57 2024 Pes Cavus I&II.pdf

PES CAVUS I&II Mathew Johnstone DPM, FACFAS, DABPM. Assistant Professor: CPMS Des Moines University LECTURE OBJECTIVES 1 Demonstrate knowledge of etiologies of the cavus foot. 2 Demonstrate knowledge of the basic clinical examination for pes cavus foot 3 4 Recognize the anatomic components of the pe...

PES CAVUS I&II Mathew Johnstone DPM, FACFAS, DABPM. Assistant Professor: CPMS Des Moines University LECTURE OBJECTIVES 1 Demonstrate knowledge of etiologies of the cavus foot. 2 Demonstrate knowledge of the basic clinical examination for pes cavus foot 3 4 Recognize the anatomic components of the pes cavus deformity. Demonstrate knowledge of conservative and surgical treatment options for pes cavus COPYRIGHT NOTICE This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. DEFINITION Pes -Latin- ”Foot” Cavus- Latin- “Hollow, concave, excavated” IDENTIFYING THE CAVUS FOOT Presents most often as a “High arch foot” however this is not the only defining feature Heel varus “Cavo-varus foot” Often presents with muscular weakness/imbalance Associated with many NM conditions, UMN and LMN CLINICAL PRESENTATION Patients often present with CC’s like: “Walking on the outside of my heel” Frequent ankle sprains or falls Lateral foot pain Difficulty walking or fitting shoes Wearing out shoes very quickly Clawing of the toes PATIENT HISTORY Because it is so frequently seen with neuromuscular disorders, be sure to inquire if patient (or family members) have been diagnosed with any, such as: Hereditary Motor-Sensory neuropathy (CMT is an example) Cerebral palsy CVA Spinal Dysraphism's (spina bifida) Myelomeningocele (pictured) Spinal tumors Poliomyelitis Parkinsonism PATIENT HISTORY Cavus foot is also associated with previous MSK and dermatological pathology Trauma Talar neck Fracture Tibial Fracture Calcaneal Fracture Compartment Syndrome Burns Scarring/contractures Tarsal coalition Clubfoot/ CVT Tumor resections (shown) Nerve damage from tumor or removal DURATION/ONSET/COURSE Neurogenic cavus is progressive in nature Ask: How long have you had this high of an arch? Is it getting worse? Does anyone in your family have a similar foot issue? Do you have any pain or weakness in your hands? Pictured: advanced CMT in the hand ASSOCIATIONS WITH NEUROMUSCULAR DISEASE Each NM disease affects muscle function in a different way Not always symmetrical Not always the same muscle groups Not always with sensory deficits Weakness may be subtle, even imperceptible in some Foot and hand Intrinsic muscles (due to small size) tend to be disproportionately affected Thorough patient history is critical to diagnosis INTRINSIC MUSCLE FUNCTION Recall my MTPJ pathology lecture? What was the function of the interossei and lumbricals? Without functional intrinsic muscles? Long flexor and extensor act unopposed Buckling of the MTPJ claw toes THE PHYSICAL EXAM: PES CAVUS Following thorough history of the problem, patient’s medical and family hx. Begin with what you SEE Begin with gait, if you can This will guide the rest of your evaluation Elaborate with clinical evaluation especially muscle function and joint ROM. WHAT CAN WE SEE (HINDFOOT VARUS) Stand behind the patient as they stand equally on both feet (normal standing) Visually bisect the heel Compare this to the bisection of the leg Do not forget to examine the tibia and knee for gross anatomical deformity as well WHAT CAN WE SEE: PEEK-A-BOO HEEL SIGN Move in front of the patient who is still standing normally Make sure the feet are pointed straight ahead Can you see the medial aspect of the heel? “peeks out” from behind the ankle False positive: excessive metatarsus adductus WHAT CAN WE SEE?: CLAW TOES When these are associated with muscle weakness the “substitution” type hammertoes are prevalent, especially extensor substitution The next two slides should be review of Dr. Dikis’s Material on hammertoes FLEXOR SUBSTITUTION Weak triceps surae group Long flexor tendons “substitute” for the weakness, which overpowers the intrinsic toe stabilizer muscles (interosseous) Least common amongst subtypes Toe claw in Late-stance phase (as flexors try to achieve heellift) EXTENSOR SUBSTITUTION EDL gains advantage over intrinsic muscles Biomechanical/positional (anterior cavus) Neuromuscular Weak foot dorsiflexors (CVA, CMT etc) Intrinsic muscle wasting (neuropathy) Swing-phase of gait evident etiology May disappear upon weight bearing. Hallux also hammered in this etiology Hammertoe subgroups are definitions of dynamic adaption, they do NOT describe paralytic contractures, rather the dynamic response of the muscles which are functioning WHAT CAN WE SEE?: GAIT Does patient have difficulty walking? Do their toes “clear the ground” ? Does one hip drop as they walk? At which point do their toes curl? WHAT CAN WE SEE?: METATARSAL ALIGNMENT Non-Weight bearing: put the heel in neutral alignment if you can Examine the forefoot Does this patient’s first metatarsal look normal to you? WHAT CAN WE SEE: CALLUSING Note the locations of the calluses Most often first and 5th metatarsal heads Also note: Size? Is it raised? Color? All tan? Tan with hemorrhagic staining? Shape/texture Diffuse? Nucleated? Pain (can't see this I know) NOW THE MUSCLE AND JOINT TESTING! Gather as much information as you can by observation, then use this to direct your suspicions for weakness or muscle imbalance If the first metatarsal is plantarflexed: why? Fixed deformity? If the heel is in varus: why? Fixed deformity? COMMON MUSCLE WEAKNESSES IN CAVUS FEET: THE PERONEUS BREVIS What is the function of this muscle? Which muscle does this primarily oppose? Where does this insert? How would I individually test this muscle? REVIEW: PERONEUS BREVIS STRENGTH TEST Plantarflex and evert foot against resistance COMMON MUSCLE WEAKNESSES IN CAVUS FEET: THE TIBIALIS ANTERIOR What is the function of this muscle? What happens when this muscle doesn’t work? How do you test this muscle in isolation? REVIEW: TIBIALIS ANTERIOR MUSCLE STRENGTH TEST Dorsiflex and invert foot against resistance MUSCLE TESTING Assume this deformity is not rigid Which muscle might do this to the first metatarsal? How would you test this muscle in isolation? REVIEW: PERONEUS LONGUS MUSCLE TESTING Plantarflex the 1st metatarsal head against resistance DON’T FORGET TO TEST THE ACHILLES! Triceps surae strength Heel rise Watch the heels to see if they invert! Silfverskiold test JOINT ROM: SUBTALAR JOINT Rigidity of the STJ (especially in pediatric patients) should raise suspicion for tarsal coalition Depending on orientation each type of Tarsal coalition can result in the cavus foot FLEXIBILITY Check and document joint mobility Especially STJ Ankle First TMTJ Flexible vs rigid deformity will guide your surgical decision making MUSCLE TESTING: CLONUS The modified Tardieu scale is often used to describe the degree of spasticity Grade 0 No resistance throughout passive ROM Grade 1 Slight resistance Grade 2 Catch at a precise angle interruption passive ROM, followed by release Grade 3 Non sustained clonus of 4mm) In-phase transfer Distal aspects of the EDL are tenodesed to the EDB to preserve some of their function LET’S DO: A HIBBS TENOSUSPENSION Incision planning Variants often used for combined procedures Be aware of underlying anatomy LET DO: A HIBBS TENOSUSPENSION Completed Jones Identify the long extensors LET DO: A HIBBS TENOSUSPENSION Identify the brevis tendons (underlying) LET DO: A HIBBS TENOSUSPENSION Tenodese (join) the long and short extensor distal aspects You are going to release the proximal aspect of the long extensors LET DO: A HIBBS TENOSUSPENSION You can bulk harvest the proximal tendon for insertion into the midfoot bone (Right) Or transfer individual slips under the peroneus tertius (Left) LET DO: A HIBBS TENOSUSPENSION Bulk harvested proximal tendon will need to be anchored down to the bone (yellow suture anchor insertion tool seen top) Individual tendon slips may be sutured back onto themselves following transfer. HIBBS TENOSUSPENSION Results speak for themselves when used on the appropriate patients MIDFOOT TENDON TRANSFERS: STATT Split Tibialis Anterior Tendon Transfer Lateral half of the TA tendon is transferred to the cuboid “Balances the dorsiflexion” (removes some of the inversion effect of the TA) Useful for post CVA patients without functioning opposition muscle groups. In phase transfer PT harvested at insertion and tagged with long suture, PT tendon withdrawn to the medial leg in preparation for transfer through IO membrane Remember you want that straight line, also make sure it can reach without lengthening it MIDFOOT TENDON TRANSFERS: PT Posterior Tibial Tendon Transfer through the interosseus membrane OUT OF PHASE TRANSFER! PT tendon passed through the IO (separate incision anterior leg, then it is guided subcutaneously to the lateral midfoot and secured PT TRANSFER SCHEMATICS Note the long hemostat used to transfer the tendon PT TRANSFER SCHEMATICS Separate anterior leg incision used to guide the PT through a “window” cut into the interosseous membrane PT TRANSFER SCHEMATICS Another incision must be made over the dorsal lateral midfoot for the insertion of the PT PT TRANSFER SCHEMATICS Tendon can be secured with an interference screw as shown PT TRANSFER SCHEMATICS PT has been transferred from a deforming inverter and plantarflexion force to a dorsiflexor force OUT OF PHASE PT required TENDON TRANSFERS: PL TO PB PL is often the deforming force driving the cavus foot This transfer removes the PL as a deforming force and reinforces the PB to oppose the inversion force on the cavus foot Also known as an anastomosis In phase LET'S DO: A PL TO PB TRANSFER Incision planning How much exposure do you need? Be aware of neurovascular anatomy Which nerve is in this region? LETS DO: A PL TO PB TRANSFER Incise through the skin and develop bluntly to the level of the peroneal tendon sheath The sheathe will need to be incised as well to access the tendons Advice: tag the sheath with a suture for later repair LET'S DO: A PL TO PB TRANSFER Top: split the peroneus longus tendon Middle: Z lengthening is the only lengthening for me Bottom: you can discard the distal split PL tendon slip LETS DO: A PL TO PB TRANSFER Lasso the proximal split PL tendon with suture and prepare to tenodese this to the PB LET'S DO: A PL TO PB TRANSFER PL proximal tendon slip is woven into the PB, adding the strength of the PL muscle to the PB tendon\ Anastomosis-Latin, from Greek anastomoun - “To provide with a mouth” Applied to vascular anastomoses as well LETS DO: A PL TO PB TRANSFER Secure the tenodesis with absorbable suture and close the sheath over the newly united tendons COMBINED PROCEDURES: SEQUENTIAL RELEASE PT tendon transfer Achilles/Gastroc release Tarsal tunnel release Release/lengthen FDL, FHL Posterior capsule release Plantar fascia and intrinsic muscle release “Foot unwinds” Goal is a brace-able foot PLANTAR RELEASE: THE STEINDLER STRIPPING Complete detachment of plantar fascia Detachment of plantar intrinsic muscles FDB Abductor Hallucis Abductor digiti minimi Quadratus plantae Release of plantar ligaments Plantar incision is the classic approach Can also be performed through medial heel incision OSTEOTOMIES Rigid deformity correction Dorsiflexory first ray osteotomy Cole midfoot osteotomy Dwyer Calcaneal Osteotomy (shown) Lateralizing Calcaneal slide osteotomy Can be supplemented with soft tissue work like tendon transfers and releases Do the bone work first DORSIFLEXORY FIRST RAY OSTEOTOMY For rigid first ray driven cavus Incision placed over the first TMTJ See bottom: Unguided Dorsally based Wedge of 2-3mm VS Oblique wedge cut planned to allow for screw fixation Use the law of cosines to measure the length of the dorsal arm (wedge) LESSER METATARSALS One the first ray is fixated in position, correct any excess plantarflexion of the lesser metatarsal with a similar base wedge The return of the BRT osteotomy! MIDFOOT OSTEOTOMY The most powerful corrections are achieved at the apex of the deformity Cole popularized this procedure in 1940 Occasionally must pair with plantar fascia release or Steindler stripping to close the wedge May be combined with other procedures such as calcaneal osteotomy CHOOSING THE COLE Rare indication Apex of the deformity centered over the midfoot (can use hibbs angle to find this) Severely arthritic midfoot (no hope to reduce) Patients WITHOUT progressive cavus Cole osteotomy does not address the TMTJ or STJ LET'S DO: A COLE OSTEOTOMY Plan the osteotomy Radiographic analysis Detailed clinical examination Is STJ work also needed? Soft tissue rebalancing? LET’S DO: A COLE OSTEOTOMY Incision placement LET’S DO: A COLE OSTEOTOMY Incise the skin and develop the incision to the level of the EDB LET’S DO: A COLE Elevate the EDB and retract this dorsally LET'S DO: A COLE Expose the midtarsal joint (capsulotomy) LET’S DO: A COLE Create the osteotomy LET’S DO: A COLE Fixation: traditionally with screws, staples are also an option LET’S DO: A COLE Check radiographic position CALCANEAL OSTEOTOMIES Rotate calcaneal tuberosity out of varus Structural deformities of the calcaneal bone And/or Lateralize calcaneal tuber Base decision for this surgery on the results of the Coleman block test DWYER CALCANEAL OSTEOTOMY Rarely performed in isolation Laterally based wedge resected from calcaneus Rotate the heel out of varus Useful for intrinsic varus of the calcaneus (frontal plane) Fixation with two parallel screws inserted from the posterior calcaneus through the osteotomy site Size of wedge affects the degrees of correction Every 1mm is about 3 degrees of correction LATERALIZING CALCANEAL SLIDE OSTEOTOMY Calcaneal tuber is slid laterally to relocate the calcaneal tuber beneath the tibia Minimalize the hindfoot moment arm Smaller incision than true Dwyer TRIPLE ARTHODESOS For severe combined Cavo-varus with rigid deformity Prepare all joints TB first STJ second Check alignment after temporarily fixating the triple Calcaneal lateralizing osteotomy needed as well? Soft tissue work last Flexible deformity (pediatric patient) Tendon transfers Plantarflexed first ray: positive Coleman block Dorsiflexory first ray PL to PB transfer Plantarflexed First ray: negative Coleman block Dorsiflexory first ray Lateralizing calcaneal osteotomy PL to PB Severe arthritis, nonreducible: Triple Arthrodesis SURGICAL DECISION LADDER CASE STUDY 49-year-old female patient presents to clinic with progressive change in both feet. Complaints of frequent ankle sprains, increase tripping and near falls “I wear out my shoes so fast that I feel like I can't keep any on” MEDICAL HISTORY Past medical history: HTN, HLD Previous surgical hx: appendectomy 5 years ago no complications Social history: no alcohol or tobacco use, no illicit drugs Family history: mother died in her 40s of car accident, father alive and in good health PHYSICAL EXAMINATION Vascular: DP and PT pulses fully palpable, CFT immediate to all digits of both feet, pedal hair sparse, but present, no discernable edema of the bilateral foot and leg skin temperature warm to cool proximal to distal. MSK: mild tenderness with palpation of the lateral heel and base of the fifth metatarsal, there is a prominent first metatarsal head plantarly when forefoot to rearfoot relationship evaluation, unable to passively reduce the STJ to neutral (45 degrees inversion -5 eversion available), ankle joint ROM limited with the knee extended and flexed. Coleman block test is negative (heel does not reduce), digital contractures 1-5 which increase during swing phase. MMT: 5/5 strength with PF and inversion, 4/5 with eversion, 3/5 with dorsiflexion, gait is partial steppage type, visible atrophy of the anterior muscles with prominence of the tibial crest Derm: discrete plantar calluses sub-metatarsal head 1, and 5 as well as lateral heel and base of the 5th metatarsal Neuro: gross sensation intact, no loss of pinprick sensation ASSESSMENT/PLAN Pes cavus Drop foot Peroneal tendon weakness Extensor substitution hammertoes Strong clinical suspicion for CMT Plan: Referral to neurology for confirmation of diagnosis EMG results demonstrate reduced NCV, neurology diagnoses CMT AFO bracing ordered After 6 months of bracing patient reports that the braces “don’t fit” and is developing pre ulcerative calluses SURGICAL PLANNING Dwyer osteotomy Dorsiflexory First Ray osteotomy Plantar fasciotomy PL to PB transfer LECTURE REVIEW Identify the clinical features of cavus foot deformity Identify common pathological processes associated with cavus feet Utilize clinical and plain film radiographic examination to identify the presence and type of cavus deformity Use radiographs to quantify cavus foot deformity For the conditions associated with cavus foot, recognize why this leads to cavus deformity Muscle weakness? Imbalance? LECTURE REVIEW II Injury to tendon or muscle? Choose an appropriate conservative treatment for each type of cavus deformity Recognize each named surgical procedure (by appearance and name) and its utility Why (and when) would you choose a certain procedure over another? Identify the goals of each surgical procedure (what exactly is the purpose of each?) Identify important adjunct procedures for each (are these done in isolation?) THANK YOU Which of the following represents an OUT OF PHASE tendon transfer? SAMPLE QUESTION 1 Hibbs tenosuspension Jones Tenosuspension Peroneus longus to Peroneus Brevis anastomosis STATT (split tibialis anterior tendon transfer) Posterior tibial to dorsal midfoot transfer In a patient with the classical presentation of lower extremity weakness of Charcot-Marie-Tooth disease, with neurogenic cavus and Claw toes, when would you expect the digital deformities to be MOST evident/increased. SAMPLE QUESTION 2 Early Stance phase Just before heel off At heel off Swing phase Midstance SAMPLE QUESTION 3 Which of the following procedures has been done here A Cole osteotomy A Dwyer procedure A lateralizing calcaneal slide and a Dwyer procedure A STATT and a Cole osteotomy A lateralizing calcaneal slide and a Cole osteotomy SAMPLE QUESTION 1: RATIONALE Which of the following represents an OUT OF PHASE tendon transfer? (Rationale: This is a knowledge-recall question; however, it is vital to a patient’s postoperative course to identify in phase and out of phase transfers. each of the tendon transfers below as listed as in phase (Hibbs on slide 71, jones on slide 70, PL to PB on slide 86, and the STATT on slide 79, only the PT transfer slides 80—85 is out of phase, the PT tendon is an inverter and plantar-flexor, transferring it to the dorsal midfoot turns this into a dorsiflexory force, hence out of phase(of gait)) Hibbs tenosuspension Jones Tenosuspension Peroneus longus to Peroneus Brevis anastomosis STATT (split tibialis anterior tendon transfer) Posterior tibial to dorsal midfoot transfer (correct answer!) SAMPLE QUESTION 2: RATIONALE In a patient with the classical presentation of lower extremity weakness of Charcot-Marie-Tooth disease, with neurogenic cavus and Claw toes, when would you expect the digital deformities to be MOST evident/increased. (CMT is closely associated with progressive cavo-varus foot deformity, the weakness pattern is anterior leg compartment, then lateral and foot intrinsic muscles (slide 64-64)) the extensor tendons are recruited to aide in dorsiflexion of the foot (extensor substitution slide 17) making them evident during SWING phase, not while the foot is on the ground.) Early Stance phase Just before heel off At heel off Swing phase (correct answer!) Midstance SAMPLE QUESTION 3: RATIONALE Which of the following procedures has been done here Rationale: from the images you can see that a midfoot and calcaneal osteotomy has been performed, the midfoot osteotomy should be correctly identified as a Cole (slides 92-101), as for the calcaneal osteotomy is does not matter if this is a Dwyer or lateralizing slide as one can eliminate the incorrect choices otherwise A Cole osteotomy A Dwyer procedure A lateralizing calcaneal slide and a Dwyer procedure A STATT and a Dwyer osteotomy A lateralizing calcaneal slide and a Cole osteotomy CITED Sarathy K, Doshi C, Aroojis A. Clinical Examination of Children with Cerebral Palsy. Indian J Orthop. 2019;53(1):35-44. doi:10.4103/ortho.IJOrtho_409_17 Shortland, A Muscle deficits in cerebral palsy and early loss of mobility: can we learn something from our elders?Volume51, Issues4 Special Issue: Adults with Cerebral Palsy: A workshop to define the challenges of treating and preventing the secondary musculoskeletal and neuromuscular complications in this rapidly growing population. October 2009 Pages 59-63 Rodda J, Graham HK. Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm. Eur J Neurol 2001;8(suppl 5):98-108\ J. Cottalorda, P. Violas, R. Seringe, Examen neuro-orthopédique des enfants et des adolescents : une méthode simplifiée, Revue de Chirurgie Orthopédique et Traumatologique, Volume 98, Issue 6, Supplement, October 2012, Pages S262-S270 Jonathan M. Labovitz, Marc A. Benard, Edwin J. Harris, Harold D. Schoenhaus, Difficult and Controversial Pediatric Cases: A Roundtable on Conservative and Surgical Management,Clinics in Podiatric Medicine and Surgery, Volume 23, Issue 1, 2006, Pages 77-118, ISSN 0891-8422, ISBN 9781416033790, https://doi.org/10.1016/j.cpm.2005.10.010. Popliteal Angle Hamstring Test | Test for Hamstring Tightness | Knee Injury | Vail, CO Robert Laprade MD June 18 2012 Paley orthopedics and spine-for tendon trasnfer scematics diagrams.