PES CAVUSPES CAVUS

Pes cavus is a high Pes cavus is a high arch of the foot that arch of the foot that does not flatten with does not flatten with weight bearing. No weight bearing. No specific radiographic specific radiographic definition of pes cavus definition of pes cavus exists. The deformity exists. The deformity can be located in the can be located in the forefoot, midfoot, forefoot, midfoot, hindfoot, or a hindfoot, or a combination of these combination of these sites.sites.

PROBLEMPROBLEM The spectrum of The spectrum of

associated deformities associated deformities observed with pes cavus observed with pes cavus includes clawing of the includes clawing of the toes, posterior hindfoot toes, posterior hindfoot deformity (described as an deformity (described as an increased calcaneal angle), increased calcaneal angle), contracture of the plantar contracture of the plantar fascia, and cock-up fascia, and cock-up deformity of the great toe. deformity of the great toe. This can cause increased This can cause increased weight bearing for the weight bearing for the metatarsal heads and metatarsal heads and associated Metatarsalgia associated Metatarsalgia and calluses.and calluses.

ETIOLOGYETIOLOGY The etiology of pes cavus can be identified approximately The etiology of pes cavus can be identified approximately

80% of the time. 80% of the time. The causes include malunion of calcaneal or talar fractures, The causes include malunion of calcaneal or talar fractures,

burns, sequelae resulting from compartment syndrome, burns, sequelae resulting from compartment syndrome, residual clubfoot, and neuromuscular disease. residual clubfoot, and neuromuscular disease.

The remaining 20% of cases are idiopathic and The remaining 20% of cases are idiopathic and nonprogressive. nonprogressive.

Neuromuscular diseases, such as muscular dystrophy, Neuromuscular diseases, such as muscular dystrophy, Charcot-Marie-Tooth (CMT) disease, spinal dysraphism, Charcot-Marie-Tooth (CMT) disease, spinal dysraphism, polyneuritis, Intraspinal tumors, poliomyelitis, polyneuritis, Intraspinal tumors, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy, and spinal syringomyelia, Friedreich ataxia, cerebral palsy, and spinal cord tumors, can cause muscle imbalances that lead to cord tumors, can cause muscle imbalances that lead to elevated arches. A patient with a new-onset unilateral elevated arches. A patient with a new-onset unilateral deformity but without a history of trauma must be deformity but without a history of trauma must be evaluated for spinal tumors.evaluated for spinal tumors.

PATHOGENESISPATHOGENESIS

Multiple theories have been proposed Multiple theories have been proposed for the pathogenesis of pes cavus. for the pathogenesis of pes cavus. Duchenne described intrinsic muscle Duchenne described intrinsic muscle imbalances causing an elevated imbalances causing an elevated arch. Other theories include the arch. Other theories include the extrinsic muscle and a combination extrinsic muscle and a combination of the intrinsic and extrinsic muscles of the intrinsic and extrinsic muscles being causes of the imbalance being causes of the imbalance

(1992, Mann) described the pathogenesis of (1992, Mann) described the pathogenesis of pes cavus in patients with CMT disease. An pes cavus in patients with CMT disease. An agonist and antagonist model for the muscles agonist and antagonist model for the muscles determines the deformity. In CMT, the anterior determines the deformity. In CMT, the anterior tibialis muscle and the peroneus muscle tibialis muscle and the peroneus muscle develop weaknesses. Antagonist muscles, develop weaknesses. Antagonist muscles, posterior tibialis and peroneus longus, pull posterior tibialis and peroneus longus, pull harder than the other muscles, causing harder than the other muscles, causing deformity. Specifically, the peroneus longus deformity. Specifically, the peroneus longus pulls harder than the weak anterior tibialis, pulls harder than the weak anterior tibialis, causing plantar flexion of the first ray and causing plantar flexion of the first ray and forefoot valgus. The posterior tibialis pulls forefoot valgus. The posterior tibialis pulls harder than the weak peroneus brevis, causing harder than the weak peroneus brevis, causing forefoot adduction. Intrinsic muscle develops forefoot adduction. Intrinsic muscle develops contractures while the long extensor to the contractures while the long extensor to the toes, recruited to assist in ankle dorsiflexion, toes, recruited to assist in ankle dorsiflexion, causes cock-up or claw toe deformity. With the causes cock-up or claw toe deformity. With the forefoot valgus and the hindfoot varus, forefoot valgus and the hindfoot varus, increased stress is placed on the lateral ankle increased stress is placed on the lateral ankle ligaments andligaments and instability can occur. instability can occur.

CLINICAL PRESENTATIONCLINICAL PRESENTATION

Patients can present with lateral foot pain Patients can present with lateral foot pain from increased weight bearing on the from increased weight bearing on the lateral foot.lateral foot.

Metatarsalgia Metatarsalgia keratosis keratosis Ankle instabilityAnkle instability hindfoot varushindfoot varus The forefoot plantar flexionThe forefoot plantar flexion hindfoot varus hindfoot varus

CLINICAL TESTCLINICAL TEST The The Coleman blockColeman block

test determines if the test determines if the subtalar joint is flexible. subtalar joint is flexible. The test is performed by The test is performed by having a patient stand having a patient stand with a 1-inch wood block with a 1-inch wood block under the heel and under the heel and lateral foot. This allows lateral foot. This allows the first ray to be the first ray to be plantar-flexed off the plantar-flexed off the block. If the hindfoot block. If the hindfoot corrects to a neutral corrects to a neutral position, the deformity position, the deformity is flexible. If the hindfoot is flexible. If the hindfoot does not correct, the does not correct, the deformity is rigid.deformity is rigid.

Increased Increased calcaneal anglecalcaneal angle

TREATMENTTREATMENTMedical therapyMedical therapy The goal of treatment is to allow the patient to ambulate without The goal of treatment is to allow the patient to ambulate without

symptoms. The underlying cause must be identified in order to symptoms. The underlying cause must be identified in order to determine if the disorder is progressive. determine if the disorder is progressive.

The goal of surgery is to produce a plantigrade foot and pain relief. The goal of surgery is to produce a plantigrade foot and pain relief. Repeat surgical procedures may be necessary, especially if the Repeat surgical procedures may be necessary, especially if the deformity is progressive. Preoperative patient education is deformity is progressive. Preoperative patient education is essential for patient satisfaction. essential for patient satisfaction.

Nonoperative treatment may provide patients with significant Nonoperative treatment may provide patients with significant relief. Physical therapy to stretch tight muscles and relief. Physical therapy to stretch tight muscles and strengthen weak muscles may provide early relief.strengthen weak muscles may provide early relief.

Orthotic with extra-depth shoes to offload bony prominences and Orthotic with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may improve symptoms. For varus prevent rubbing of the toes may improve symptoms. For varus deformities, a lateral wedge sole modification can improve deformities, a lateral wedge sole modification can improve function. Bracing for supple deformities or foot drop may allow function. Bracing for supple deformities or foot drop may allow patients to ambulate; however, in patients with sensation deficits, patients to ambulate; however, in patients with sensation deficits, Plastazote linings in the brace are required and frequent Plastazote linings in the brace are required and frequent inspection of the skin for ulceration is warranted.inspection of the skin for ulceration is warranted.

SURGICAL THERAPYSURGICAL THERAPY

Correcting a cavovarus foot Correcting a cavovarus foot Most of the corrections involve tendon Most of the corrections involve tendon

transfers and capsular and facial releasestransfers and capsular and facial releasesCorrection of plantar flexion of the first Correction of plantar flexion of the first

ray by performing a dorsiflexion 1ray by performing a dorsiflexion 1STST tarsometatarsal arthrodesis. tarsometatarsal arthrodesis.

Reduction of hindfoot varus by performing Reduction of hindfoot varus by performing a lateralizing calcaneal osteotomy. a lateralizing calcaneal osteotomy.

Arthrodesis 1st TMT joint, lateral Arthrodesis 1st TMT joint, lateral calcaneal osteotomy for hind calcaneal osteotomy for hind

foot varusfoot varus

Lateral view showing Lateral view showing both.both.

PLANTAR FASCIA PLANTAR FASCIA RELEASE(MANN 1993)RELEASE(MANN 1993)

In pes cavus, the In pes cavus, the plantar fascia may plantar fascia may become contracted. become contracted. Plantar fascia Plantar fascia release is usually release is usually combined with a combined with a tendon transfer, an tendon transfer, an osteotomy, or both. osteotomy, or both. This is frequently This is frequently the first step in the first step in improving the improving the deformity deformity

GREAT TOE JONES GREAT TOE JONES PROCEDUREPROCEDURE

A great toe Jones procedure is performed for A great toe Jones procedure is performed for a cock-up deformity of the great toe with a cock-up deformity of the great toe with associated weakness of the anterior tibialis associated weakness of the anterior tibialis muscle. In this case, the EHL has been muscle. In this case, the EHL has been recruited to assist in ankle dorsiflexion, recruited to assist in ankle dorsiflexion, which causes hyperextension at the MTP which causes hyperextension at the MTP joint and hyperflexion at the interphalangeal joint and hyperflexion at the interphalangeal (IP) joint. This procedure transfers the EHL (IP) joint. This procedure transfers the EHL to the neck of the first metatarsal, with to the neck of the first metatarsal, with arthrodesis of the IP joint to improve the arthrodesis of the IP joint to improve the dorsiflexion of the ankle and remove the dorsiflexion of the ankle and remove the deforming force at the MTP joint deforming force at the MTP joint

EXTENSOR SHIFT EXTENSOR SHIFT PROCEDUREPROCEDURE

The extensor shift procedure involves The extensor shift procedure involves transferring the EHL and the extensor transferring the EHL and the extensor digitorum longus (EDL) to the first, third, and digitorum longus (EDL) to the first, third, and fifth metatarsals. The technique includes fifth metatarsals. The technique includes completion of the Jones procedure, with completion of the Jones procedure, with incisions in the second and fourth web space. incisions in the second and fourth web space. The tendons are harvested. The second and The tendons are harvested. The second and third tendons are transferred through a drill third tendons are transferred through a drill hole on the third metatarsal, and the fourth hole on the third metatarsal, and the fourth and fifth tendons are transferred to the fifth and fifth tendons are transferred to the fifth metatarsal.metatarsal.

GIRDLE STONE TAYLOR GIRDLE STONE TAYLOR TRANSFERTRANSFER

The Girdle stone-Taylor transfer The Girdle stone-Taylor transfer procedure is used for flexible claw procedure is used for flexible claw toe deformities. The deforming force toe deformities. The deforming force of the flexor digitorum longus tendon of the flexor digitorum longus tendon is transferred to the extensors to is transferred to the extensors to correct the deformity.correct the deformity.

Base of the first metatarsal Base of the first metatarsal osteotomyosteotomy

In patients with a fixed plantar-flexed In patients with a fixed plantar-flexed first ray, a base of the metatarsal first ray, a base of the metatarsal closing wedge osteotomy corrects closing wedge osteotomy corrects the deformity, which is especially the deformity, which is especially observed in CMT disease. This observed in CMT disease. This procedure is usually combined with a procedure is usually combined with a plantar fascia release in a mild plantar fascia release in a mild deformity or a Jones procedure deformity or a Jones procedure

Midfoot osteotomyMidfoot osteotomy

Tarsal osteotomy has been described Tarsal osteotomy has been described for deformities through the Midfoot; for deformities through the Midfoot; however, these osteotomies require however, these osteotomies require cutting through multiple joints. They cutting through multiple joints. They are quite technically complex and are quite technically complex and are rarely performed are rarely performed

Peroneus longus to peroneus Peroneus longus to peroneus brevis tenodesisbrevis tenodesis

In patients with CMT disease who In patients with CMT disease who have a weak peroneus brevis (PB) have a weak peroneus brevis (PB) and a preserved peroneus longus and a preserved peroneus longus (PL), a tenodesis can be performed to (PL), a tenodesis can be performed to help stabilize the ankle. This is help stabilize the ankle. This is frequently combined with a calcaneal frequently combined with a calcaneal osteotomy osteotomy

Calcaneal osteotomyCalcaneal osteotomy

Patients with hindfoot involvement Patients with hindfoot involvement usually require a calcaneal usually require a calcaneal osteotomy to correct the deformity. osteotomy to correct the deformity. The osteotomy can include a closing The osteotomy can include a closing wedge, a vertical displacement, or a wedge, a vertical displacement, or a combination (triplaner osteotomy). combination (triplaner osteotomy). This procedure is usually combined This procedure is usually combined with a plantar fascia release and, with a plantar fascia release and, frequently, a tendon transfer.frequently, a tendon transfer.

Beak triple arthrodesisBeak triple arthrodesis The Siffert beak triple The Siffert beak triple

arthrodesis corrects pes arthrodesis corrects pes cavus deformities through cavus deformities through wedge resection and a wedge resection and a triple arthrodesis. This triple arthrodesis. This procedure is used for procedure is used for treatment of rigid fixed treatment of rigid fixed deformities in adults. The deformities in adults. The technique involves technique involves mortising the navicular into mortising the navicular into the head of the talus and the head of the talus and depressing the navicular, depressing the navicular, cuboids, and cuneiforms to cuboids, and cuneiforms to improve forefoot cavus improve forefoot cavus deformities. This procedure deformities. This procedure is complex and technically is complex and technically demanding demanding

OUTCOMES AND PROGNOSISOUTCOMES AND PROGNOSIS

The results of surgical intervention are The results of surgical intervention are difficult to compare because of the difficult to compare because of the multiple possible combinations of multiple possible combinations of procedures necessary for successful procedures necessary for successful treatment treatment

Also, patients have varying degrees of Also, patients have varying degrees of deformity, disease progression, and deformity, disease progression, and underlying etiology, making comparison underlying etiology, making comparison virtually impossible; however, some virtually impossible; however, some positive findings have been reported.positive findings have been reported.

RESEARCHESRESEARCHES

Wetmore and Drennan's report that Wetmore and Drennan's report that 24% of patients with CMT disease 24% of patients with CMT disease who underwent a triple arthrodesis who underwent a triple arthrodesis had satisfactory results at an had satisfactory results at an average of 21 years of follow-up. average of 21 years of follow-up. They recommended the triple They recommended the triple arthrodesis as a salvage procedure.arthrodesis as a salvage procedure.

Mann and Hsu reported on 12 feet in Mann and Hsu reported on 12 feet in patients with CMT disease that patients with CMT disease that underwent triple arthrodesis, with a underwent triple arthrodesis, with a follow-up that averaged 7.5 years. Five follow-up that averaged 7.5 years. Five feet were plantigrade, asymptomatic, feet were plantigrade, asymptomatic, and united. Three feet were plantigrade and united. Three feet were plantigrade and asymptomatic but had nonunion. and asymptomatic but had nonunion. Four feet were nonplantigrade and Four feet were nonplantigrade and symptomatic. The authors stated that symptomatic. The authors stated that positioning is the key to satisfactory positioning is the key to satisfactory results.results.

Roper and Tibrewal reported the Roper and Tibrewal reported the results of soft-tissue procedures results of soft-tissue procedures combined with osteotomies. Ten combined with osteotomies. Ten cases of CMT disease were reviewed cases of CMT disease were reviewed 14 years after surgery. Two patients 14 years after surgery. Two patients required repeat surgery secondary to required repeat surgery secondary to recurrent deformity. At last follow-up, recurrent deformity. At last follow-up, all patients had plantigrade feet, all patients had plantigrade feet, without requiring a triple arthrodesis.without requiring a triple arthrodesis.

Gould discussed 18 feet in 10 Gould discussed 18 feet in 10 patients with a 3- to 6-year follow-up. patients with a 3- to 6-year follow-up. All had satisfactory results with soft-All had satisfactory results with soft-tissue procedures combined with tissue procedures combined with osteotomies, and all patients had osteotomies, and all patients had plantigrade feet at last follow-up plantigrade feet at last follow-up

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