gave an almost perfect score for non-sports-related items and a score of 83.3 for sports-related items. We believe that the addition of treatment of the pes cavus, which was the center of the pathology, as well as treatment of the peroneal tendon, resulted in a good outcome.
... Comparing RoM , the high group had a smaller RoM than the low arch group which could be explained by the stiffness of high arch foot types through the midfoot (Younger and Hansen, 2005;Barnes et al., 2008;Aminian and Sangeorzan, 2008) leading to less RoM. Coinciding low arch foot structures can be characteristically more flexible (Cobb et al., 2009) and the wider RoM which has been indicated using fluoroscopy techniques in a study by Wang et al., (2019) found low arch foot population have a mean RoM 13° (6) and normal foot types have a mean RoM of 7° ...
... and the normal arch foot reported a mean RoM of 7° (3), which could be explained by the stiffness of high arch foot types through the midfoot(Younger and Hansen, 2005;Barnes et al., 2008;Aminian and Sangeorzan, 2008) leading to less RoM. Conversely, flatfooted structures can be characteristically more flexible(Cobb et al., 2009) which could indicate the wider RoM.Considering frontal plane movements (eversion/inversion) of the talonavicular joint, Wang et al., (2019) found similar RoM measurements for both flat and normal groups 25° (9) and 21° (5) respectively, indicating there is little difference between the foot types, however the flatfoot group had double the standard deviation of the normal foot group. ...
The aim of this thesis is to outline an approach applying a statistical shape model and developing a 26-segment patient specific foot model to identify relationships between foot posture and function. The premise of structural and functional variance between different foot arch types exists, however an analytical pipeline using segmentations from medical images integrated into a 26-segment multi-body foot model capable of computing foot function could help address the gaps in knowledge. The proposed method aims to answer questions applied to extremes of foot posture. Knowledge around variance in position and morphology between foot postures is answered using a statistical shape modelling approach to bones of the hindfoot, midfoot and medial ray. Further knowledge relating to motion of the medial ray joints including ankle plantarflexion, subtalar eversion, talonavicular dorsiflexion, talonavicular abduction, talonavicular eversion and first metatarsophalangeal dorsiflexion is generated. The thesis was constructed to enable academics and researchers to apply similar, musculoskeletal modeling pipelines to the foot and ankle in future, and for clinicians to build upon these preliminary findings between foot postures to describe clinical populations using a larger number of patients. Using variations in extremes of foot postures, the thesis shows empirical positional shape differences between high and low arch foot types comparable to the clinical notion of medial longitudinal arch being a significant contributing factor to variance. In addition, subtle morphological differences were also present for each of the bones analysed. Using statistical parametric mapping, the thesis further shows kinematic differences at each of the medial ray joints analysed demonstrating the sensitivity of the 26-segment model to variance in foot postures. The significance of this thesis is in combining two modeling approaches to understand and start to quantitate the relationship between foot structure and function, where flat, normal and high arch foot types showed systematic differences.
... 11 Reconstruction typically requires numerous joint-sparing procedures including medial soft tissue releases, tendon transfers, lateralization of the calcaneal tuberosity, first metatarsal dorsiflexion osteotomy, plantar fascia release, and Achilles lengthening or gastrocnemius recession. 11,21 These procedures are some of the available options but not all are indicated for every case. 8,16 Weightbearing computed tomography (WBCT) has helped advance our assessment of complex foot deformity, because it is taken in a physiologic, weightbearing stance that allows us to evaluate the foot in multiple planes. ...
Background
The complex deformities in cavovarus feet of Charcot-Marie-Tooth (CMT) disease are difficult to evaluate. The aim of this study was to quantify the initial standing alignment correction achieved after joint-sparing CMT cavovarus reconstruction using pre- and postoperative weightbearing computed tomography (WBCT).
Methods
Twenty-nine CMT cavovarus reconstructions were retrospectively analyzed. Three-dimensional measurements were performed using semiautomated software (Bonelogic 2.1) to investigate changes in sagittal, axial, and coronal parameters. Pre- and postoperative data were compared, along with normative data. Correlation among the preoperative measurements and the amount of correction in sagittal, axial, and coronal parameters were analyzed.
Results
The sagittal, axial, and coronal malalignment of the hindfoot, and the sagittal and axial malalignment of the forefoot, was significantly improved after corrective surgery ( P < .05). Sagittal Meary angle (from 14.8 to 0.1 degrees), axial talonavicular angle (TNA, from 3.6 to 19.2 degrees), and coronal hindfoot alignment (from 11.0 to −11.1 degrees) showed significant changes postoperatively ( P < .001). Hindfoot, forefoot sagittal, and forefoot axial parameters reached comparable outcomes compared with normative value ( P > .05). Regarding amount of correction, Spearman correlation demonstrated that axial Meary angle and TNA were most strongly related to improvement in sagittal Meary angle and coronal hindfoot alignment.
Conclusion
Preoperative and postoperative WBCT measurements demonstrated that joint sparing CMT cavovarus reconstruction significantly improved sagittal, axial, and coronal deformities of CMT, and sagittal Meary angle was restored toward normative values. Apparent axial plane correction, the majority of which occurred at the talonavicular joint, had the strongest correlation with deformity correction in multiple planes. This suggests that soft tissue releases and correction of the talonavicular joint may be a key component of a cavovarus foot correction.
Level of Evidence
Level IV, retrospective case series.
... Nevertheless, according to published research, a subset of patients may present with a subtler form of cavus foot without an underlying disease process. [13,14] Surgical treatment for rigid pes-cavus is soft-tissue reconstruction, lateralizing calcaneal valgus-producing osteotomy, and triple arthrodesis. Our case is an adult with acquired pesplanus deformity of one foot and contralateral pes-cavus deformity. ...
Normal alignment of the arches and adequate stability is essential for the foot to function correctly. Pes planus and pes cavus are fairly common foot deformities, but it is uncommon to see both in the same patient simultaneously. This study aimed to describe the clinical presentation and prognosis of an uncommon combination of bilateral foot abnormalities named “windswept heels” resembling windswept knees. A 43-year-old female employee experienced frequent pain in her right foot and swelling and pain in her left foot, mainly when walking barefoot. She had a severe cavovarus deformity of the right foot with pressure callosities on the lateral side, clawing of the toes, and a positive Coleman’s block test. With the loss of the medial arch, severe heel valgus, and forefoot abduction, the left foot developed a planovalgus deformity. The left foot’s talus-first metatarsal angle and the right foot’s calcaneal inclination angle increased on weight-bearing radiographs. The left foot underwent staged surgical treatments, including medial sliding calcaneal osteotomy, gastrocnemius recession, and cotton osteotomy. For the right foot, lateral sliding calcaneal osteotomy, plantar fasciotomy, and peroneus longus tendon transfer. The American Orthopaedics Foot and Ankle Society Score (AOFAS) was used to measure the clinical and functional outcomes. At 1 year, her AOFAS scale was 85 compared to 59 before surgery. Since this presentation resembles the windswept knee deformity, we propose calling this disorder windswept heel deformity.
Physical examination remains a critical diagnostic tool for assessing the foot and ankle. This chapter aims to provide a systematic approach to performing a clinical examination of the foot. A thorough physical examination should first look for any abnormalities by a thorough inspection, examine structural integrity through palpation, mobility, and strength testing while also considering epidemiologic factors such as age, gender, employment, and activities. With this information in hand, physicians can individualize the history, physical examination, and treatment of patients with foot and ankle problems.
Acute brain injuries are caused by a variety of etiologies, each potentially disrupting neurological function. The neurologic impairments are on a spectrum of severity often creating functional barriers to completing activities of daily living. Initial treatment starts immediately upon diagnosis and requires a multimodal approach working to prevent systemic changes. Therapy, bracing treatment, injections, and pharmacologic treatments are the mainstay of early intervention. Worsening upper motor neurological impairment associated with involuntary muscle hyperactivity can lead to a spastic equinovarus foot deformity. Spastic equinovarus foot deformities secondary to anoxic brain injuries or traumatic brain injury pose a challenging situation for orthopaedic surgeons because of associated cognitive impairment, spastic tone, and extensive soft-tissue contractures prohibiting bracing treatment. Tendon releases and transfers in combination with functional bracing treatment are initially attempted, and selective fusions are performed for severe cases. Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot.
People with Charcot-Marie-Tooth (CMT) disease often undergo foot and ankle surgery, as foot deformities are common and cause a degree of functional limitations impairing quality of life. Surgical approaches are variable and there are no evidence-based guidelines. A multidisciplinary approach involving neurology, physical therapy and orthopaedic surgery is ideal to provide guidance on when to refer for surgical opinion and when to intervene. This review outlines the range of foot deformities associated with CMT, their clinical assessment, and their conservative and surgical and postoperative management.
Calcaneal sliding osteotomy is a frequently preferred procedure in the treatment of rigid heel varus deformity. The routine approach for calcaneal osteotomy is the lateral approach. However, wound problems, risk of iatrogenic injury to medial neurovascular structures, and difficulty in the management of the deformity are the main problems of this approach. In this article, we describe a new surgical approach, consisting of Achilles tendon lengthening in addition to calcaneal osteotomy, facilitating the intervention of other flexor tendon components and posterior structures in the correction of rigid heel varus deformity.
Level of Evidence: Diagnostic Level 5.
Charcot-Marie-Tooth (CMT) disease is the most commonly inherited neuropathy. CMT disease is a motor-sensory neuropathy with multiple genotypes. By comparison, the phenotypic expression is more uniform, with two main presentations. Most patients who need surgical care have progressive cavovarus foot deformity, with muscle imbalance causing a nonplantigrade foot, soft-tissue contractures, and abnormal bone morphology. Surgical treatment can be life-changing for these patients, allowing them to walk potentially brace free with more endurance and less pain. Early realignment procedures may reduce progression of joint arthritis. A minority of patients have diffuse paralysis below the knee. These patients are best treated with ground-reaction ankle-foot orthoses. This review article is based on the senior author's extensive experience with CMT, along with the limited evidenced-based literature.
Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.
Charcot-Marie-Tooth disease (CMT) is the most common inherited peripheral polyneuropathy, resulting in length-dependent motor and sensory deficiencies. Asymmetric nerve involvement in the lower extremities creates a muscle imbalance, which manifests as a characteristic cavovarus deformity of the foot and ankle. This deformity is widely considered to be the most debilitating symptom of the disease, causing the patient to feel unstable and limiting mobility. Foot and ankle imaging in patients with CMT is critical for evaluation and treatment, as there is a wide range of phenotypic variation. Both radiography and weight-bearing CT should be used for assessment of this complex rotational deformity. Multimodality imaging including MRI and US is also important to help identify changes in the peripheral nerves, diagnose complications of abnormal alignment, and evaluate patients in the perioperative setting. The cavovarus foot is susceptible to distinctive pathologic conditions including soft-tissue calluses and ulceration, fractures of the fifth metatarsal, peroneal tendinopathy, and accelerated arthrosis of the tibiotalar joint. An externally applied brace can assist with balance and distribution of weight but may be appropriate for only a subset of patients. Many patients will require surgical correction, which may include soft-tissue releases, tendon transfers, osteotomies, and arthrodesis when necessary, with the goal of creating a more stable plantigrade foot. The authors focus on the cavovarus deformity of CMT. However, much of the information discussed may also be applied to a similar deformity that may result from idiopathic causes or other neuromuscular conditions. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
Background:
Although surgical treatment for equinus foot has been widely described in the literature, less attention has been paid to orthopedic treatment with prostheses, which constitutes an interesting alternative approach. It has been described in the literature for treating lower-limb inequality, but not for equinus foot. The aim of this article is to report that the use of prosthetics can be a valid means of managing bilateral equinus foot.
Case description and methods:
In the present case report, we describe the management of an irreducible bilateral equinus in a 45-year-old patient with poliomyelitis sequelae, starting with orthoses and orthopedic shoes, followed by prostheses. We measured the evolution of the patient's spatiotemporal gait parameters, his autonomy, and his satisfaction with a QUEST score.
Findings and outcomes:
Despite the deterioration of the patient's physical abilities due to the onset of a postpoliomyelitis syndrome, his gait parameters and his autonomy were maintained while using the prostheses. His tolerance of the prostheses improved even more greatly, as shown by his QUEST score, which increased from 2.95 to 4.67 of 5.
Conclusion:
The use of prostheses was at least as effective and even better tolerated than orthoses and orthopedic shoes by this patient. Despite the occurrence of a postpoliomyelitis syndrome, the prostheses helped to maintain his walking performances, while improving his satisfaction.
The morphology and function of the human foot vary significantly across individuals, generally a result of the underlying musculoskeletal structures. While these are continuous, multi-dimensional spectrums, for clinical and anatomical ease of categorization, feet are generally grouped into three types: cavus (high arched), neutral, or planus (flatfoot). This chapter will provide an overview of these foot types, reviewing their structural and functional differences, as well as the tools that are used to help define each type. An overview of the biomechanics of different foot types will be presented. Associations between foot type and clinical problems along with potential treatments will be covered. Future areas of research will also be discussed.
Purpose:
We designed this study to determine how changes in coronal ankle alignment affect sagittal alignment of the foot. Specifically, we focused on the changes in medial longitudinal arch height, which could be reflected by the medial cuneiform height (MCH), Meary's angle, and calcaneal pitch angle (CPA).
Methods:
We retrospectively analyzed the radiographic findings of 37 patients who underwent open ankle arthrodesis without inframalleolar correction (such as first metatarsal dorsal closing wedge osteotomy, calcaneal osteotomies, tendon transfers, or tarsal joint arthrodesis) of severe varus ankle arthritis. The inclusion criterion was a pre-operative tibial axis to talar dome angle of 80 degrees or less. The enrolled patients were divided into two groups according to the post-operative decrease in MCH (≥ 2 mm or < 2 mm).
Results:
A post-operative MCH decrease of ≥ 2 mm was observed in 43.2% (16 patients). Although the degree of coronal ankle varus correction was similar, the decrease in the Meary's angle was significantly greater in the group with a post-operative MCH decrease of ≥ 2 mm than in those with < 2 mm (- 4.1 degrees vs. - 1.3 degrees, P = 0.01). The changes in CPA were not significantly different (P = 0.172).
Conclusion:
Correction of ankle varus deformity via ankle arthrodesis could lead to a decrease in the medial longitudinal arch height in less than half of the enrolled patients. In these patients, a cavus component of the foot might be an important factor in determining a successful sagittal foot alignment change, while the CPA was maintained post-operatively.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
This book has been written specifically for candidates sitting the oral part of the FRCS (Tr & Orth) examination. It presents a selection of questions arising from common clinical scenarios along with detailed model answers. The emphasis is on current concepts, evidence-based medicine and major exam topics. Edited by the team behind the successful Candidate's Guide to the FRCS (Tr & Orth) Examination, the book is structured according to the four major sections of the examination; adult elective orthopaedics, trauma, children's/hands and upper limb and applied basic science. An introductory section gives general exam guidance and end section covers common diagrams that you may be asked to draw out. Each chapter is written by a recent (successful) examination candidate and the style of each reflects the author's experience and their opinions on the best tactics for first-time success. If you are facing the FRCS (Tr & Orth) you need this book.
Zahlreiche Störungen und Erkrankungen können die Funktion unserer Füße beeinträchtigen. Die Einteilung in der Literatur ist uneinheitlich. Sie kann z. B. nach Art der Erkrankungen erfolgen, nach der Lokalisation oder auch nach Fachgebiet. Da der Fuß in der Primärversorgung ein komplexes Organ ist, nutzt dieser Artikel die funktionell im Vordergrund stehenden Ursachen (biomechanisch, neurophysiologisch, zirkulatorisch, metabolisch-entzündlich, psychosozial) und behandelt in der Praxis häufig vorkommende Krankheitsbilder. Die Einteilung erhebt dabei keinen Anspruch auf Vollständigkeit, fließende Übergänge sind möglich und wahrscheinlich. Für eine detailliertere Betrachtung wird auf Spezialliteratur verwiesen. Hinweise zur Untersuchung und zur evtl. Anordnung bildgebender Verfahren runden den Artikel ab.
Patients who present with lateral ankle ligament instability always need to be evaluated for cavovarus foot deformity. Cavovarus reconstruction may need to be performed in order to ensure the ankle instability procedure is successful. Which procedures are required will depend on the specific deformity present, and may need to be determined intraoperatively depending on the initial deformity correction achieved through the first procedures performed. A general though not strict algorithm for sequence of procedures involves soft tissue releases first, followed by hindfoot correction, then forefoot correction, and securing ligament reconstruction or tendon transfers as the final step. Tendon transfers can be an effective tool to aid in the deformity correction and several are described. For hindfoot and forefoot deformity correction, traditional calcaneus and metatarsal osteotomies work well, but fusion should be considered for joints with degenerative change or in cases where the deformity is severe or can't be corrected through osteotomy alone.
Forefoot-driven hindfoot valgus remains an enigmatic entity. Its causes are multiple and their interactions make it quite difficult to assess the pathology itself. In general, any affection at the forefoot, e.g. a severe hypermobility of the first ray, which would result in an incompetence of the medial column may induce biomechanical actions that lead to compensatory valgisation or variation of the hindfoot. When embarking on surgical treatment in patients suffering from forefoot-driven hindfoot valgus, it is crucial to start with a proper clinical assessment and then to continue with at least surgery needed to get the maximum result. Therefore, not only a broad knowledge of biomechanical causes is a pre-requisite but also a quite large knowledge regarding the surgical armamentarium.
The neurologic cavus foot presents with a complex array of deformities caused by muscle imbalance leading to structural changes in the foot. Depending on the muscles which are weak or strong, the shape of the foot will be varied and include a cavus, cavovarus, cavoadductovarus, and cavoequinovarus. These deformities are always associated with muscle imbalance and soft tissue contracture. The treatment of the cavus foot must take into consideration the muscle imbalance since tendon transfers are always required. In addition, the bone is corrected at each apex noting that in many feet, there is more than one apex to the overall deformity. Regardless of the flexibility or rigidity of the hindfoot, midfoot, and forefoot, the structural changes of the foot and the principles of correction are the same, which is to balance the muscles forces, release contracted soft tissues, and correct the deformities with a combination of osteotomy or arthrodesis.
Joint preserving strategies have evolved to a successful treatment option in early and midstage medial ankle OA caused by varus deformity. Though talar tilt can often not be fully corrected, it provides substantial postoperative pain relief, functional improvement, and slowing of the degenerative process. Osseous balancing with osteotomies is the main step for restoration of ankle mechanics and normalization of joint load. Overall, the key for success is to understand the underlying causes that have contributed to the varus OA in each case, and to use all treatment modalities necessary to restore appropriate alignment of the hindfoot complex.
Foot and ankle injuries and pathology are commonly encountered in primary care, emergency medicine, and orthopaedic surgery. This chapter contains a concise compilation of common ailments and their management in addition to Board Review concepts.
Muscle injuries are the most common injuries in professional athletes forced to high-intensity sprinting efforts. Due to a high recurrence rate and possible consequences for elite athletes, it is one of the most challenging tasks for a sports medicine team to prepare a professional athlete to return to performance. This results in an ongoing search for new treatments to improve and accelerate muscle healing. In this chapter, we describe the principle of muscle healing and discuss the contemporary biological therapies with the available scientific evidence on their efficacy and safety.
Acute and chronic hamstring injuries are common in athletics. Acute injuries account for 17.1% of all injuries. Chronic injuries (proximal hamstring tendinopathy) are seen less frequently, however, but true incidences are unknown. Acute injuries occur at the (from most frequent to less frequent) musculotendinous junction (MTJ), the intramuscular tendon and the free tendons (partial- or full-thickness injury). Proximal hamstring tendinopathy occurs in the proximal hamstring free tendons. Diagnosis of these injuries is mostly clinical but can be supported by imaging such as magnetic resonance imaging or ultrasound. Treatment for partial-thickness MTJ acute hamstring injuries is informed by 14 RCTs. For proximal hamstring tendinopathy and partial- or full-thickness free tendon injuries, there is little evidence to guide treatment. Cornerstone of treatment is physiotherapy-based interventions with progressive (eccentric) loading and activity modification, combined with expectation management. Surgery is usually reserved for full-thickness free tendon injuries. Other treatments such as platelet-rich plasma injections, corticosteroid injections and non-steroidal anti-inflammatory medication have little supportive evidence and should be avoided.
We report the results of transfer of the long toe flexors and lengthening of the calcaneal tendon in 33 patients with equinovarus deformity requiring orthoses after a stroke. Review of 29 patients more than two years after surgery showed that 21 were able to walk without an orthosis. Equinovarus deformity had recurred in six patients and hammer toe in 11, but walking ability without bracing was still better in seven of these. Results are improved by the release of the short toe flexors.
We treated 22 children (28 limbs) with diplegic cerebral palsy who were able to walk by the Baumann procedure for correction of fixed contracture of the gastrosoleus as part of multilevel single-stage surgery to improve gait. The function of the ankle was assessed by clinical examination and gait analysis before and at two years (2.1 to 4.0) after operation. At follow-up the ankle showed an increase in dorsiflexion at initial contact, in single stance and in the swing phase. There was an increase in dorsiflexion at initial push-off without a decrease in the range of movement of the ankle, and a significant improvement in the maximum flexor moment in the ankle in the second half of single stance. There was also a change from abnormal generation of energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Lengthening of the gastrocnemius fascia by the Baumann procedure improved the function of the ankle significantly, and did not result in weakening of the triceps surae. We discuss the anatomical and mechanical merits of the procedure.
In cases of established calcaneus after anterior poliomyelitis the deformity can be greatly reduced by combining an extensive plantar release with an oblique transverse osteotomy of the calcaneus that permits displacement upwards and backwards of the posterior weight-bearing part of the bone. The procedure greatly improves the mechanical advantage of subsequent tendon transplantations to the heel. Between 1956 and 1969 fifteen such osteotomies were carried out and the long-term results have been reviewed.
Notable historical aspects relating to the etiology and treatment of pes cavus have been critically examined. The characteristic features of the deformity are described and an explanation offered for the mechanism of their production. Although its etiology remains uncertain, a study of the literature and a great deal of clinical material has established certain well supported conclusions regarding the etiology and pathology of the condition. Certain aspects of cerebral palsy serve to strengthen impressions of earlier authors that the primary center of origin of pes cavus lies somewhere in the central nervous system. Localized foci of partial damage lying adjacent to tracts of nerve cells more seriously affected by a neurological disease could emit irritating stimuli capable of producing degrees of over-action of the invertor muscles varying from obvious spasm to clinically undetectable increase in muscle tone. Biral or other factors which stop short at creating nothing more than such a focus of irration could explain the insidious onset of the deformity in the idiopathic group. Over-action of invertor muscles for one reason or another, including ischemia, is almost certainly responsible for initiating the deformity, though primary contracture of the plantar fascia could possibly do so. With the appearance of supination of the heel, the calcanean tendon becomes an active invertor adding its force to that of the plantar fascia to produce structural varus of the calcaneum. Contracture of the plantar fascia and supination of the heel are regarded as features of major importance. Correction of the latter can be achieved more effectively by suitable osteotomy than by subtaloid fusion, which is regarded with great disfavor. Conservative treatment consists of exercises and shoe appliances. Surgical correction is based on calcanean osteotomy and plantar fasciotomy supplemented where necessary by suitable tendon transplantations, correction of clawing of the toes, and tarsal or metatarsal wedge resections. Preservation of the midtarsal subtaloid joint complex is essential. With the heel correctly aligned the degree of improvement to be expected in the forefoot deformity is such that any structural operation on it should be deferred until a fair period of walking has been tried.
The cross-sectional areas of the peroneal and anterior muscle compartments at the same level in the upper leg were measured using magnetic resonance imaging in 41 cases of forefoot pes cavus. The pes cavus group included idiopathic cases and pes cavus associated with Charcot-Marie-Tooth disease, Friedreich's ataxia, cerebral palsy, status postpoliomyelitis, nerve trauma, and spinal cord tethering. Thirty-nine of these cases were symptomatic. The results were compared with studies of 11 normal controls. It was found that in the majority of cases of forefoot cavus, the peroneal compartment was enlarged relative to the anterior compartment when compared with the normal controls. Biopsies of the tibialis anterior and peroneus longus muscles in 18 patients with forefoot pes cavus showed that any relative expansion of the peroneus longus was not due to pseudohypertrophy. Overaction of the peroneus longus in comparison to its antagonist the tibialis anterior is proposed as an important factor in the pathogenesis of the majority of symptomatic cases of forefoot pes cavus.
Of 104 patients with corrective surgery for foot deformities subsequent to a cerebrovascular accident from 1980 until 1983, 53 patients returned for clinical examination and 22 patients were evaluated by questionnaire and telephone interview. The average follow-up period was 6.4 years. The operative techniques were tenotomy of the toe flexors for hammer-toe deformity, lengthening of the aponeurosis of the gastrocnemius for equinus deformity, and transfer of the anterior tibial tendon or the posterior tibial tendon or the long toe flexors for varus deformity. In 74% of patients, correction was maintained; 79% did not use an orthosis; 51% could bathe unassisted; and 76% were satisfied with the results. The ability to walk was related to the degree of paralysis, the age of the patient at surgery, and the walking speed at discharge.
In this study we determined the effects of misalignment of the talar neck on the contact characteristics of the subtalar joint. Each of seven fresh cadaver lower extremities was mounted in a loading jig and a vertical load was applied, 90% of which was directed through the tibia and 10% through the fibula. The foot was allowed to displace freely in the horizontal plane so that relative rotations, known to occur in the subtalar joint, would not be prevented. Pressure-sensitive film, inserted into the posterior and anterior/middle articulations, was used to quantify changes in contact characteristics. After testing in the normal condition, the talar neck was osteotomized and stabilized with internal and external skeletal fixation. Contact characteristics were then determined in each of the following stages: anatomic realignment, or with 2-mm displacement of the talar neck either dorsally, medially, laterally, or complex (dorsal and varus) with respect to the body of the talus. Measurements showed no significant changes in overall contact area or high pressure area in the posterior facet, although four of the seven specimens demonstrated increased localization of the contact area into two discrete regions. The combined anterior/middle facet, on the other hand, was significantly unloaded by all but medial displacement of the talar neck. An extraarticular load path and/or increased loading directly on the talonavicular joint was presumed to account for the loss of load transfer in the talocalcaneal joint.
Thirty-nine patients with pes cavus-type deformities were treated with osteotomy of the proximal metatarsals for the cavus component of the deformity. Fifty operations were followed for an average of 15 years, many for up to 26 years. Of the 39 patients, 11 had bilateral involvement. Each patient was clinically evaluated for postoperative mobility and categorized according to the Massachusetts General Hospital rating scale. Excellent or good results were obtained in 84% of the proximal metatarsal osteotomies.
The posterior tibial tendon was rerouted by the technique described by Baker and Hill in 35 feet of children with a dynamic varus deformity due to spastic cerebral palsy. The average follow-up period was 11.4 years. In ten of the feet, rerouting of the posterior tibial tendon was the only procedure performed. Eight of the ten feet obtained a satisfactory correction. There were no overcorrection problems in these ten feet. In the remaining 25 feet, the Baker-Hill procedure was done concurrently with other procedures, such as lengthening of the triceps surae (22 feet), calcaneal osteotomy (two feet), or plantar fascia release (two feet). The dynamic equinovarus deformity was corrected in all 25, but three subsequently developed a cavus deformity. This was probably caused by excessive weakening of the triceps surae rather than transposition of the posterior tibial tendon. Based on this study, anterior rerouting of the posterior tibial tendon seems to be a simple, safe, and generally effective procedure for correction of dynamic varus of the spastic hindfoot in children with cerebral palsy.
The sequential approach to evaluating the cavus foot is integrated with a description and assessment of the various treatment options. Decision making in the treatment of these cases is complicated by the progressive neurologic condition that underlies many of these deformities. An effort is made to recommend the most appropriate surgical intervention based on the nature of the deformity and its rigidity. Although these principles apply to all cavus feet, the deformity in Charcot-Marie-Tooth disease is the most difficult to treat and the most prone to recurrence because of the progressive nature of the muscular imbalance causing it.
In the treatment of spastic equinovarus foot deformities in adults with neurologic impairment, various surgical procedures are used including the split anterior tibialis tendon transfer and tendo achillis lengthening. Release of the flexor hallucis longus and flexor digitorum longus tendons in the midfoot is routinely included with these procedures to correct or prevent toe curling. In follow-up, residual toe curling has been observed in some patients despite release of the long toe flexor tendons. This study was undertaken to investigate this problem and its consequences, treatment, and treatment success.
Forty-one feet in 34 consecutive patients were examined for residual toe curling an average of 2.5 years postoperatively. Thirty-two feet (78%) were noted to have significant flexion deformities of the lesser toes. The residual toe curling caused pain in 72% of the feet and was associated with callosities on the dorsum of the toes in 59%. The incidence of residual toe curling secondary to spasticity of the flexor digitorum brevis and intrinsic muscles of the foot was similar in the patients who had sustained traumatic brain injury and in those who had suffered a cerebrovascular accident.
Twelve of these feet (37%) underwent surgical release of the flexor digitorum brevis and intrinsic tendons to correct the toe curling. There were no complications of surgery and no recurrences of deformity following the surgery. A second surgical procedure to release the flexor digitorum brevis and intrinsic tendons to correct the toe curling was more commonly performed in the younger more active brain-injured patients than in the older stroke patients (44% versus 20%, respectively). The second surgical procedure was also more common in the ambulatory patients compared with the nonambulators (44% versus 14%).
Based on the results of this study, we recommend that release of the flexor hallucis longus, flexor digitorum longus, flexor digitorum brevis, and intrinsic tendons be performed at the base of each toe as part of the procedure to correct spastic equinovarus deformities in the adult neurologically impaired patient.
The development of lateral tibial torsion in the paralysed lower limb is well documented, but its pathogenesis is poorly understood. This paper attempts to provide an explanation for its development when it is associated with a varus or equinovarus deformity of the hindfoot. Correction of the lateral tibial torsion by supramalleolar derotation tibial osteotomy and reorientation of the ankle mortise appear to unlock the talus from the laterally rotated position, correcting a mobile hindfoot varus deformity and altering soft-tissue tensions about the ankle so that the correction achieved is maintained. In the presence of a fixed hindfoot deformity, supramalleolar derotation tibial osteotomy is useful as a first-stage procedure before corrective osteotomies of the foot. The operation described is technically simple and carries a low morbidity. Twenty supramalleolar derotation tibial osteotomies in 18 patients have been performed with satisfactory results and few complications.
One hundred and ninety-one feet with residual cavovarus deformities from club foot or poliomyelitis were treated by a plantar release followed by correction with serial cast application. Roentgenographically, there was significant improvement in the adduction of the fore part of the foot and the cavus deformity, but the varus angulation of the hind part of the foot did not improve. In children more than six years old with deformities resulting from club foot, the plantar release was particularly effective in alleviating residual cavus deformity. In cavus deformity resulting from poliomyelitis, preliminary data indicate a positive effect in feet with pure cavus deformity and cavus deformity associated with equinus angulation of the hind part of the foot, while the results in feet with a cavus deformity and associated calcaneal deformity of the hind part of the foot typically were unsatisfactory.
The indications, contraindications, technique, and end results of thirty-four tarsometatarsal truncated-wedge arthrodeses performed for cavus and equinovarus deformity of the fore part of the foot were reviewed. The etiology of deformity included idiopathic pes cavus, equinus deformity of the fore part of the foot, residual club foot, poliomyelitis, and compartment syndromes. With th truncated-wedge arthrodesis the subtalar joint is not violated and selective correction of any combination of depression of the metatarsal head is readily accomplished. By strict adherence to the indications and exacting surgical technique, complications are rare and the end results are uniformly excellent.
Fibrotic contracture of skeletal muscle can follow weeks or months after the severe ischemic insult of compartment syndrome. Commonly known as Volkmann's ischemic contracture, the affected limb often becomes dysfunctional and painful, and may lose sensibility. The pathogenesis of the muscle contracture includes prolonged ischemia, myonecrosis, fibroblastic proliferation, contraction of the cicatrix, and myotendinous adhesion formation. Resultant shortening or overpull of involved muscles leads to stiffness and deformity. Simultaneously, nerve injury from initial ischemia or subsequent soft tissue fibrotic compression leads to muscle paresis or paralysis of the involved compartment and of those muscles more distally innervated. The resultant deformity is thus a combination of varying degrees of contracture and weakness depending on which muscles and nerves are affected. Deformity and functional impairment in the foot and ankle secondary to ischemia are determined by many factors, including: (1) which leg compartment, if any, has been affected and to what degree extrinsic flexor or extensor overpull is exhibited, (2) degree of nerve injury sustained causing weakness or paralysis of extrinsic or intrinsic foot and ankle muscles (3) which foot compartment, if any, has been affected and to what degree intrinsic overpull is exhibited, and (4) degree of sensory nerve injury leading to anesthesia, hypoesthesia, or hyperesthesia of the foot. Therefore, a variety of clinical presentations can be encountered following compartment syndrome of the leg and foot. Treatment is based on an appreciation of the pathoanatomy of the deformity. Nonoperative therapy is aimed at obtaining or preserving joint mobility, increasing strength, and providing corrective bracing and accommodative footwear. Operative management is usually reserved for treatment of residual nerve compression or severe and problematic deformities. Established surgical protocols are performed in a stepwise fashion, to include: (1) release of residual or secondary nerve compression, (2) release of fixed contractures, using infarct excision, myotendinous lengthening, muscle recession, or tenotomy, (3) tendon transfers or arthrodesis to increase function, and (4) ostectomy or amputation for severe, refractory deformities.
We reviewed 42 patients who had had triple arthrodesis 25 years after surgery. The patients' age averaged 20 years. All patients had deformities due to poliomyelitis. They were satisfied with the operation, except for one patient. Good results were noted in 13, fair in 26, and poor in 3 cases. There was delayed wound healing in 8, superficial infection in 4, and avascular necrosis of the talus in 2 cases. There was no case of delayed union or nonunion. We found degenerative joint changes in 12 ankles and in 9 feet; fourteen patients experienced pain. In spite of these long-term changes, which appear acceptable, triple arthrodesis is a useful procedure for many deformities of the foot and can solve patients' problems for many years.
The incidence of pes cavus and scoliosis was studied in three groups of patients. Group A contained 130 patients with idiopathic scoliosis, Group C contained 210 patients with idiopathic pes cavus, and Group B (control) contained 200 patients of similar age.
To investigate the joint presentation of pes cavus and idiopathic scoliosis, because both deformities may share a common etiology linked to muscle imbalance.
Sixty five percent of Group A patients (85 of 130) had an abnormally high plantar arch, compared to only 9.5% (19 of 200) of Group B control subjects. Nine percent (20 of 210) of the patients in Group C had scoliosis curves, compared to only four patients in Group B.
Radiographs were taken to determine the type of scoliosis curve, its location, and its magnitude, and to identify the incidence of spina bifida occulta in the three groups. The incidence and degree of pes cavus were established by means of foot prints. Statistical analyses were performed on all results.
A statistically significant relationship (P < 0.01) was found for the incidence of pes cavus between Group A (scoliosis) and Group B (control), and for the incidence of scoliosis between Group C (pes cavus) and Group B (control). No statistical significance was observed for the other relationships investigated (sex, curve location, magnitude, spina bifida).
There was a significant correlation between scoliosis and pes cavus--spina bifida was not an etiologic factor. Therefore, in certain patients where scoliosis and pes cavus present jointly, deformity may be secondary to altered balance or to disorders of the central nervous system.
This study was a long-term retrospective review of patients with cerebral palsy (CP) who had triple arthrodeses as children before 1981. The medical records were reviewed, and the patients were requested to return for reevaluation, during which a radiograph, physical examination, and patient questionnaire were obtained. Twenty-four patients who had triple arthrodesis on 35 feet returned for evaluation. Twenty-three feet had planovalgus deformities and 12 equinovarus deformities. Mean age at operation was 14.2 years, with a mean follow-up of 17.8 years (range 11-45 years). Of the 24 patients questioned, 19 were satisfied and five were dissatisfied with their result. Nine patients had occasional pain; one patient reported frequent pain in one foot. Six patients had limited distance ambulation owing to their feet. Radiographic evaluation demonstrated that 43% of the feet had degenerative changes at the ankle joint. Four of six patients reported ambulatory limitation due to pain. Ankle joint range of motion (ROM) and degenerative arthritis were not correlated with pain, distance limitations, residual deformity, or patient satisfaction. Patient satisfaction was predominantly related to persistent pain, especially pain causing distance limitations in ambulation. Patient satisfaction was also strongly correlated with residual deformity. Persistent pain and distance limitation were also strongly correlated with residual planovalgus deformity.
The term Charcot-Marie-Tooth disease represents a spectrum of neurological dysfunction more recently described as hereditary motor-sensory neuropathies. An abnormality of myelination is thought to be responsible for the clinical manifestations. While histological findings have been well described, the exact biochemical basis for this disorder remains unknown.
Over one half of patients with Charcot-Marie-Tooth disease manifest foot and ankle problems, including pain, weakness, deformity, and, rarely, paresthesias. Characteristic patterns of neuromuscular weakness have been identified. Bilateral pes cavovarus is the most common pathologic foot deformity seen. The specific components include hindfoot varus, anterior or forefoot cavus, and, often, clawtoes. The etiology of this abnormal foot posture usually results from tibialis posterior overpowering peroneus brevis coupled with peroneus longus overpowering tibialis anterior.
Multiple treatment options have been described. Rationale for specific tendon transfers, soft tissue release, osteotomies, and arthrodesis is discussed. Results of surgical intervention are difficult to interpret and compare because of the wide spectrum of both neurological dysfunction and described operative procedures. In the presence of flexible deformity, early soft tissue release and tendon transfers may help prevent or delay more extensive bony procedures. The clinical results of triple arthrodesis in the Charcot-Marie-Tooth disease patient appear to deteriorate with time.
Genetic transmission, progression of the neurological dysfunction, flexibility of the deformity, distribution of muscular weakness, and anticipated foot demands vary a great deal within this patient population. Treatment decisions, therefore, must be individualized and based upon a clear history, careful examination, and well-defined patient goals.
Patterns of muscle degeneration in patients with peripheral neuropathies exhibiting pes cavus deformity were studied by computed tomography (CT). Twenty-six patients attending the muscle disease clinic at Newington Children's Hospital with hereditary sensory motor neuropathies (HSMN) I, II, or III had clinical and radiographic assessment in addition to CT scans of the feet and legs at designated levels. The pattern of muscle degeneration was analyzed with other variables, including age, sex, tibial torsion, cavus, heel varus, and claw toes. Multiple regression/correlation analysis clearly demonstrated earlier and more severe involvement of the intrinsic muscles of the foot as compared with the extrinsic muscles. The most consistent early degeneration occurred in the pedal lumbricals and interossei, which have the most distal innervation. The order of muscle degeneration is a centripetal pattern, with two types of degeneration occurring in the leg muscles: type P patients had earlier degeneration of the leg muscles innervated by the peroneal nerve, and type T patients showed earlier degeneration of those extrinsics innervated by the posterior tibial nerve.
We reviewed the results for forty-three patients who had a diastematomyelia. All of the patients had been skeletally immature when the diagnosis was made, the mean age being six years (range, birth to thirteen years), and were skeletally mature by the time that they were evaluated by us. When they were first seen at our institution, twenty-four patients (56 per cent) had a cutaneous lesion, such as hairy patch, dimple, hemangioma, subcutaneous mass, or teratoma at or near the level of the diastematomyelia; thirty-four patients (79 per cent) had congenital scoliosis; and forty-two patients (98 per cent) had at least one associated musculoskeletal anomaly, such as spinal dysraphism, asymmetry of the lower extremities, club foot, or a cavus foot. In twenty-seven patients (63 per cent), the diastematomyelia was located in the lumbar spine. Thirty-six patients had eighty-four neurological manifestations. Resection of the spur was performed in thirty-three patients at a mean age of seven years (range, three months to seventeen years). Twenty-two patients who had a resection had no change in neurological condition, nine patients had improvement, and one patient had one symptom improve and another symptom worsen after the operation. We believe that resection of the spur should be performed in patients who have progressive neurological manifestations. Patients who do not have progressive neurological manifestations should be observed; if progression is noted, a resection should then be performed.
A modification of Cobey's method for radiographically imaging the coronal plane alignment of the hindfoot is described. Using this view, we estimated the moment arm between the weightbearing axis of the leg and the contact point of the heel. Normative data on 57 asymptomatic adult subjects are presented. The weightbearing line of the tibia falls within 8 mm of the lowest calcaneal point in 80% of subjects and within 15 mm of the lowest calcaneal point in 95% of subjects. The technique for measuring coronal plane hindfoot alignment is reliable, with an interobserver correlation coefficient of 0.97. This radiographic technique should help in the evaluation of complex hindfoot malalignments.
When overuse injuries of the lower limbs are diagnosed in athletes, the architecture and function of the foot should be examined. Foot structure was evaluated in 10 male and 14 female athletes. Based on this examination, the subjects were classified into three groups: pes planus, pes cavus, and pes rectus. While running, the plantar pressure pattern of these athletes was assessed with pressure-measuring insoles. Using these measurements, peak pressures and impulses were calculated for different foot anatomical locations.
The plantar heel load was distributed significantly ( P < 0.05) more toward the anterior part of the calcaneus in the pes planus group compared with the normal group. The relative load under the midfoot region was significantly ( P < 0.05) lower in the pes cavus group compared with the other foot types. The relative load of the forefoot was significantly ( P < 0.05) higher in the pes cavus group and lower in the pes planus group. Both feet of an athlete showed a similar plantar pressure pattern. Three successive steps were comparable in terms of impulses, but the peak pressures varied significantly from step to step. The local impulse and peak pressure values obtained in barefoot running differed significantly from the values obtained in running with sport shoes.
Sixteen patients (23 feet) who underwent split posterior tibial tendon transfers were evaluated. The patients were seen on a followup basis for a minimum of 1 year postoperatively. The causes were spastic cerebral palsy in 13 feet, spastic-athetoid cerebral palsy in 3 feet, hydrocephalus in 3 feet, and other diseases in 4 feet. The indication for surgery was varus deformity during the stance phase of gait and increased varus deformity during the swing phase of gait because of spasticity of the posterior tibial muscle. Heel cord lengthening was done on 17 feet. Preoperative and postoperative gaits were evaluated while the patients were walking. Axial radiographs of the calcaneus and the tibia were taken of all patients while they were weightbearing. There were 15 excellent, 6 good, and 2 poor results. The poor ratings were assigned to patients who had recurrence of varus deformity; there were no cases of overcorrection. Split posterior tibial tendon transfer was effective for treating spastic varus deformity of the hind part of the foot. This treatment also could be considered for a patient with spastic-athetoid cerebral palsy, if the deformity was determined to be caused by overactivity of the tibialis posterior muscle.
The split posterior tibial tendon transfer procedure was first reported by Green for correction of equinovarus hindfoot deformity in patients with cerebral palsy. A modification of the split posterior tibial tendon transfer combined with an Achilles tendon lengthening is described in 17 children (21 procedures) with a minimum follow-up of 3 years.
This modified technique is indicated in young children with a continuously spastic posterior tibial tendon to correct a dynamic equinovarus. It restores active dorsiflexion when the anterior tibial and extensor muscles are weak.
The anterior half of the split tibialis posterior is transferred through the interosseus membrane to the dorsum of the foot. Excellent or good results and two poor results were noted after a mean follow-up of 29 months. In the patients with an excellent or good result, marked improvement of their equinovarus foot deformity in stance and swing phase of gait was seen. In two patients, the procedure failed because of technical errors.
Between 1984 and 1994, 40 patients with a posttraumatic compartment syndrome of the lower leg and foot were treated for talipes equinovarus adductus foot deformity, which subsequently developed. Twenty patients had a wedge osteotomy followed by arthrodesis of the midtarsal joint (Chopart joint). Another 17 patients had an arthrodesis of the midtarasal and subtalar joints. In the remaining three patients, in addition to arthrodesis, lengthening of the tendons of the long flexors and the Achilles tendon was performed. Complications included wound infections (six cases), drill hole infections (three cases), chronic osteomyelitis (one case), and an ankle joint infection (one case). The clinical result was assessed as good in 37.5%, fair in 52.5%, and poor in 10% of the patients. Before the operation, 37 patients required modified footwear. After the operation, only eight patients needed them. Wedge osteotomy of the midtarsal and subtalar joints followed by an arthrodesis is an advantageous treatment modality for the correction of severe postischemic equinovarus adductus foot deformities. In our study, patient satisfaction was high. While complications frequently occur, it is not extraordinary considering the salvage nature of the procedure.
Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.
A malunion of the talar neck after a Hawkins type II fracture/dislocation of the talar neck occurred in a 34-year-old man after nonoperative treatment. Rigid varus deformity of the forefoot was a source of severe pain and disability in this patient. We describe our surgical technique for osteotomy of the talar neck with insertion of a tricortical iliac crest bone graft to correct the deformity. At follow-up (56 months), the patient had consistent relief of pain and was employed at his preinjury job doing heavy labor. The score on the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale improved from 11 points, preoperatively, to 85 points, postoperatively. Radiographs showed maintenance in the position of the osteotomy and no evidence of avascular necrosis in the talar body. Evidence of arthrosis of the talonavicular joint was apparent radiographically, but the patient did not complain of symptoms referable to this area.
We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically.
The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001).
The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.
We treated 22 children (28 limbs) with diplegic cerebral palsy who were able to walk by the Baumann procedure for correction of fixed contracture of the gastrosoleus as part of multilevel single-stage surgery to improve gait. The function of the ankle was assessed by clinical examination and gait analysis before and at two years (2.1 to 4.0) after operation. At follow-up the ankle showed an increase in dorsiflexion at initial contact, in single stance and in the swing phase. There was an increase in dorsiflexion at initial push-off without a decrease in the range of movement of the ankle, and a significant improvement in the maximum flexor moment in the ankle in the second half of single stance. There was also a change from abnormal generation of energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Lengthening of the gastrocnemius fascia by the Baumann procedure improved the function of the ankle significantly, and did not result in weakening of the triceps surae. We discuss the anatomical and mechanical merits of the procedure.
Twenty-one osteotomies fifteen patients underwent osteotomies of the calcaneus and one or more metatarsals for symptomatic cavovarus foot deformity. Seven (nine feet) were male, and eight (twelve feet) were female. The etiology included hereditary motor sensory neuropathy (HMSN) (fifteen feet), post-polio syndrome (two feet), sacral cord lipomeningocele (two feet), parietal lobe porencephalic cyst (one foot), and idiopathic peripheral neuropathy (one foot). Presenting complaints were metatarsalgia (fifteen feet), ankle instablility (five), and ulceration beneath the second metatarsal head (one foot). Eleven feet were assessed using the Maryland Foot Rating Score. Maryland Foot Rating Score (University of Maryland, Baltimore, MD) improved from 72.1 (avg,) preoperatively to 89.9 (avg,) post-operatively (follow-up 70.9 months avg.). Eight feet were assessed using the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot and Midfoot Scores. The AOFAS Ankle-Hindfoot Score improved from 46.3 (avg,) pre-operatively to 89.1 (avg.) post-operatively, and the AOFAS Midfoot Score improved from 40.9 (avg.) pre-operatively to 88.8 (avg,) post-operatively (follow-up 20.8 months avg,). The postoperative AOFAS Ankle-Hindfoot Score for all nineteen feet was 90.8 (avg,) and the post-operative AOFAS Midfoot Score for all nineteen feet was 90.2 (avg,). Two patients were lost to follow-up and were not included in the study. Ankle, hindfoot, and midfoot motion was maintained or improved in sixteen feet. Complications included delayed union in two and nonunion in three of 66 metatarsal osteotomies. While three patients required an AFO (ankle-foot orthosis) for ambulation preoperatively.
A prospective case-control study was performed comparing axial and coronal CT scan images of 11 patients (14 ankles) with chronic lateral instability and 12 controls. Scans were performed in a standardized fashion to simulate weight-bearing. Nine measurements to evaluate the alignment of the hindfoot and forefoot were made on two occasions by two observers. The blinded images were read in order of assigned random number. The angle between the calcaneus and the vertical plane showed a statistically significant difference between patients (6.4 +/- 4 degrees varus from vertical) and controls (2.7 +/- 5 degrees) using unpaired ANOVA (p < 0.01). Intra-observer (R2 = 0.49 +/- 0.19) and interobserver (R2 = 0.71 +/- 0.13) variation showed moderate reliability across all measurements. This study demonstrates a method to evaluate hindfoot varus on CT scan. Many factors have been studied (e.g., proprioception) as the cause for recurrent instability, and this is the first time, to our knowledge, that an anatomic cause has been demonstrated. Although calcaneal osteotomy is clearly not indicated routinely, it may have a role in correcting extreme varus, which may contribute to failed ligament reconstruction in patients with ankle instability.
- Liggio