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CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS
ARMEN S KELIKIAN MD
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CONFLICTS
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INTRODUCTION/SUMMARY
Level IV- H&P Rx soft tissue disorders Realign osseous deformities Ubiquitous locked foot & cavus is
more of a musculoskeletal problem than PTD!
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Questions?
Cavus foot incidence? 10,16, 23,43% If the hindfoot remains in varus with
the Coleman block test it should not be corrected? True/false
Cavovarus causes > anteromedial joint pressure in vitro at 15 degrees? True/false
Bilateral cavovarus in peds population regardless of FHx is most likely HSMN?Y/N
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Cavus & sports mannifestations
23% all feet Most idiopathic not neurogenic Locked foot is ubiquitous ‘Peek a boo” heel-Manoli 1st metatarsal fat bulge Address underlying pathology Otherwise recurrence likely
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Sports manifestations
Jones & Torg Fx- 5th metatarsal Stress Fx’s tibia/fibula Medial knee pain Varus ankle with arthritis Peroneal tendon tears & dislocation Anterolateral ankle instability
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NORMAL ANATOMY OF PERONEAL TENDONS &
RETINACULUM
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PERONEAL SUBLUXATION USN 100,85,90% (s/s/a)JBJS-
A 8/05
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Complex peroneus brevis tear Rx tubularize
42% unable return
sports(Syeel-Deorio FAI 1/07)
Tears seen at groove,tubercle, or os in cuboid tunnel
Pl tears > cavovarus
Can excise peripheral tears <50%
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Retinacular flap & groove deepening
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PB repair & retinacular reefing
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PL III Rx Pulvertaft weave
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Peroneus longus overpull
Inability to raise lesser mt level with 1st
With forced pf 1st ray pf > lesser mts If TA weak transfer EHL to TA or M-1 Tenodese PL to PB
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Dislocation-subluxation
2004 world series “bloody sock”
Acute-cast 4-6wks-seldom successful
Provocative stress-DF/EVERSION
USN-subtle cases Superior
retinaculum
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Chronic Ankle Instability ANKLE SPRAINS
– COMMON INJURY
LATERAL COLLATERAL LIGAMENTS OF ANKLE Ant.
Talofibular Lig. Calcaneofibula
r Lig.
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Calcaneal deformity-varus-Biomechanics
McEllvany-reciprocal relationship HF & FF
Coleman block test Carroll test Sarrafian twisted
plate
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Twisted plate – rigid lamina pedis
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Lamina pedis
Loose pack Ext rot load column Hindfoot varus Forefoot pronation Pf loose
Tight pack Int rot load column Hindfoot valgus Forefoot supination Pf taut
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Cavovarus-Mosca 2014
Acquired sometimes progressive pronation deformity of the HF on FF
FF pronated,MF adducted, HF endorotaion
Ankle apparent equinus in child-more FF
Tibia ET Motor PL >> TA;Recruited EHL >FHL Flexibility HF vs FF flexible vs stiff
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CLINICAL EVALUATION Wt. bearing exam Prone biomechanical exam ROM GSC strength Heel width & height Coleman block test Neurologic
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PRINCIPLES Assume proper osseous realignments Identify motor deficits:
agonist/antagonist Access soft tissue contractures Rules of tendon
transfers:length,strength, in phase, rom, tension
Underlying pathologies Functional deficits
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CLINICAL EVALUATION Wt. bearing exam Prone
biomechanical exam
ROM GSC strength &
contracture Coleman/Chestnut
block test Manoli “peek-a-
boo” H Kelikian “push-up
test” Neurologic
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No correction w Carroll/Coleman
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RADIOGRAPHS
AP/Lateral wt. bearing foot Broden’s Axial Weight bearing axial -Cosby
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Coleman block Xray w Saltzman view
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Considerations
Age Unilateral vs bilateral Progressive or static ? Idiopathic,traumatic,hereditary Rigid or flexible?-rom Agonist vs antagonist:PB/PT,PL/TA,E/F Hindfoot varus reciprocal to forefoot
pron.
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Nonsurgical options
Cavovarus orthotic device Unload 1st mtp head Lateral heel sole wedge
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CMT 30 TYPES-HSMN
Type I a-c 50% all case AD IA 80% of I ncvs are
10-30ms IB point mutation
severe demyelinating IC-? Defect rare
Others II, X,IV II-20%,AD,ncv
normal,indolent course
X-linked females clinically, male carriers,10-20%=defect conexin protein # 32
IV-AR,rare,absent myelin proteins
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JM-HSMN
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IMR
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60 mo f/u
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Bilateral TTC fusions
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5th metatarsal banana
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23 yo football 100kg
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Removal 4mm retap insert 6.5mm & 1st ray DCWO
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Calcaneal deformity-varus
Varus hinfoot Pronated 1st ray McEllvenny CO:1958; reciprical
relation Coleman block test Carroll test Hind foot alignment view
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Cavovarus :Surgical Options
Dwyer osteotomy:1cm lateral closing wedge
Lateral displacement osteotomy <5mm Scarf triplane osteotomy 45 degree osteotomy Transfix with axial screw or staple Keep screw in lateral 1/3 of heel 2 incision technique 5cm bridge:Anderson/ Davis (AOFAS 8/04) for lat recon. Sx
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1cm lateral cw osteotomy
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Skin bridge 5cm
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41yo ankle pain
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Allograft ligament failed Brostrom with cavovarus
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mobilization
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1st MT & Z osteotomy
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12mo post
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AAAA @ 3mo
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MA HF driven cavus Rx Dwyer/1st MTO
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Cavovarus: Surgical Options
If 1st ray pronated Or Coleman block shows correction Modified Lapidus Dorsal closing wedge 1st TMT joint Cross screw,plate or staple fixation
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1st MT DCW Osteotomy
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1st ray Rx via dorsal cwo
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Bibliography Kelikian AS.:Calcaneal
Osteotomies.Ch;#23.Operative Rx of the Foot & Ankle,Appleton & Lange,Stamford,Conn;417-32,1999.
Mosca, VS; Principle and management of pediatric foot & ankle deformities & malformations. Wolters Klumar,2014
Rodrigues RP.:Medial displacment calcaneal osteotomy in the Rx of PTD. Foot & Ankle Clinics.#3,545-67,2001.
Sammarco GJ, Taylor R.:Combined calcaneal & metatarsal osteotomies for the Rx of the cavus foot.Foot & Ankle Clinics.#3:533-43.2001