Pes Cavus Treatment & Management
- Author: Norman S Turner, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
The goal of treatment is to allow the patient to ambulate without symptoms. The underlying cause must be identified to determine whether the disorder is progressive. The patient must understand the rationale for treatment and realize that surgical reconstruction does not provide a normal foot. The goal of surgery is to produce a plantigrade foot and pain relief. Repeat surgical procedures may be necessary, especially if the deformity is progressive. Preoperative patient education is essential for patient satisfaction.
Nonoperative treatment may provide significant relief. Physical therapy to stretch tight muscles and strengthen weak muscles may provide early relief. Orthotics with extra-depth shoes to offload bony prominences and prevent rubbing of the toes may improve symptoms. For varus deformities, a lateral wedge sole modification can improve function. Bracing for supple deformities or foot drop may allow patients to ambulate; however, in patients with sensation deficits, Plastazote linings in the brace are required, and frequent inspection of the skin for ulceration is warranted.[12, 13]
Surgical decision-making requires a careful and complete examination of the foot and ankle, especially for rigidity, strength, and deformities.[14, 15, 16] The goal of surgery is to provide a plantigrade foot.
Surgical procedures can be broadly categorized into soft-tissue and bony procedures. No single procedure is appropriate for all patients, and frequently, multiple individual procedures need to be performed. Tendon transfers and osteotomies can provide correction of the deformity without requiring an arthrodesis; however, arthrodesis may be warranted if arthritic changes are observed in the joints or if complete muscle paralysis is present. The most common procedures are discussed below.
Plantar fascia release
In pes cavus, the plantar fascia may become contracted. Plantar fascia release is usually combined with a tendon transfer, an osteotomy, or both. This is frequently the first step in improving the deformity. Techniques for stripping the fascia off the calcaneus and complete resection of the plantar fascia have been described.
As described by Mann, plantar fascia release is initiated by placing the patient in a supine position, with external rotation of the leg so that the plantar fascia can be exposed. A thigh tourniquet is usually used.
An oblique incision is made just distal to the weight-bearing plantar fat pad of the heel and extended over the contracted plantar fascia. This protects against injury to the branches of the calcaneal nerve. The incision is deepened through the fat to the level of the plantar fascia. The plantar fascia and the fascia of the abductor hallucis are exposed.
The fascia is cut while tension is applied to the metatarsophalangeal (MTP) joints by dorsiflexion. A segment of the fascia is removed. If the fascia surrounding the abductor hallucis is tight, it is also released. The area is inspected for any tight bands that should be released.
The wound is sutured closed in the usual fashion. Postoperatively, the patient, with the foot in neutral position, is placed in a compressive dressing with a plaster splint. The cast remains in place for 4 weeks or longer, depending on whether other procedures are combined.
The complications of plantar fascia release include incomplete release and nerve injury.
Great toe Jones procedure
A great toe Jones procedure is performed for a cock-up deformity of the great toe with associated weakness of the anterior tibialis.[19, 20] In this case, the extensor halluces longus (EHL) has been recruited to assist in ankle dorsiflexion, which causes hyperextension at the MTP joint and hyperflexion at the interphalangeal (IP) joint. This procedure transfers the EHL to the neck of the first metatarsal, with arthrodesis of the IP joint to improve the dorsiflexion of the ankle and remove the deforming force at the MTP joint.
This procedure is initiated with the patient supine and under general or spinal anesthesia. The lower extremity is exsanguinated, and a thigh tourniquet is inflated.
An incision is started at the medial border of the distal phalanx and extended across the IP joint, curving proximally to the level of the first metatarsal neck. Dissection is carried down to the extensor mechanism. The EHL insertion on the base of the distal phalanx is freed.
The surfaces of the IP joint are prepared by removing the articulating cartilage with a saw and aligned in 5° of plantarflexion. A guide pin is placed from the arthrodesis site distally out the tip of the toe and then retrograde into the proximal phalanx. An incision is made over the guide pin at the tip of the toe. A cannulated 4.0 screw is placed across the arthrodesis site. A Kirschner wire (K-wire) can be used to augment the fixation if needed. The final fixation is usually placed after the tendon transfer has been completed to prevent loss of fixation.
A suture tag is placed in the EHL tendon. The neck of the first metatarsal is identified, and a drill hole large enough to accommodate the tendon is made from the medial side to the lateral side. A Swanson tendon passer is used to bring the tendon from the lateral to medial side through the drill hole. The tendon is sewn to itself, with the ankle in 15° of dorsiflexion.
The incision wounds are closed in layers, and a compressive dressing with a posterior splint in 10° of dorsiflexion is used. Casting is left in place for a total of 8 weeks, with the patient restricted to non–weight-bearing for the first 4 weeks.
The complication most commonly observed with the great toe Jones procedure is nonunion of the IP joint, which is often asymptomatic.
Extensor shift procedure
The extensor shift procedure involves transferring the EHL and the extensor digitorum longus (EDL) to the first, third, and fifth metatarsals. The technique includes completion of the Jones procedure, with incisions in the second and fourth web spaces. The tendons are harvested. The second and third tendons are transferred through a drill hole on the third metatarsal, and the fourth and fifth tendons are transferred to the fifth metatarsal.
The Girdlestone-Taylor transfer procedure is used for flexible claw toe deformities. The deforming force of the flexor digitorum longus tendon is transferred to the extensors to correct the deformity.
The patient is positioned supine with a tourniquet. A small transverse incision is made at the proximal flexion crease. Blunt dissection with a curved hemostat is performed down to the flexor tendon sheath.
The sheath is opened with a longitudinal incision, and the long flexor tendon is identified. The tendon is retracted, and a percutaneous flexor tenotomy is performed at the incision site at the base of the distal phalanx. The tendon retracts into the wound.
A dorsal longitudinal incision is made over the proximal phalanx. Dissection is carried down to the extensor hood. A curved hemostat is passed from the dorsal side to the plantar side, next to the bone, to avoid injury to the neurovascular bundle. The medial long flexor tendon is transferred medially, and the lateral tendon is transferred laterally. The tendons are sewn onto the extensor mechanism, with the toe in 20° of plantarflexion. A K-wire can be placed across the MTP joint and kept in place for 3 weeks to protect the repair.
The wounds are closed in the usual fashion, and the foot is placed in a postoperative shoe. The toe is taped in a slight plantarflexed position, which is maintained for 6 weeks. Motion through the MTP is allowed after 6 weeks.
Base of first metatarsal osteotomy
In patients with a fixed plantarflexed first ray, a base of the metatarsal closing wedge osteotomy corrects the deformity, which is especially observed in Charcot-Marie-Tooth (CMT) disease. This procedure is usually combined with a plantar fascia release in a mild deformity or a Jones procedure.[19, 21]
The patient is placed in a supine position under either general or regional anesthesia. A dorsal incision is made over the base of the first metatarsal extending proximally to the medial cuneiform. The osteotomy is located 1 cm distal to the first tarsal-metatarsal (TMT) joint. After determining the amount of bone to be removed with a closing wedge, a 3.5-mm drill hole is made 1 cm distal to the final osteotomy site.
The osteotomy is made parallel to the TMT joint but not through the plantar cortex. The next cut is made, removing the amount of bone needed to correct the deformity, and the wedge of bone is removed. The plantar cortex is cracked with manipulation, and the osteotomy is closed.
To verify the correction, plantar pressure is applied to the base of the fifth and first metatarsal heads. Equal pressure should be found at these points.
The 2.5-mm drill with the centering guide is placed in the previous drill hole and advanced. The drill hole is tapped, and the 3.5 cortical screw is placed.
The wound is closed in the usual fashion, and the patient is placed in a compressive dressing with a plaster splint. The casting is maintained for 8 weeks, and the patient is restricted to non–weight-bearing for the first 4 weeks.
Tarsal osteotomy has been described for deformities through the midfoot; however, these osteotomies require cutting through multiple joints. They are quite technically complex and are rarely performed.[22, 23, 24] Zhou et al reported good results from performing midfoot osteotomy combined with adjacent joint-sparing internal fixation to treat rigid pes cavus deformity.
Peroneus longus to peroneus brevis tenodesis
In patients with CMT disease who have a weak peroneus brevis (PB) and a preserved peroneus longus (PL), a tenodesis can be performed to help stabilize the ankle. This is frequently combined with a calcaneal osteotomy.
Because there are other procedures that are frequently performed along with tenodesis, the patient is positioned supine with a bolster under the ipsilateral hip. An oblique incision is made just posterior to the peroneal tendons, with care taken to avoid damage to the sural nerve. The tendon sheath is identified and entered. The PL and PB tendons are identified, and a tenodesis is performed. The wound is closed in layers and immobilized in a cast.
Patients with hindfoot involvement usually require a calcaneal osteotomy to correct the deformity. The osteotomy can include a closing wedge, a vertical displacement, or a combination (triplanar osteotomy). This procedure is usually combined with a plantar fascia release and, frequently, a tendon transfer.
The patient is positioned supine with a bolster under the ipsilateral hip. A thigh tourniquet is used.
An oblique incision is made just posterior to the fibula and posterior to the peroneal tendons. Careful dissection is carried down to the calcaneus to avoid the sural nerve. Subperiosteal dissection is performed on the lateral calcaneus with an elevator. The posterior facet is palpable and verified under image to prevent violation of the subtalar joint.
An oblique cut is made 1 cm posterior to the posterior facet. The cut does not penetrate the medial cortex. A second cut can be made, to create a V-type cut, so that the wedge of bone can be removed laterally. The medial cortex is penetrated carefully to avoid injury to the neurovascular bundle. If a closing wedge osteotomy is not needed or is combined with displacement, then the soft tissues are stretched medially with a laminar spreader. The osteotomy can then be displaced laterally or superiorly.
The osteotomy is usually fixed with a cannulated screw placed from the posterior side to the anterior side. Staples or large Steinmann pins can be used.
The wounds are closed in the usual fashion and placed in a compressive dressing with a plaster splint. A cast is placed when the swelling subsides, and the patient is restricted to non–weight-bearing for 4 weeks and then partial weight-bearing for another 4 weeks.
Beak triple arthrodesis
The Siffert beak triple arthrodesis corrects pes cavus deformities through wedge resection and a triple arthrodesis. This procedure is used for treatment of rigid fixed deformities in adults. The technique involves mortising the navicular into the head of the talus and depressing the navicular, cuboid, and cuneiforms to improve forefoot cavus deformities. This procedure is complex and technically demanding.
The patient is positioned supine with a bolster under the ipsilateral hip. A thigh tourniquet is used. An incision is made laterally from the tip of the fibula to the base of the fourth metatarsal.
The extensor digitorum brevis is removed from its origin on the sinus tarsi and reflected distally. The subtalar and calcaneocuboid joints are exposed, and the lateral talonavicular joint may be visualized through the lateral wound.
A medial approach is made from the tip of the medial malleolus to the naviculocuneiform joint. The capsule of the talonavicular joint is exposed with care, to avoid excess dissection dorsally and to preserve blood flow.
The first cut involves the posterior facet of the subtalar joint, with resection of 3-5 mm of bone laterally.
From the medial incision, a segment of the plantar two thirds of the talus is resected 1 cm in depth. The dorsal one third of the talus is left intact. The dorsal aspect of the navicular is removed so that the navicular can be placed against the talus.
The calcaneocuboid joint is prepared by removing the joint surfaces with a saw to correct the abduction-adduction alignment in the foot.
The arthrodesis sites are fine-tuned for position and apposition. The sites are then fixed in the following order: subtalar, talonavicular, and calcaneocuboid. They are fixed with cannulated screws, staples, Steinmann pins, or a combination of these.
The wounds are closed in the usual fashion, and a compressive dressing is applied with a posterior plaster splint. Postoperatively, casting is maintained for 6 weeks, and the patient is restricted to non–weight-bearing during the 6 weeks and then to partial weight-bearing for 4 weeks.
Follow-up care is based upon the procedure that has been performed and is listed after each procedure in Surgical therapy.
The complications of these procedures include nonunion, malunion, infection, undercorrection, overcorrection, recurrence of the deformity, progression of the deformity, nerve injury, and continued pain.
For progressive disorders, deformities can recur; patients need to be educated about this possibility before the initial surgery.
Outcome and Prognosis
The results of surgical intervention are difficult to compare because of the multiple possible combinations of procedures necessary for successful treatment. Also, patients have varying degrees of deformity, disease progression, and underlying etiology, making comparison virtually impossible.
Nevertheless, some positive findings have been reported, such as Wetmore and Drennan's report that 24% of patients with CMT disease who underwent a triple arthrodesis had satisfactory results at an average of 21 years of follow-up. They recommended the triple arthrodesis as a salvage procedure.
Mann and Hsu reported on 12 feet in patients with CMT disease that underwent triple arthrodesis, with a follow-up that averaged 7.5 years. Five feet were plantigrade, asymptomatic, and united. Three feet were plantigrade and asymptomatic but had nonunions. Four feet were nonplantigrade and symptomatic. The authors stated that positioning is the key to satisfactory results.
Roper and Tibrewal reported the results of soft-tissue procedures combined with osteotomies. Ten cases of CMT disease were reviewed 14 years after surgery. Two patients required repeat surgery secondary to recurrent deformity. At last follow-up, all patients had plantigrade feet, without requiring a triple arthrodesis.
Gould discussed 18 feet in 10 patients with a 3- to 6-year follow-up. All had satisfactory results with soft-tissue procedures combined with osteotomies, and all patients had plantigrade feet at last follow-up.
Sugathan et al treated lesser-toe clawing in 11 feet (eight patients) with flexible pes cavus using a modified Jones procedure. At final clinical review, all 11 feet were improved, with minor complications in six. The mean Bristol Foot Score was 27, and the mean modified American Orthopaedic Foot and Ankle Society Midfoot Score was 76, which indicated excellent results. Half of the patients had mild persistent foot pain, but all were satisfied with the outcome.
Naudi et al reported radiologic and clinical results with anterior tarsectomy in 39 cases (33 patients) of pes cavus. Pain decreased considerably in 75% of cases, and 68% of patients recovered normal activity. The foot was aligned correctly in 67% of cases, but at last follow-up, pes cavus remained undercorrected in 80%. In 74% of feet, adjacent joints showed progressive osteoarthritic degeneration. Subjectively, 70% of patients were very satisfied or satisfied with minor reservations, and objective outcome was excellent or good in 66% of feet.
According to Naudi et al, the overall results of this study showed that outcome in terms of function, motion, complications and satisfaction was good, but pain relief results were poor. They added that anterior tarsectomy is able to correct initial pes cavus deformity and compensate anomalies of the hindfoot, but its correction capacity is limited and its efficacy in case of clawfoot is poor.
Limitations to the literature exist. Most of the reported results include reviews of adolescents and not of adults. Multiple variables are included with a small population of patients; however, the current trends are toward soft-tissue procedures combined with osteotomies. Arthrodesis is reserved for salvage procedures.
Future and Controversies
The current controversy in the reconstruction of these deformities is whether to proceed with osteotomies and tendon transfers or arthrodesis. The current trend is to preserve the joints, if possible, and to perform an extensive arthrodesis as a salvage procedure.
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