Disorders of The Foot

CHAPTER 19
Disorders of the Foot Anthony I. Riccio
and the intermediate cuneiform at 3 years. The navicular ossifies

Chapter Contents between the second and fifth years of life (Figs. 19.1–19.3).
The foot has its own growth pattern, which differs from the
Introduction 682
growth rate of the rest of the body. Blais, Green, and Ander-
Normal Variations 682
son showed that the foot grows rapidly between infancy and 5
Osteochondroses 689
years old and slows to a rate of 0.9 cm per year between 5 and
Congenital Deformities 691
12 years old in girls and between 5 and 14 years old in boys,
Neurogenic Abnormalities 755
when growth usually ceases.1 Gould and co-workers found
Toe Deformities 768
that children younger than 2 years old underwent a half-size
increase in shoe size every 2 to 3 months. Those between 2 and
3 years old changed a half size every 3 to 4 months, and those
between 3 and 5 years old changed a half size every 4 months.
Introduction Boys at a given age were one size longer and one size wider
than girls.3 The foot of a 1-year-old girl or an 18-month-old
The human foot is a complex structure capable of support- boy has achieved half its adult length. These growth charts
ing body weight, accelerating the body in running, changing have been used for timing procedures that affect future foot
position for uneven terrain, and even assuming prehensile growth, such as a triple arthrodesis.1,2,4–7,9–12
function in a person missing upper extremities.4,6–8,10,12 For References, see expertconsult.com.
The major articulation of the hindfoot is the joint between
the talus and the complex of the navicular, calcaneus, and
cuboid. The calcaneocuboid- navicular complex has been Normal Variations
called the acetabulum of the foot, with the talus being the
figurative femoral head. The “acetabular” configuration Many variations of a “normal” foot are seen, especially in a
allows motion in several planes—a more complex concep- newborn. Intrauterine crowding is blamed for metatarsus
tualization than the older description of an oblique hinge. adductus and calcaneovalgus deformities, both of which
Movements of the foot are often described in confusing usually resolve spontaneously. The normal range of configu-
terms. The hindfoot inverts and everts into varus and valgus ration of the arch of the foot varies from high to flat and is
positions. When the hindfoot inverts, the rest of the foot not much influenced by shoe or orthotic wear, much to the
rolls onto the outer border of the foot as it supinates. When consternation of many grandmothers.
the heel everts into valgus, the forefoot pronates, thereby Many common radiographic variations have been
increasing weight bearing on the first ray. Smaller arc move- described in the foot, some resembling pathologic condi-
ments occur in the midfoot between the cuneiforms, navic- tions. In more than 20% of children, one or more accessory
ular, cuboid, and metatarsals.5,9 bones are seen on radiographs (Figs. 19.4–19.6).31 Fig. 19.7
The medial longitudinal arch of the foot is maintained illustrates the commonly recognized accessory bones of the
by a combination of ligamentous and muscle attachments. foot. The os trigonum and accessory navicular are described
Relative overactivity of the plantar muscles produces a high, in detail because they are of clinical importance.
cavus arch, whereas underactivity, as in the case of posterior
tibial tendon rupture, will cause flattening of the arch.
Os Trigonum
Ossific development of the foot begins in utero.2,11 During
embryonic development the foot passes through three different The os trigonum is formed from the lateral portion of the
positions. Early on (15 mm) the foot is in a straight position. By groove in the posterior aspect of the talus, through which passes
the 30-mm stage the foot is in an equinovarus and adducted pos- the flexor hallucis longus (Fig. 19.8). It has also been called
ture, much like a clubfoot. By the 50-mm mark the foot returns the trigonal process, the Stieda process, and the posterior pro-
to a neutral, slightly adducted and equinovarus position termed cess. Between 8 and 11 years old, medial and lateral centers
the fetal position. It has been postulated that a clubfoot is the of ossification appear radiographically in the two portions of
result of an arrest in development at the 30-mm stage.13 At the walls of the groove for the flexor hallucis longus. Normally,
birth, the talus, calcaneus, and cuboid are ossified but the navic- these ossification centers fuse to the talus within a year though
ular and cuneiforms remain cartilaginous. The metatarsals and longitudinal radiographic studies have shown that 30% remain
phalanges are also ossified at birth. The lateral cuneiform ossi- unfused at skeletal maturity.17 When the ankle is fully plantar
fies between 4 and 20 months, the medial cuneiform at 2 years, flexed, the tubercles contact the posterior edge of the distal
end of the tibia, and forceful plantar flexion may cause the lat-
The author wishes to acknowledge the contribution of John A. Herring
eral tubercle to break away from the talus. Radiographically, a
and B. Stephen Richards for their work in the previous edition ver- fractured os trigonum may be distinguished from one that has
sion of this chapter. yet to fuse to the talus by the finding that the unfused os has a
682
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CHAPTER 19 Disorders of the Foot 683
A B
FIG. 19.1 (A) Lateral radiograph of a newborn foot. The cuboid is the only ossified midtarsal bone. Note the convergent talocalcaneal angle.
(B) Anteroposterior radiograph of a newborn foot. The cuboid is ossified, but no ossification is present in the navicular or cuneiform.
A B
FIG. 19.2 Ossification of the tarsal bones and metatarsals in a 3-year-old boy. (A) Anteroposterior radiograph of both feet. (B) Lateral radio-
graph of the right foot. Note that the medial and intermediate cuneiform and navicular bones are ossified.
A B C D
E F G H
FIG. 19.3 Ossification of the distal epiphyses of the tibia and fibula. (A) One-year old; (B) 2 years; (C) 4 years; (D) 6 years; (E) 7 years; (F) 10
years; (G) 12 years; (H) adult.
684 SECTION II Anatomic Disorders
GIRLS BOYS
30 30
28 28
26 26
24 24
22 22
Length (cm)
20 20
18 18
16 16
Percentiles
14 14
3 and 97
25 and 75
12 50 12
10 10
0 0
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
Age (years) Age (years)
FIG. 19.4 Length of the normal growing foot, derived from serial measurements made in 512 children from 1 year to 18 years old. (Re-
drawn from Blais MM, Green WT, Anderson M. Lengths of the growing foot. J Bone Joint Surg Am. 1956;38:998–1000.)
bringing into question the traumatic etiology of these ossicles.17

The vast majority of children with an os trigonum never experi-
ence associated symptomatology. When symptoms do occur,
they may include pain localized to the posterior aspect of the
ankle that is increased with forced plantar flexion, limitation
of motion, weakness, swelling, and neurologic changes.20,38
Increased uptake may be seen on a bone scan in the region of
the os trigonum, and computed tomography (CT) may reveal
separation of the ossicle. Magnetic resonance imaging (MRI)
best demonstrates mobility of the fractured os trigonum in
flexion and extension.36 A high T2 signal posterior to the talo-
calcaneal joint indicative of synovitis often has been found.
Other findings include thickening of the posterior capsule of
the ankle and tenosynovitis of the flexor hallucis longus. Bone
marrow edema in the posterior talus or in a patchy distribution
is another common finding. These findings are more common
than signal changes within the os trigonum itself.26
FIG. 19.5 Accessory ossification center of the medial malleolus, a A trial of immobilization may relieve the pain, and some
normal anatomic variation. patients have a lasting response to one or more steroid
injections around the os trigonum.24 Open or arthroscopic
very smooth, regular, radiolucent area between it and the tibia. excision should be reserved for those in whom conserva-
In contrast, a fractured os trigonum has a rough border. Grogan tive therapy fails (Video 19.1).21 Marotta20 and Micheli
and colleagues, in an anatomic study of 7-, 12-, and 14-year-old reported improvement after excision of the ossicle in a
specimens, found the os trigonum to be part of the talus (i.e., in series of ballet dancers in whom conservative treatment
the cartilage anlage of the talus) as a secondary ossification cen- failed. Although two thirds still had occasional discomfort,
ter, similar to the posterior calcaneal apophysis. They felt that all were able to return to dance, with their time to full activ-
a noncontiguous os trigonum was the result of an injury to the ity averaging 3 months.20 Abramowitz and colleagues noted
chondro-osseous border of the synchondrosis, either because of worse results after resection in patients who had symptoms
a chronic stress fracture or, less frequently, an acute fracture,11 for longer than 2 years when compared with those who had
with onset after acute injury, often an ankle sprain (Fig. 19.9). symptoms of a shorter duration.1 Wredmark and associates
More recent work has suggested that approximately one third released the flexor hallucis sheath if thickened at the time
of os trigonums never achieve osseous continuity with the talus of os trigonum removal.38
FIG. 19.6 Accessory ossicle at the base of the fifth metatarsal (os vesalianum).
Talus secundarius, ?
Os sustentaculi I, 5%
Os trigonum, 13%
Os cuboideum
secundarium, 1%
Os fibulare, 10%
Os tibiale Os tibiale externum, 10%
externum, 10%
Os vesalianum, ?
Os intercuneiforme, ?
Os intercuneiforme,
Pars fibularis ossis seldom
metatarsalis I, Os trigonum, 13%
seldom
Os intermetatarseum,
9%
Calcaneus secundarius 4, 4%
Os vesalianum, ? Os fibulare, 10%

FIG. 19.7 Accessory bones in the foot and the percentage of individuals in which they are found. (Redrawn from von Lanz T, Wachsmuth W.
Praktische anatomie. Berlin: Julius Springer; 1938:359.)
FIG. 19.8 Os trigonum in a 12-year-old child. Note also the ac-

cessory navicular, visible in a lateral projection. The sclerosis of the
apophysis of the os calcis is normal.
FIG. 19.9 Fracture of a fused os trigonum.

Accessory Navicular
Of all the accessory bones in the foot, an accessory navicu- had an accessory navicular bone and half had a hypertro-
lar is most often associated with symptoms. The condition phic posterior tibial tendon. Some of the accessory navicular
was first described by Bauhin in 1605.13,39 It has also been bones were true sesamoids, lying in the tendon before it split
termed the prehallux, accessory scaphoid, os tibiale externum, and separated from the navicular bone by a 3-mm distance.
os naviculare secundarium, and navicular secundum.8–10,13 Most accessory naviculars were connected to the navicular
The estimated prevalence of accessory navicular bones in the by fibrous tissue and were within the main insertion of the
general population ranges from 14% to 26%.11,19,32 tendon. Another cadaver study found that the posterior
Three types of accessory navicular bones have been tibial tendon inserted directly into the accessory navicular
described.28,30 Type I (os tibiale externum) is a small ossicle without extending to the sole of the foot; the second part
within the substance of the tibialis tendon. Type II is an of the posterior tibial tendon extended from the accessory
8-to 12-mm ossicle extending medially and plantarward navicular to the normal plantar insertions. No connection
from the navicular bone and connected to the navicular by a was present between these two portions of the tendon, and
cartilaginous synchondrosis. Type III is a cornuate navicular when traction was placed on the proximal tendon, the distal
remaining after fusion of the accessory navicular with the portion showed no movement, suggesting that the presence
primary navicular bone. of this anomaly would lead to a pronated foot.16
A more recent analysis using MRI to assess the insertions of
Etiology the posterior tibial tendon in cadaveric feet confirmed that in
An accessory navicular is considered to be a normal ana- all feet with a type I accessory navicular, the tendon inserted
tomic variant that may become symptomatic for a variety directly into the accessory bone with a slip less than 1.5 mm
of reasons. Several reports describe autosomal dominant in thickness extending to the medial aspect of the navicular.25
inheritance with incomplete penetrance.7,15 The accessory navicular was thought to interfere with
normal leverage of the tibialis posterior and result in a weak
Pathology longitudinal arch and flatfoot13,14; subsequent studies have
In an examination of accessory naviculars removed from shown no relationship between the two.33
symptomatic patients, Grogan and associates found areas
of microfracture of the cartilaginous synchondrosis, hemor- Clinical Features
rhage, acute and chronic inflammation within and around Controversy exists regarding how often the entity is painful
the synchondrosis, and cellular proliferation in tissues sur- and how often its presence goes unnoticed. Many children have
rounding the fractures.10 All the accessory naviculars exhib- asymptomatic accessory navicular bones that may be noticed
ited chronic inflammation indicative of chronic injury with incidentally on clinical examination or on radiographs. In addi-
a prolonged inflammatory response. All the fractures were tion, the true native navicular extends well medially and toward
partial separations, with no cases of complete separation the plantar surface of the foot, and a prominence in this area
from the primary navicular. These changes were considered may often be due to pressure over this normally large bone.
to be the result of chronic stress, occurring from overuse. A child with a symptomatic accessory navicular will have
Bareither and colleagues studied 38 cadaveric feet in a pain over an enlarged area at the medial aspect of the mid-
cadaver study of feet with a prominent navicular area2; half foot (Figs. 19.10 and 19.11). The enlarged site is seldom
A B
FIG. 19.10 Accessory navicular of the left foot. (A) Clinical appearance. Note the local fullness. (B) Radiographic anteroposterior appearance.
Note the smooth and rounded outline of the accessory ossicle (arrow).
sports. The pain is alleviated by wearing less constraining

footwear.
On examination, there will be some tenderness over the
enlarged area. Skin irritation over the prominence is not
uncommon. It may be possible to feel motion between a
prominent accessory navicular and the primary navicular.
Resisted inversion is sometimes painful, and there may be
tenderness over the tibialis posterior tendon.
Radiographic Findings
An accessory navicular is best seen on an oblique radiograph
directed medially to laterally (the external oblique view) (see
Figs. 19.10 and 19.11).10 It may also be seen on a standard
anteroposterior (AP) projection. The navicular is the last tarsal
bone to ossify. Ossification occurs in girls between 1 and 3 years
old and in boys between ages 3 and 5 years.12,37 An accessory
navicular ossifies at an even later age. Feet with accessory navicu-
lar bones have been found to have wider and more prominent
native navicular bones with greater medial prominences than
feet without accessory naviculars.29 Radiographic diagnosis of
the condition is usually made in later childhood or adolescence.
CT can be useful to better delineate the extent of an acces-
sory navicular but is rarely necessary for diagnosis or preop-
erative planning. Technetium bone scans may help identify
symptomatic accessory naviculars, although some asymptom-
atic accessory naviculars will also have increased uptake of
FIG. 19.11 External oblique view sowing a type II accessory navicular. tracer (Fig. 19.12).6,10,32 In a study of patients with focal pain
over the navicular, MRI showed edema of the marrow.22
A bipartite navicular (which is an entity distinct from an
larger than a centimeter in diameter and is generally some- accessory navicular; Fig. 19.13) appears on radiographs as a
what smaller. This area, which is just at the insertion of the dorsally displaced, comma-shaped, separate segment of the
tibialis posterior tendon, is frequently callused or red. Tight- navicular. Despite the dorsal displacement, the segment still
fitting shoes aggravate the pain, especially those worn for articulates with the talus.24
A B
FIG. 19.12 Accessory navicular. (A and B) Technetium bone scans demonstrating increased tracer uptake in the symptomatic right foot
(arrows) versus the asymptomatic left foot. (From Grogan DP, Gasser SI, Ogden JA. The painful accessory navicular: a clinical and histopatho-
logical study. Foot Ankle. 1989;10:164–169.)
anatomic repair of the tendon is the procedure of choice for

patients in whom conservative therapy fails.18 We have not
found it necessary to detach the tendon from its broad inser-
tions. The incision extends along the medial surface of the
foot, directly over the accessory navicular from the midtalus
to the base of the first metatarsal. The subcutaneous tissue
and the deep fascia are divided, and the wound margins are
retracted to expose the posterior tibial tendon and the medial
portion of the navicular. The posterior tibial tendon inserts
into the tuberosity of the navicular and into the plantar sur-
faces of the three cuneiform bones, as well as into the bases
of the second through fourth metatarsals and laterally into
the cuboid. The accessory navicular is dissected free from
the central portion of the posterior tibial tendon while the
remainder of the tendon insertions are left intact. The acces-
FIG. 19.13 Lateral radiograph showing a bipartite navicular articu- sory navicular is excised and the medial and plantar portions
lating with the talus. of the navicular are resected until it is flush with or slightly
depressed relative to the adjacent talus and cuneiform. If
the primary navicular is still prominent after excision of the
Treatment accessory navicular, the surgeon should consider complete
Treatment varies from observation and symptomatic man- removal of the medial prominence of the true navicular. The
agement to excision. A child with an accessory navicular wound is then closed and soft dressings applied. A short-
initially should be treated with soft pads between the foot leg walking cast may be used postoperatively for four to six
and the sole of the shoe and should avoid wearing tight, weeks for ease of ambulation and to allow healing of the
stiff shoes. Elevated arch pads are not beneficial for these posterior tibial tendon to the native navicular.
patients because the pads may aggravate the pressure over Other authors prefer the Kidner procedure,13,14,28,34
the navicular. If these treatment measures fail and there which entails rerouting the central slip of the tibialis poste-
is a planovalgus deformity of the foot, a valgus-correcting rior laterally onto the plantar surface of the navicular where
shoe insert may be effective. Such inserts relieve pressure it is sutured under tension to the local ligaments or to the
over the navicular by inverting the patient’s heel during gait navicular itself using suture anchors. A short-leg walking
rather than by pushing up on the arch of the foot. cast is then generally applied for 3 to 4 weeks postoperation.
In more recalcitrant cases, the surgeon may consider
injecting the joint between the accessory navicular and the Results and Complications
primary navicular with steroids and an analgesic agent. Immo- In many cases, patients obtain full relief of symptoms after
bilization in a short-leg cast has also been recommended.10 simple excision of an accessory navicular (>90%) and after
A number of surgical procedures have been used for the Kidner procedure (96%).3,10,27,30,33 Comparing the results
this condition (Video 19.2). One report cites good results of simple excision with the Kidner procedure, no differences
in type II accessory naviculars with percutaneous drilling to in results or patient satisfaction have been identified and we
achieve union between the accessory and primary navicular therefore recommended the simpler approach.5,35
bones.23 Simple excision of the navicular by shelling it out of Occasionally, symptoms persist after surgical exci-
the substance of the posterior tibial tendon accompanied by sion of the accessory navicular. If the primary navicular
FIG. 19.14 Anteroposterior radiograph of both feet of a 4-year-old FIG. 19.15 Köhler disease. Lateral radiograph of the 4-year-old
girl who complained of foot pain. The left navicular is sclerotic and girl’s left foot showing apparent compression of the navicular.
wafer-thin, characteristic findings in Köhler disease.
center. At maturity, the navicular is supplied by five or six

is prominent medially, pain and tenderness may continue arteries, which anastomose with the bone. In rare cases a
over the area even though the accessory navicular has been different pattern is found in which a single dorsal or plantar
removed. In other cases, the scar itself and the area beneath artery supplies most of the nutrition to the bone. The vascu-
the scar remain tender despite adequate removal of bone. lar etiology of Köhler disease is supported by biopsy studies
The cause of this tenderness is unclear, however. Over time showing areas of necrosis, resorption of dead bone, and for-
the symptoms usually diminish, but they can be annoyingly mation of new bone.8 One author reported bilateral involve-
persistent. ment in identical twins, suggesting a genetic etiology.18
For References, see expertconsult.com.
Clinical Features
The disorder occurs more often in boys than in girls, usu-
Osteochondroses ally between 2 and 7 years old. The child will complain of
pain in the midfoot and limping (Fig. 19.14). Symptoms last
Köhler Disease
from a few days to more than a year. There is no apparent
Köhler disease, described by Alban Köhler in 1908,11 is relationship between the duration of symptoms and radio-
osteochondrosis of the tarsal navicular. The disease is char- graphic changes. In one study, a fifth of the patients had no
acterized by pain in the midfoot accompanied by radio- symptoms, and the diagnosis of Köhler disease was made
graphic changes consisting of sclerosis, flattening, and incidentally from radiographs. A small number of patients
irregular radiolucency of the tarsal navicular. will have a distinct history of trauma.
Physical signs include tenderness, swelling, and some-
Etiology times redness over the dorsum of the foot (occasionally this
The cause of Köhler disease is not known. It has been sug- clinical picture has been mistaken for an infection). The
gested that because of its late ossification relative to the other foot is generally held in pronation. Occasionally, however, it
tarsals, the navicular is vulnerable to mechanical compression will be in supination as the child walks on the lateral side of
injury. In a study of normal navicular ossification, Karp found the foot to relieve stress on the painful medial arch.
that ossification occurs much earlier in girls than in boys.6 The natural history of the disorder is one of spontaneous
The navicular had ossified in half of the studied girls by 2 resolution of the clinical symptoms and radiographic abnor-
years old and in all girls by 3 years old. In half of the boys, the malities over a period ranging from 18 months to 3 years.19
navicular did not ossify until 3 years old, and more than one- Persistence of symptoms into adulthood is extremely rare.14
third were 3 years old before the nucleus ossified. In patients
with slow ossification, the nucleus often appeared similar to Radiographic Findings
Köhler disease. Karp thought that the delay in ossification in The radiographic findings in Köhler disease are distinct (Fig.
boys predisposed them to development of the disorder. 19.15). Often there is dense sclerosis of the navicular, with
Another possible cause of the disease process is avascular narrowing and apparent flattening of the bone (especially on a
necrosis (AVN) secondary to periodic compression of the lateral projection). On an AP view, both sclerosis and lucency
bone. The abundant blood supply of the navicular would of the navicular are seen. These changes gradually disappear
allow rapid, spontaneous healing, unlike AVN occurring over a period of several years, with the radiographic appearance
in areas of marginal blood supply (e.g., the hip).19 Blood of the navicular ultimately returning to normal (Fig. 19.16).
is supplied to the navicular bone by a dense perichondrial
network of vessels on the nonarticular surfaces. As a child Treatment
matures, one or more penetrating arteries appear, and ossi- Karp in 1937 found that the mainstay of treatment was
fication begins around these vessels. When more than one restriction of weight bearing.6 Supportive measures, such as
vessel penetrates, there will be more than one ossification shoe inserts and casts, did not seem to affect the course of
FIG. 19.17 Lateral radiograph obtained 1 year later showing recon-

FIG. 19.16 Anteroposterior radiograph of the navicular obtained 1 stitution of the navicular.
year following conservative treatment showing partial reconstitu-
tion of the navicular with reduced sclerosis. This will eventually
undergo full healing.
the disorder. Reports indicate that symptoms resolve faster

in patients treated with walking casts than in patients who
did not wear a cast.3,20 Short-term cast treatment for 3 to
4 weeks is currently recommended for patients with persis-
tent symptoms that limit their activities.
Outcomes
Köhler disease is a self-limiting disorder that in virtually all
cases resolves over time. Radiographic changes return to
normal, and persistence into adulthood does not occur (Fig.
19.17). In a 31-year follow-up study, Borges and co-workers
found that only two patients had persistent symptoms after
being treated by cast immobilization.3 One patient had a talo-
calcaneal coalition and the other had a large accessory navicu-
lar. The authors concluded that patients could expect full
resolution and normal function with symptomatic treatment.
Freiberg Infraction
Freiberg infraction is a disorder usually seen in adolescence
that is characterized by pain over the plantar aspect of the
second metatarsal head and associated destructive radio- FIG. 19.18 Freiberg infraction. A radiograph of the metatarsals
graphic changes. Occasionally the disease involves other shows the typical flattening and sclerosis of the head of the second
metatarsals. In the European literature this disorder is known metatarsal.
as Köhler second disease to distinguish it from Köhler disease
of the navicular. Freiberg, however, was the first to describe
the disorder,4,5 and his name is more appropriately applied. Clinical Features
The disorder appears most often in adolescents, usually
Etiology after 13 years old. It occurs more frequently in girls than
The cause of the disorder is not known. It is commonly in boys. Pain under the second metatarsal head is the most
thought to be due to AVN of the metatarsal head, and the common complaint, with resultant limping and a decrease
histologic findings resemble those of AVN of other bones.1 in physical activities. An antalgic gait with poor push-off is
Repetitive stress on the metatarsal head, caused by micro- generally present as well. Physical findings are normally lim-
fracture secondary to abnormal stress on the metatarsal ited to tenderness over the affected metatarsal head, with
head, trauma, and abnormal circulation have been proposed occasional swelling noted.
as etiologies.2,7,15 Stanley and colleagues, however, found no
evidence to support trauma as the cause and, through pedo- Radiographic Findings
barographic studies, found that pressure was not increased Radiographs of the second metatarsal head show areas of
at the affected metatarsal head.16 Interestingly, 85% of the lucency and collapse with flattening and loss of the nor-
affected metatarsals were the longest in the foot, and the mal shape of the condyles (Fig. 19.18). This area shows
authors believed that this was an etiologic factor. increased uptake on technetium bone scans.
Congenital Deformities
Postural Deformities
Metatarsus Adductus
Occasionally, children are born with inward deviation of
the forefoot relative to the hindfoot. The deformity may be
very mild and resolve spontaneously, it may be slightly fixed
and persist to walking age, or it may be rigid and associated
with valgus of the hindfoot (Fig. 19.19).11 Milder deformi-
ties require only parental reassurance. Moderate deformities
respond well to manipulation and casting. Those rare cases
with severe, rigid deformation may require surgical correction.
The terminology of these conditions is confusing because
A different authors use various terms, such as metatarsus
adductus, hook-foot, bean-shaped foot, serpentine foot, and
congenital metatarsus adductus, with little agreement
among authors (see Fig. 19.19).
For simplicity, we will call most of these abnormalities
metatarsus adductus and qualify them as actively correct-
able, passively correctable, or rigid. In this text the term
skewfoot will be reserved for a foot with fixed adductus of
the forefoot, increased valgus of the hindfoot, and lateral
subluxation of the navicular on the talus.
Etiology
It has long been presumed, but never proved, that intra-
uterine compression produces metatarsus adductus. The
condition is associated with torticollis and developmental
dislocation of the hip to some degree; but unlike develop-
mental hip dysplasia, it is not related to birth order. The
B incidence of ultrasonographic or clinical hip instability in
children with metatarsus adductus has been reported to be
FIG. 19.19 Bilateral mild metatarsus adductus. (A) Dorsal view as high as 1 in 25, with some authors advocating hip screen-
showing medial deviation of all the metatarsals. (B) Plantar view ing examinations in children with this foot deformity.14
showing the “bean-shaped” foot. This type of foot is easily cor-
rected with serial casting. Incidence
Although flexible metatarsus adductus is a common neo-
natal problem, it is often overlooked. Thus it is difficult to
Treatment accurately determine the true incidence of very mild forms
An initial trial of conservative treatment is strongly recom- of the abnormality. In a screening of 2401 neonates, Widhe
mended. A period in a hard-soled shoe or a trial in a short-leg and associates noted foot abnormalities in 4% of the infants,
walking cast will often relieve the symptoms. Subsequent with 1% having metatarsus adductus (by comparison, 0.7%
use of a metatarsal pad in the shoe may reduce pressure on had calcaneovalgus).20 Hunziker and colleagues found that
the metatarsal head. whereas metatarsus adductus was equally common in pre-
Excision of the metatarsal head, which is recom- term and full-term infants, the condition was more likely to
mended in very refractory cases, has been reported to persist in premature babies.6 Wynne-Davies found an inci-
relieve symptoms. Interpositional arthroplasty using dence of metatarsus varus of 1 in 1000 births and reported
the extensor digitorum brevis can be performed as an that if 1 child were affected, the risk of deformity in a sec-
adjunct to metatarsal head excision.12 Tachdjian advo- ond child in the same family was 1 in 20.21
cated curettage of the metatarsal head, with a cancellous
bone graft placed in the cavity in the head.17 Dorsiflexion Pathology
osteotomy of the metatarsal head, and metatarsophalan- Morcuende and Ponseti studied two fetuses (16 and 19
geal (MTP) joint débridement also have been shown to weeks of gestation) that had metatarsus adductus and found
improve symptoms.7,9,10 Shortening of the second meta- that the shape of the medial cuneiform was altered, with
tarsal provided excellent relief; however, persistent stiff- medial deviation of the articular surface.12 There was also
ness was a problem.15 Long-term follow-up in patients adduction of the metaphyses of the second through the fifth
managed with an extraarticular dorsal wedge closing metatarsals. No joint subluxations or tendon abnormalities
osteotomy of the metatarsal has demonstrated high sat- were noted. Based on findings after dissection of stillborn
isfaction rates, minimal pain, and excellent quality-of- infant feet, Reimann and Werner concluded that the primary
life indices.13 abnormality was medial subluxation of the tarsometatarsal
For References, see expertconsult.com. joints in utero when the foot was in a dorsiflexed position.16
Box 19.1 Characteristic Features of Metatarsus

Adductus
• pontaneous active medial deviation of the foot by the child
S
• High arch
• Concave medial border of the foot
• Separation of the first and second toes
• Fixed adductus of the forefoot when the hindfoot is held in
neutral
• Bean-shaped sole of the foot
Data from Kite JH. Congenital metatarsus varus. J Bone Joint Surg Am.
1967;49:388–397.
Clinical Features
The deformity is usually noted at birth, but it may initially be
recognized at any age. The clinical hallmark of the condition is
medial deviation of the forefoot relative to the hindfoot. When
the foot is viewed from the dorsal surface, the entire foot often
appears to be turned inward. When the foot is viewed from
the plantar surface, the sole of the foot has the shape of a bean.
The base of the fifth metatarsal is usually prominent and the
arch frequently appears higher than normal. In addition, the
space between the first and second toes is wider than normal,
and the first toe seems to be reaching medially. Kite listed six FIG. 19.20 Lichtblau test to demonstrate contracture of the
characteristic features of the disorder (Box 19.1). abductor hallucis muscle, often present in metatarsus adductus.
The full extent of the deformity can be best appreciated (From Lichtblau S. Section of the abductor hallucis tendon for
when the examiner grasps the heel and compares the align- correction of metatarsus varus deformity. Clin Orthop Relat Res.
ment of the heel with that of the forefoot. Although it is 1975;110:228.)
not seen on a casual examination, careful evaluation of the
hindfoot reveals slight valgus of the heel. There is always
full range of ankle and subtalar motion. There is controversy as to whether or not metatarsus
It is important to establish the degree of flexibility of the adductus of intermediate severity, in which the deformity
deformity. In mild cases the foot will correct actively when does not actively correct but is easily corrected passively,
the lateral border of the foot is stimulated. In less flexible requires treatment. Many physicians believe that these
cases the foot will not correct actively but can easily be cor- deformities will self-correct over time without interven-
rected passively. The examiner should maintain the hindfoot tion. Rushforth found asymptomatic moderate deformity
in neutral during this maneuver, grasp the heel with one in 10% of children with untreated metatarsus adduc-
hand, and with the web space of the hand placed against the tus, and residual deformity and stiffness in 4% at 7-year
head of the first metatarsal, push the foot laterally. A gen- follow-up.17 Some physicians advocate passive parental
tle push will align the metatarsals in most children. A rigid stretching of the foot by the child’s parent (Fig. 19.21).
deformity has a medial soft tissue crease at the tarsometa- Parents are taught to hold the heel in a neutral position
tarsal level and a medial soft tissue contracture that prevents with one hand and abduct the forefoot with the web space
passive correction of the foot. As the forefoot is abducted, a of the other hand. Some physicians also recommend that
tight abductor hallucis can be palpated medially (Fig. 19.20). the child wear straight last shoes. For a child younger
Many of these children will also have internal tibial tor- than 6 months, a short series of short-leg plaster casts
sion, which will contribute to an intoed appearance. This is will easily correct the foot position, and this treatment
the most common parental complaint, and this component approach may be warranted for patients with obvious
of the deformity should be noted separately. deformity. Some authors prefer long-leg bent-knee casts
but reports indicate that only 10% of patients require such
Radiographic Findings treatment.15
Radiographs show medial deviation of the metatarsals at The technique of cast correction is similar to the stretch-
the tarsometatarsal level, with some degree of valgus of the ing procedure taught to the parent. The child’s heel is
hindfoot. Older children with more severe forms of meta- grasped and held in a neutral position while the forefoot is
tarsus adductus may have medial deformation of the meta- abducted. The thumb of the hand holding the heel should
tarsal shafts. reach the cuboid so that the fulcrum for abducting the fore-
foot is at the level of the cuboid metatarsal joint. Eversion
Treatment of the foot should be avoided. Before discontinuing cast
If the metatarsus adductus is flexible and actively corrects treatment,7–9 the convexity of the lateral border of the foot
as the foot is stimulated, the condition does not need to be should be straightened or reversed, the prominence of the
treated. These mild deformities will resolve gradually. Par- base of the fifth metatarsal should no longer be noticeable,
ents should be reassured and shown how to gently stretch and active adduction should no longer occur when the child
the foot and how to stimulate it to actively correct. moves the foot.7–9
A B
C D
E F G
FIG. 19.21 Correction of metatarsus adductus by passive stretching. Arrows indicate the point of application of corrective forces. (A and B)
Incorrect method of manipulation. The entire foot is abducted and everted by forcefully abducting and everting the forefoot without apply-
ing counterpressure to the hindfoot. The foot is simply twisted at the ankle, with little corrective force exerted at the metatarsotarsal joints.
The diagram illustrates how the valgus deformity of the heel is increased and shows that the improved appearance of the varus deformity
of the forepart of the foot is spurious and not real correction. (C and D) Correct method of manipulation. The hindfoot is slightly plantar
flexed, and the anterior process of the talus is displaced medially underneath the head of the talus; the metatarsals are pushed into abduc-
tion while counterpressure is applied over the cuboid. The diagram illustrates the proper method. (E) The foot points somewhat medially
while the first section of the plaster cast is applied. (F) The foot and leg are in slight external rotation while the second section of the plaster
cast is applied. (G) Completed plaster cast. The heel and anterior part of the foot are immobilized in a position as near normal as possible.
(Adapted from Ponseti IV, Becker JR. Congenital metatarsus adductus: the results of treatment. J Bone Joint Surg Am. 1966;48:706, with
permission from The Journal of Bone and Joint Surgery, Inc.)
Metatarsus adductus that cannot be passively corrected The best way to manage older children with fixed adduc-
should be more vigorously treated.2 These feet usually have tus is also controversial. The Heyman-Herndon release of the
significant rigidity and a medial crease with an overactive tarsometatarsal joints has had mixed results; some authors
abductor hallucis. Most such feet can be corrected with serial have reported excellent outcomes, whereas others have had
stretching and cast application, which should be started as numerous failures (Fig. 19.22).5,18 We occasionally recom-
soon as possible.7 If the foot is resistant to cast correction, mend this procedure for treating severe adductus in children
surgical release of the abductor hallucis and capsulotomy of too young to undergo osteotomies. Children with significant
the first tarsometatarsal joint may be indicated, followed by deformity who are older than 3 years may benefit from meta-
further cast correction.1,19 Good results have been reported in tarsal osteotomies to realign the foot (Video 19.3). Care must
children (3.5 years old) at an average follow-up of 3.5 years.1 be taken, though, to avoid forcing the hindfoot into valgus
A B
C D
FIG. 19.22 Very resistant metatarsus adductus in a young girl. (A) Radiograph obtained at 3 months old showing marked medial deviation
of the metatarsals at the tarsometatarsal joints. Note also the increased talocalcaneal angle indicative of valgus of the hindfoot. (B) Stand-
ing lateral radiograph showing an increased talocalcaneal angle indicative of valgus of the hindfoot. (C) Anteroposterior (AP) radiograph
obtained at 15 months old after a period of serial casting. There is still marked adduction of the forefoot, and the valgus of the hindfoot
has increased. (D) AP radiograph obtained after a tarsometatarsal soft tissue release and realignment stabilized with pins. This procedure is
necessary only for the most severe cases of metatarsus adductus.
and creating a skewfoot deformity. Napiontek and others

reported good results with the use of an opening wedge oste-
otomy of the medial cuneiform in children younger than 4
years old. Their cases were mostly clubfoot residua, but four
cases were primary adductus abnormalities.13 A percutane-
ous method of treatment that incorporates osteotomies of
the central metatarsals and medial soft tissue releases has
been described with favorable results.10
Two other surgical procedures that have been recom-
mended for treating metatarsus adductus are anteromedial
release with capsulotomy of the medial metatarsocuneiform
and naviculocuneiform joints4 and transfer of the poste-
rior tibial tendon with capsulotomy of the naviculocunei-
form joint.3 We have no experience with either of these
approaches.
Talipes Calcaneovalgus
Etiology and Clinical Features
FIG. 19.23 Severe talipes calcaneovalgus in a newborn. Note the This postural deformity of infancy is characterized by an
foot “plastered” up against the anterior aspect of the tibia. The oftentimes dramatic hyperdorsiflexion of the foot that
clinician should always examine the hips to rule out congenital appears to be “plastered” up against the anterior surface
dislocations. of the tibia (Figs. 19.23 and 19.24). Plantar flexion of the
A B
FIG. 19.24 Talipes calcaneovalgus in an infant. (A) The foot is dorsiflexed and everted. (B) Plantar flexion is limited to the neutral position.
foot is frequently limited as a result of contracture of the Less subtle is the association of posteromedial bowing of
anterior ankle and foot structures. This deformity results the tibia with a calcaneovalgus foot. The deformation of the
from abnormal in utero positioning of the foot, described as tibia is easily understood as a packaging defect associated
a “packaging” defect, in which all anatomic structures form with the hyperdorsiflexed foot (see Figs. 19.23 and 19.24).
normally but are deformed at the end of the pregnancy However, there is more to this “packaging” combination
because of in utero crowding. Unlike a “manufacturing” in that there is usually growth inhibition of the lower part
or “parts” problem, such as congenital clubfoot, in which of the leg as a result of the posteromedial bow, generally
embryologic formation is defective, postural deformities mandating some form of limb equalization procedure later
such as calcaneovalgus resolve spontaneously in the vast in childhood and adolescence. Thus, as opposed to a pure
majority of cases. packaging defect, which should resolve without sequelae,
Not only is the foot hyperdorsiflexed, but the heel is calcaneovalgus with posteromedial bow of the tibia repre-
also frequently in marked valgus, with the forefoot appear- sents a more serious defect in morphogenesis.
ing abducted. The calcaneus is palpable in the heel pad Perhaps most commonly associated with calcaneovalgus
and is noted to be in the dorsiflexed (“calcaneus”) posi- is external rotation of the lower extremities. This becomes
tion. This differentiates a calcaneovalgus foot from the most obvious as the child begins to take weight on the lower
more serious pathologic congenital vertical talus, where extremities, with the feet sometimes pointing outward
the heel is in equinus, giving the foot a “rocker bottom” nearly 90 degrees. The source of the foot position may be
appearance. The forefoot may be equally dorsiflexed in persistent eversion and external rotation from the calca-
both conditions, but it is the heel equinus and rocker bot- neovalgus, or it may be an external rotation contracture of
tom deformity that distinctly differentiate congenital ver- infancy at the hip.6 The latter is destined to resolve sponta-
tical talus from a calcaneovalgus foot. It is important to neously once the child begins walking, again with the caveat
look for associated problems accompanying the packaging that silent hip dysplasia should be ruled out with an imaging
problem of the foot—in particular, hip dysplasia. Although study (plain radiography or ultrasound), especially if there is
no initial instability may be appreciated during the new- any suggestion of asymmetry in the hip examination or hip
born hip examination, the association of hip dysplasia with rotational profiles.
calcaneovalgus seems somewhat stronger when a contra- The incidence of talipes calcaneovalgus has been reported
lateral metatarsus adductus is present, giving the feet a to be as high as 30% to 50% in newborns.8 This estimate is
“windblown” appearance.8 Although the association of hip likely too high as this same investigator found an increased
dysplasia with metatarsus adductus is controversial, with incidence of flatfoot on long-term follow-up of patients with
some investigators reporting it as a close association4,5,8 calcaneovalgus in infancy. The study was skewed toward fol-
and others refuting such an association,1 the simultaneous lowing patients with severe flatfoot. A more likely incidence
occurrence of calcaneovalgus in one foot and metatarsus is the 1 in 1000 live births reported by Wynne-Davies.10
adductus in the other seems to heighten the likelihood of The incidence, like that of congenital dislocation of the
at least silent dysplasia.8 hip, is higher in first-born children (because of intrauterine
A B
FIG. 19.25 Severe flexible flatfoot in a 12-year-old girl. (A) Posterior view. Shortening of the Achilles tendon has produced marked valgus
eversion of the heels. The talar heads are prominent. (B) Medial view (right foot). Weight bearing on the entire arch, particularly on the
talonavicular area, is a source of symptoms.
crowding) and girls, and is associated with hip dysplasia, as For example, Staheli and colleagues37 regarded flatfeet as
mentioned earlier. Because a calcaneovalgus foot position is “usual in infants, common in children, and within the nor-
either relatively common or extremely common, depend- mal range in adults” in assessing and documenting the spon-
ing on which investigator is believed, the role of the ortho- taneous development of the longitudinal arch. Others have
paedist in assessing what may be a normal variant of foot concurred with these observations.16,17 It may be surpris-
position is to eliminate true pathologic foot conditions (con- ing, therefore, that flatfoot is evaluated and treated, often
genital vertical talus), associated tibial anomalies (postero- prophylactically, with significant fervor by certain nonor-
medial bow of the tibia), and most importantly, associated thopaedic branches of medicine, where the controversy
hip dysplasia. surrounding the “deformity” has not been resolved. On the
other hand, because concern about abnormal-looking feet
Treatment will never appreciably decrease among parents and pediatri-
The prognosis of calcaneovalgus foot is excellent. Only in cians, especially in feet with a more clinically severe appear-
the most severe cases, with marked restriction of plantar ance (Fig. 19.25), children with flatfoot will continue to be
flexion and supination/inversion, is anything more than gen- referred to the pediatric orthopaedist for the treatment of
tle stretching exercises by the parents necessary. Generally, pain, perceived disability, and abnormal shoe wear.
the foot position normalizes within 3 to 6 months. In more The heel shows excessive eversion during weight bearing,
severe cases there may be a role for corrective casting or and the forefoot is usually abducted, producing a midfoot
splinting (or both) in association with stretching exercises. sag with lowering of the longitudinal arch (see Fig. 19.25),
The clinical experience of several authors has identified a so that the talar head and navicular tuberosity appear to
correlation between talipes calcaneovalgus and a symp- be in contact with the floor and to participate excessively
tomatic form of hypermobile pes planovalgus in an older in weight bearing. The medial column of the foot appears
child.2,3,7,9 There is thus little downside to the applica- longer than the lateral column. The entire foot is often
tion of two or three sets of corrective casts in the newborn described as pronated, although this description is mislead-
period when there is significant limitation of plantar flexion ing because the forefoot is actually supinated in relation to
and inversion.3 Casting may then be followed by stretching the hindfoot, a fact that is most appreciated when the hind-
exercises and an ankle-foot orthosis type of splint for a few foot is corrected operatively or stabilized manually during
additional months to ensure satisfactory foot position when physical examination.27,42 The relationship of the forefoot
the infant begins to pull to stand. to the hindfoot may also be appreciated when one contem-
For References, see expertconsult.com. plates a cavovarus foot, the anatomic reverse of a flatfoot,
in which the forefoot is pronated in relation to the hindfoot
Flexible Flatfoot (Pes Planovalgus) and an excessively high longitudinal arch is produced.42
Clinicians might be tempted to use radiography as the
Definition defining diagnostic examination, with flatfoot being consid-
Although the exact incidence of flatfoot in children is ered a foot with measurements greater than two standard
unknown, it is undoubtedly one of the most common “defor- deviations from the mean.27 Because flatfeet are relatively
mities” evaluated by pediatric orthopaedists. Whether or common and generally benign, radiographs to document
not flatfoot represents a true deformity is questionable. this diagnosis are rarely obtained, thereby perpetuating the
A B
C
FIG. 19.26 Measurement of Meary angle on a lateral weight-bearing radiograph. (A) A line drawn through the longitudinal axis of the talus,
and the first metatarsal is essentially straight on a normal foot. (B) In talonavicular sag, the apex is plantarward, with the talar longitudinal
axis intersecting only the most inferior tip of the navicular (because of its dorsal subluxation). (C) In naviculocuneiform sag, the apex of the
angle is still plantar, but the navicular remains located centrally on the head of the talus.
A B
FIG. 19.27 Flatfoot. (A) Standing lateral radiograph. Talonavicular sag and relative plantar flexion of the talus suggest an Achilles tendon
contracture. (B) Standing anteroposterior radiographs showing marked hindfoot and midfoot eversion and valgus as suggested by the diver-
gent talocalcaneal axes and the lateral displacement of the navicular on the talar head.
lack of a specific definition of flatfoot. A standing lateral “deformity” other than idiopathy. The differential diagnosis
radiograph allows measurement of the lateral talus–first includes such bony abnormalities as tarsal coalition, con-
metatarsal angle, or Meary angle (Fig. 19.26). This angle is genital vertical talus (convex pes valgus), persistent talipes
normally 0 degrees (a straight line). In a flexible flatfoot an calcaneovalgus, an accessory navicular, and various arthritic
apex-plantarward angle will be present. The normal range of and inflammatory conditions. Most of these conditions are
this angle also varies with age, with spontaneous improve- diagnosed primarily from the history and physical examina-
ment in plantar sag seen until age 8 years.40 The location tion findings, and in such situations radiographs should be
of the sag—talonavicular or naviculocuneiform joint—can used to confirm a suspected diagnosis.
be determined and may suggest the cause of an abnormal
measurement (i.e., a tight heel cord producing a plantar Clinical Features
flexed talus and talonavicular sag; Fig. 19.27). The degree Regardless of the exact definition of flatfoot, it is estimated
of plantar flexion of the talus—the angle formed by the lon- that a depressed longitudinal arch occurs in approximately
gitudinal axis of the talus and the horizontal—can also be 23% of the adult population.16 Of this population, approxi-
measured (normal, 26.5 ± 5.3 degrees6) as can the calcaneal mately two thirds have a flexible, hypermobile flatfoot with
pitch angle, which is formed by the axis of the calcaneus and normal or increased mobility of the subtalar complex and
the horizontal. ankle joint. Approximately one fourth of flatfeet exhibit a
Perhaps the most compelling reason to obtain radio- contracture of the triceps surae associated with an other-
graphs in cases of flatfoot is to rule out causes of the wise typical hypermobile flatfoot, and this form of flatfoot
C D
FIG. 19.28 Flexible flatfoot. (A–D) Reconstitution of the longitudinal arch and inversion of the heels during tiptoe standing, the hallmarks of
flexible pes planovalgus.
is a known cause of disability in army recruits.16,17 The activity. Obviously, with walking or more vigorous activity,
remainder of flatfeet are characterized by more rigidity of both sets of muscles are active, thus suggesting dynamic
the subtalar joint, typically seen with tarsal coalitions. Dif- stabilization of the arch. However, flatfoot is a well-known
ferentiating between flexible and more rigid deformities is sequela of a lacerated or insufficient tibialis posterior ten-
therefore a wise first step in the assessment of all flatfoot don, so there must be some contribution to static integrity
deformities. of the arch from this muscle because its absence results in
The height of the longitudinal arch is determined by the deformity.
bony structure and degree of ligamentous laxity. Electro- In the typical flexible flatfoot, the longitudinal arch
myographic studies have documented that neither the reconstitutes when the foot is in a non–weight-bearing posi-
intrinsic nor the extrinsic muscles of the foot have electrical tion. The arch should also reconstitute during active plantar
activity during standing at rest.3 Therefore, the static struc- flexion, such as when a patient is asked to stand on tiptoes
ture of the longitudinal arch is independent of any muscular (Fig. 19.28). Inversion of the heels and arch reconstitution
during toe standing are requisite examination findings for a present.16,17 There has even been a suggestion that shoes may
diagnosis of flexible flatfoot. Because the arch reconstitutes be detrimental to development of the longitudinal arch.31,34
during such active muscle function, it is tempting to pre- Indeed, controlled prospective randomized studies on the
scribe muscle-strengthening exercises of the plantar flex- effect of shoe modifications and inserts on development of
ors and invertors in a patient with a planovalgus deformity. the arch have failed to demonstrate any effect.15,43 The use
Although Tachdjian in the second edition of this textbook of these devices for correction of such a “deformity” must be
denigrated such exercises,38 no scientific study has evalu- considered ineffective and probably unnecessary. It is there-
ated their effectiveness. fore the orthopaedist’s primary role to educate parents seek-
If flexibility of the hindfoot and arch reconstitution are ing treatment of their child’s flatfeet that the condition is
not demonstrated on the tiptoe test, then other conditions both benign and unaffected by prophylactic treatment with
must be considered, especially if there is a complaint of such devices.
pain. The general neurologic assessment—observation of The development of bunions has also been related to the
gait, coordination, and reflexes—will uncover neurologic presence of a flatfoot. However, in Kilmartin and Wallace’s
or myopathic conditions associated with flatfeet in which longitudinal study of children with flatfeet, bunion develop-
the foot position may be due to weakness (poliomyelitis, ment was independent of the longitudinal arch.18
peripheral neuropathy), weakness with Achilles tendon con-
tracture (Duchenne muscular dystrophy), or spasticity with Treatment
equinus (cerebral palsy). Abnormal hindfoot motion, espe-
cially if painful or rigid, suggests tarsal coalition or inflam- Conservative Treatment
matory arthritis. A rigid rocker bottom deformity with In the typical case of a hypermobile (postural) flatfoot, no
equinus suggests a congenital vertical talus. Specific areas treatment is indicated in an asymptomatic pediatric patient.
of pain, such as the navicular, may point to an accessory Education and reassurance are the mainstays.
navicular or osteochondritis. Radiographs or consultation Orthoses and medial arch supports have traditionally been
with a neurologist or rheumatologist may be appropriate if prescribed, even though there is no scientific evidence that
an idiopathic, hypermobile flatfoot is ruled out by the his- such modifications are efficacious.15,43 With the evidence
tory and physical examination. that flatfooted army recruits and children who do not wear
Particular attention to the Achilles tendon is important shoes have essentially normal function as adults, and with the
because a contracture tends to make hypermobile flatfeet lack of objective studies demonstrating a lasting change in the
symptomatic.17 After tiptoeing to confirm subtalar flexibil- radiographic anatomy of the foot with the use of corrective
ity, a child should be asked to walk on the heels. An Achilles devices, there is no medical indication for the treatment of
tendon contracture will make this activity difficult. Pas- asymptomatic flatfeet. In light of the not insubstantial cost
sive dorsiflexion of the foot, with the heel locked in varus of some of the custom-molded inserts and orthoses, there is
(inverted), will further demonstrate this contracture. little justification for prescribing such devices, and the tra-
As with any lower extremity deformity, joint range of dition of prescribing special shoes or inserts for orthopaedic
motion and torsional profile must be evaluated to assess for management of the child’s foot should be abandoned.
more proximal causes that may have encouraged develop- If an Achilles tendon contracture is present, stretching
ment of the flatfoot. exercises—both manually by the parents and actively by the
child, if old enough to cooperate—are an appropriate form
Natural History of management. These children may have symptomatic cal-
The arch is usually obscured in an infant’s foot because of sub- luses under the head of the plantar flexed talus associated
cutaneous fat, and spontaneous resolution of “fat foot” can be with the Achilles tendon contracture. Emphasis should be
anticipated as the young child matures and such fat atrophies. placed on stretching the heel cord with the heel inverted
Both footprint25,37 and radiographic40 studies of the child’s and the knee straight, and in the case of an older child, exer-
foot demonstrate that the longitudinal arch develops during cises involving the use of an elastic Thera-Band and dorsi-
the first decade of life. As discussed, the lateral talus–first flexion stretching with the heel maintained on the ground
metatarsal angle demonstrates a decrease in the amount of (with the patient leaning forward while the hands are sup-
plantar sag of the midfoot until 8 years old.40 Such improve- ported on the wall) are recommended (Fig. 19.29).
ment in the sag of the medial ray of the foot would suggest In symptomatic patients, arch supports and orthoses may
that ligamentous laxity in a toddler spontaneously resolves as be of benefit. Typical symptoms include medial arch pain,
the ligaments become more taut. This observation also leads callosities, and fatigue. Lateral ankle pain may occur as well
to the overwhelming conclusion that prophylactic treatment due to impingement between the everted calcaneus and the
of a typical flatfoot is unnecessary, with profound implica- distal fibula. In addition to gastrocsoleus stretching exercises,
tions for the corrective shoe and insert- orthosis industry. we have found that the footwear sold in sporting goods stores,
Development of the arch is independent of the use of such especially that designed for running, is often more readily
external orthoses or the wearing of corrective shoes. Studies accepted for social reasons by children and adolescents than
from countries where shoes are not worn at all tend to sub- the more traditional devices placed inside shoes. Running
stantiate the opinion that symptomatic deformities do not shoes designed for a “pronated” or “hyperpronated” foot have
develop with aging in flatfooted children.29 The classic study significant heel and arch support built into the shoe itself,
of 3600 army recruits by Harris and Beath documented that thus making prescription of additional orthoses superfluous.
the presence or absence of a longitudinal arch did not cor- Because running shoes usually support the relaxed portion of
relate with disability and that a flatfoot was compatible with the arch or hindfoot, the suggestion to use such footwear may
normal function unless an Achilles tendon contracture was be all that is necessary to resolve the problem.
It should again be emphasized that no permanent change

in foot anatomy or arch structure has been documented
with the use of any orthosis or shoe modification.
Surgical Treatment
Indications. Surgical management of a true hypermo-
bile flatfoot is reserved for a patient who has intractable
A symptoms unresponsive to shoe or orthotic modifications
and who is unable to modify the activities that produce
pain. Thus patients with talonavicular calluses, medial arch
“strain,” or calcaneofibular abutment whose daily activities
are limited by foot pain are the only true candidates for
surgical management. Although surgery can alter the shape
of the arch by reconstructing it with either soft tissue imbri-
cation or bony procedures, with generally good short-term
results, long-term evidence of continued foot health after
such procedures is generally lacking.
Indeed, unsatisfactory results from surgery have been
reported in 49% to 77% of longer-term studies,7,10,33 and all
longer-term follow-up studies of limited tarsal fusion pro-
cedures have described osteoarthritic changes at adjacent
unfused joints.a Because such changes are known to occur
de novo in untreated tarsal coalitions, it should come as
no surprise that creation of an iatrogenic coalition during
reconstruction of the longitudinal arch by tarsal bone fusion,
however limited, produces the same degenerative changes
at the adjacent joints. Thus surgical correction of flatfoot
must emphasize joint-sparing procedures, usually combin-
ing extraarticular osteotomy with soft tissue imbrication.
Arthroereisis. Arthroereisis of the subtalar joint, using a

metal, silicone, or Silastic implant, has been reported as
an alternative to more complex joint reconstruction. The
rationale of the procedure is to limit the amount of valgus
motion in the subtalar joint by using an interposition peg.
Long-term results of this procedure are lacking, and because
of potential complications of intraarticular placement of for-
B eign material, especially in the normal cartilaginous surfaces
FIG. 19.29 Exercises to treat flatfoot. (A) Manual stretching with of a child’s hindfoot, this procedure is not warranted given
the knee extended and the hindfoot inverted. Multiple daily repeti- that the natural history of a flexible flatfoot is generally ben
tions are prescribed. (B) Passive stretching of the triceps surae in an ign.1,20,39,41 Nevertheless, the use of silicone, Silastic, and
older child. Note that the feet are inverted, the knees are extended, metal spacers interposed in the subtalar joint is common in
and the heels remain on the floor. the podiatric literature.1,21,35,39 The potential for synovitis
necessitating implant removal is real (Fig. 19.32).
In more recalcitrant cases, formal orthotic management
with custom devices such as a University of California Bio- Heel Cord Lengthening. An Achilles tendon contracture
mechanics Laboratory (UCBL) insert can be attempted. Such should always be considered and treated during any surgery for
an orthosis can acutely change the talonaviculocuneiform axis flatfoot. If the patient has severe enough symptoms to warrant
and improve calcaneal pitch (Fig. 19.30); it has been reported surgery, a heel cord lengthening or gastrocnemius recession
to alleviate symptoms and improve shoe wear in symptom- should be part of a comprehensive procedure to reconstruct
atic patients.6,23 Acceptance of this more rigid device—the the longitudinal arch. The selection between these two options
orthosis is made from a plaster cast of the patient’s foot and for lengthening of the triceps surae is usually based upon intra-
molded from rigid plastic to invert the valgus heel and support operative Silfverskiöld testing, often following provisional cor-
the arch—may be problematic in that the rigid orthosis can rection of the hindfoot valgus deformity.
be somewhat uncomfortable, similar to the proverbial “rock
in the shoe”; because there is no evidence that it has any last- Subtalar Fusion. Subtalar fusion as a primary procedure for
ing effect on flatfeet, its use should not be pursued if an initial hypermobile flatfoot should probably be condemned. While
prescription fails. We have used soft inserts (Plastazote; Fig. there is no question that excessive heel valgus and restoration
19.31) in symptomatic patients who have rejected the UCBL of the longitudinal arch can be achieved through this proce-
type of device, with better acceptance and probably the same dure, the sacrifice of subtalar motion for this purpose is too
efficacy, and have prescribed a rigid formal orthosis much less
over the past several years. a References 2, 4, 7, 10, 11, 30, 32, 33, 36.
A B
C D
FIG. 19.30 (A and B) The University of California Biomechanics Laboratory (UCBL) orthosis used for the treatment of flatfoot. (C) Standing
lateral radiograph showing naviculocuneiform sag. (D) Standing lateral radiograph with the UCBL orthosis. The naviculocuneiform sag and
calcaneal dorsiflexion (“pitch”) are improved.
LATERAL
A
STANDING
FIG. 19.32 Lateral radiograph of a subtalar arthroereisis screw,

which was removed due to unrelenting subtalar pain.
B
FIG. 19.31 (A and B) Soft molded insert with arch support and a
medial heel “wedge” to invert the hindfoot. Furthermore, it should only be considered after selective
joint injection with local anesthetic has demonstrated that
it is the mobility of the hindfoot-midfoot complex that is
great a cost. The mechanics of the hindfoot are completely producing the pain and disability (Fig. 19.33).
altered by subtalar fusion, and the mobility of the remaining
midfoot joints—talonavicular, calcaneocuboid, and the entire Lateral Column Lengthening. Lateral column lengthen-
midfoot complex—is irretrievably altered by subtalar fusion. ing by insertion of a bone graft into an osteotomy of the
The more extensive triple arthrodesis eliminates all hindfoot calcaneal neck is currently the most attractive proce-
mobility, and although deformity is effectively corrected by dure to correct a flatfoot deformity and not sacrifice joint
such a procedure, it is again indicated only as a salvage proce- motion.13,26,31 The lateral column is lengthened by inserting
dure in a foot in which other surgical procedures have failed. a trapezoid-shaped tricortical iliac crest allograft between
A B
C D
F
FIG. 19.33 Painful flatfoot in a 12-year-old girl. (A) Posterior view shows marked hindfoot valgus. (B) Plantar view shows abnormal medial
plantar pressure distribution. (C) Preoperative lateral radiograph showing naviculocuneiform sag. (D) Postoperative radiograph following a
right-sided calcaneal lengthening and medial imbrication procedure showing restoration of Meary angle. (E) Postoperative posterior view
shows improved hindfoot alignment. (F) Postoperative plantar view shows a normalized plantar pressure pattern.
Bone graft
A B
FIG. 19.34 Dorsal view (A) and lateral view (B) of lateral column lengthening to treat flatfoot. K-wire fixation can be useful to prevent dis-
placement of both the graft and the distal osteotomy fragment.
the anterior and middle facets of the calcaneus (Fig. 19.34). of subtalar motion. This outcome is achieved in more than
A transverse osteotomy of the neck of the calcaneus, 90% of patients observed in short-term reviews,18,26 and
approximately 1.5 to 2 cm proximal to the calcaneocuboid 75% of patients show no evidence of degenerative changes
joint, is gently spread apart to receive a graft of the same in longer-term follow-up.27
length. Prior to spreading the osteotomy site, it is critical to
stabilize the calcaneocuboid articulation with a percutane- Imbrication of Talonaviculocuneiform Complex. Imbrica-
ous, centrally placed Steinmann pin to prevent subluxation. tion of the talonaviculocuneiform complex medially is per-
In addition, we typically lengthen the peroneus brevis to formed in combination with calcaneal lengthening. It is not
decrease tension across the osteotomy site as lengthening recommended as a single procedure because of progressive
occurs. The technique of spreading the osteotomy is cru- stretching of the medial repair with weight bearing, espe-
cial to success of the procedure. Forceful spreading, with a cially when the lateral column has not been lengthened. The
lamina spreader for example, can crush the cortical edges of technique has evolved from limited fusions of the talona-
the two sides of the osteotomy and make it difficult to prop vicular and naviculocuneiform joints with tendon imbrica-
the osteotomy open. One technique is to place threaded tion,24 to “tightening” of the naviculocuneiform joint14 with
Steinmann pins transversely into each osteotomy segment plantar imbrication, to opening wedge osteotomy of the
so that the osteotomy can be opened using the pins as han- cuneiform to re-create the arch.22 Combined use of a lateral
dles. This technique has the advantage of not obstructing column lengthening and medial opening wedge osteotomy
the osteotomy site during insertion of the graft. Once the has been shown in a cadaveric model to result in greater
graft has been properly impacted into place, internal fixa- deformity correction and significantly diminished pressure
tion with screws or a staple can be selected though we pre- under the lateral forefoot.5
fer to simply advance the Steinmann pin which can be cut One technique involves initial detachment and later
outside the skin for later removal in clinic (see Fig. 19.33).26 imbrication of the tibialis posterior tendon and raising of
Soft tissue tensioning will usually hold the graft in place and an osteoperiosteal flap of the cuneiform-navicular capsules
would obviate the need for pin stabilization if it were not by sharply dissecting a tongue of the medial capsules from
important to prevent joint subluxation. Calcaneocuboid proximal talonavicular to distal and leaving the flap attached
subluxation should be avoided with longitudinal pin inser- at the cuneiform (Fig. 19.35).8,9 The talonaviculocuneiform
tion though no disability has been identified in patients who alignment is corrected (usually after lateral column length-
have healed with this malunion.26 ening); the osteoperiosteal flap is advanced proximally
Postoperatively, short- leg cast immobilization is main- and plantarward, and is reattached to the talar neck with
tained for 8 to 10 weeks to ensure healing of the osteotomy. heavy suture. We usually protect the medial reconstruc-
Results of calcaneal lengthening have been considered satis- tion with a smooth K-wire, which is removed at the time
factory when there is relief of medial arch pain, resolution of cast removal. As mentioned, the tibialis posterior should
of calluses, correction of heel valgus, improvement in the be shortened and advanced to restore appropriate ten-
appearance of the arch, radiographic restoration of the Meary sion after “shortening” of the medial column by soft tissue
angle and the lateral talocalcaneal angle, and maintenance imbrication.
Tibialis posterior muscle

cut and reflected
Navicular
Incision
Osteoperiosteal flap
Head of talus First cuneiform

Periosteum
Insertion of
A tibialis posterior muscle
Osteoperiosteal
flap Talus
Navicular
Cuneiform
Reattachment
of tibialis posterior
muscle
B C
FIG. 19.35 Medial imbrication of the talonavicular-cuneiform joints in the surgical treatment of flatfoot. (A) The tibialis posterior is divided
(for later imbrication). The osteoperiosteal flap is raised in a proximal-to-distal direction. (B) After reduction of the talonavicular displacement
by translating the navicular medially and plantarward, the osteoperiosteal flap is advanced proximally. Internal fixation is r ecommended. (C)
The tibialis posterior is shortened/imbricated after proximal reattachment of the osteoperiosteal flap.
Our preferred technique involves cutting the tibialis pos- to reestablish the weight-bearing line in the center of the
terior tendon in a z-type fashion without detachment from ankle-subtalar coronal plane, merely creates a compensa-
its insertion distally. A segment of the oftentimes redundant tory varusization for talocalcaneal valgus,27 the effect of
medial capsule of the talonavicular joint is then removed such a shift seems to be helpful in supporting the plantar
and the remaining capsule is imbricated plantarward. Lastly, flexed talus and decreasing overall eversion and midfoot
the posterior tibial tendon is repaired in a shortened posi- abduction (Fig. 19.36). Thus, when combined with medial
tion. Postoperative care of the soft tissue generally requires column shortening–imbrication, good results are achieved
an additional 4 to 6 weeks of casting to allow complete (Fig. 19.37). Significant improvement in both pain mea-
healing of the repair. Although excellent results have been sures and radiographic parameters has been reported in
reported with this medial reconstruction alone,8,9 we con- adolescents undergoing this combined correction.28 The
tinue to use it only in conjunction with a calcaneal lengthen- need for Achilles tendon lengthening, peroneal lengthen-
ing osteotomy. ing, and corrective metatarsal or medial cuneiform oste-
Medial imbrication can also be combined with a sliding otomy if forefoot supination is excessive after a calcaneal
calcaneal osteotomy.12,19,42 Although one may argue that osteotomy with medial imbrication must be assessed during
displacement of the posterior half of the calcaneus medially, the combined procedures.42 In particular, careful attention
Line of
osteotomy Medial displacement
at operation
A B
FIG. 19.36 Medial displacement osteoto-

my of the calcaneus in severe pes planoval-
gus. The weight-bearing line and relation
of the talus to the calcaneus are seen from
the posterosuperior aspect. (A) The axis
of weight transmission passes medial to
the calcaneus. The line of the osteotomy
parallels the subtalar joint. (B) Appear-
ance after medial displacement osteotomy
of the calcaneus. The medial margin of
the distal calcaneal fragment is placed in
line with the sustentaculum tali, and a
normal weight-bearing axis is restored. (C)
C Threaded Steinmann pin transfixing the
osteotomized calcaneus.
A B D
FIG. 19.37 Result of medial imbrication/calcaneal sliding osteotomy. (A) Lateral radiographs of both feet of the patient (see Fig. 19.27) 6
months after correction of the right foot (bottom). The talonaviculocuneiform axis is normally aligned. (B) Lateral radiograph of the right
foot obtained at 10-year follow-up. The correction is maintained and the foot is asymptomatic. (C and D) The left foot of the same patient,
which was not operated on. Note the arthritic changes in the talonavicular joint (arrows in C). This foot was only mildly symptomatic and
was never treated surgically, although the degenerative changes provoke some concern.
must be paid to a forefoot supination deformity which is cuboid–fifth metatarsal articulation, children may become
often unmasked once hindfoot correction is achieved. If symptomatic.6,7,9,12,14
the first ray is elevated on simulated weight bearing intra-
operatively, a medial cuneiform osteotomy should be per- Radiographic Findings
formed to plantarflex the first ray. Radiographically, there is an increase in the talocalcaneal
Complications of the combined procedure include non- angle in both the AP and lateral projections,5 along with
union of the calcaneal graft or displacement of the graft lateral and dorsal subluxation of the navicular on the talus.
requiring revision, displacement of the calcaneocuboid joint, On the AP radiograph, a line drawn along the first metatar-
recurrence of the deformity, or pain that develops with time sal through the navicular, then to the head of the talus and
or prolonged weight bearing. Nonunion may be particularly through the body of the talus, makes a Z shape. Similarly,
difficult to treat because it is frequently accompanied by on the lateral radiograph, there is dorsiflexion of the talona-
calcaneocuboid joint degeneration with subsequent pain. A vicular joint (probably secondary to increased talar plantar
painful arthrosis of this nature often mandates treatment flexion) and plantar flexion of the tarsometatarsal joints,
via a triple arthrodesis. It goes without saying that the need which creates a sagittal plane Z deformity.
for a salvage fusion procedure is an extremely untoward
outcome following a “joint-sparing” operation. It cannot be Treatment
overemphasized, therefore, that attention to sizing and sta- Because of the lack of criteria for definition of the defor-
bility of the graft is essential to avoiding nonunion. mity and its relative severity, early treatment of skewfoot is
often based on the perception of need to treat the metatarsus
Summary adductus. Thus a more severe adductus that is not passively
In summary, a hypermobile flatfoot is a normal variant of correctable and is rigid can be treated by stretching and serial
foot structure and does not require prophylactic treat- casting. The cast technique must carefully mold the hindfoot
ment. Should an Achilles tendon contracture accompany into varus to avoid exacerbating the existing valgus while cor-
the deformity, vigorous stretching of the heel cord should recting the forefoot.1,7 Because hindfoot valgus cannot be cor-
be instituted to lessen the possibility of symptoms later in rected by casting, this treatment basically converts skewfoot
life. Nonoperative management of painful flatfeet in ado- into flatfoot. Such an outcome is not unreasonable, because
lescents is generally successful and entails shoe modifica- flatfeet are generally less symptomatic and are responsive to
tions (running shoes suffice for this purpose), orthoses, nonoperative treatment later in life, if necessary. Reverse-last
and strengthening exercises. Surgical correction, truly a shoes and the Denis Browne bar are probably contraindicated
last resort for this normal variant, should emphasize joint- in true skewfoot because they can exacerbate hindfoot valgus.
sparing procedures, including lateral column lengthening or In children beyond 10 years old, symptomatic skewfoot
a calcaneal medial sliding osteotomy, often combined with usually has an Achilles contracture, not unlike symptomatic
heel cord lengthening, medial soft tissue imbrication, and flatfoot. Stretching and orthoses can be tried, but because
possible medial cuneiform osteotomy to provide symptom- skewfoot deformities are more inflexible than those present
atic relief by realigning the talonaviculocuneiform complex in pes planovalgus, these approaches are generally unsuc-
and improving the hindfoot valgus deformity. cessful. As a result, operative treatment, ideally the last
For References, see expertconsult.com. resort, is often pursued for lack of a useful alternative.
Earlier reports of extensive soft tissue releases (tarsometa-
Skewfoot tarsal capsulotomies) combined with subtalar fusion14 or cal-
caneal osteotomy2 included only small numbers of patients,
Skewfoot is a condition that may resemble metatarsus
and because of recurrence and degenerative arthritis arising
adductus though the elements of forefoot adductus and
from the joint-damaging procedures,15,16 have fallen into dis-
hindfoot valgus are more severe and rigid. In addition,
favor. Mosca proposed an Evans calcaneal lengthening proce-
lateral subluxation of the navicular on the talus is a radio-
dure combined with a Fowler-type opening wedge osteotomy
graphic hallmark of skewfoot. Skewfoot is also called the S-
of the medial cuneiform and Achilles tendon lengthening to
shaped foot, the serpentine foot, or the Z-foot (Fig. 19.38).
completely avoid any joint incursion and correct all the dif-
A similar deformity is sometimes seen in a clubfoot that has
ferent deformities.3,4,8,10–12 With this combination, 9 of 10
undergone inadequate midfoot release and excessive hind-
feet were well corrected while joint motion was preserved.
foot release. Unfortunately, there are no criteria to establish
This approach would appear to be the procedure of choice
how much metatarsus adductus is necessary to reclassify
for a skewfoot requiring surgical correction.
flatfoot as skewfoot or how much hindfoot valgus is required
to reclassify metatarsus adductus as skewfoot.10 This lack of
defining criteria often makes the diagnosis subjective.
Congenital Talipes Equinovarus (Clubfoot)
Incidence and Natural History The deformity known as clubfoot is probably the most com-
By all reports, skewfoot is a rare deformity; Peterson found mon (1–2 in 1000 live births) congenital orthopaedic condi-
only 50 cases and Kite just 12 in 2818 cases of forefoot tion requiring intensive treatment. It most likely represents
adduction.6,7,14 The first accurate description in the Ameri- congenital dysplasia of all musculoskeletal tissues (muscu-
can literature was published in 1933.13 lotendinous, ligamentous, osteoarticular, and neurovascular
The natural history of skewfoot is unknown. In some structures) distal to the knee. This conclusion is based on
patients the deformity undoubtedly resolves, just as meta- multiple investigators’ observations of a myriad of different
tarsus adductus and flexible pes planovalgus can resolve. abnormal anatomic findings and on the functional outcome
On the other hand, with more rigid feet, calluses on of patients believed to have received optimal nonoperative
each side of the foot, over the talar head, and over the or operative treatment and who nevertheless subsequently
B C
D
FIG. 19.38 (A) Photograph of a child with skewfoot and a moderate degree of forefoot adduction. (B) Posterior view showing increased
valgus of the heel. (C) Anteroposterior radiograph of a skewfoot showing marked adductus of the metatarsals with lateral subluxation of the
navicular. (D) Lateral radiograph showing an increased talocalcaneal angle indicative of valgus of the hindfoot.
always had some degree of impairment. As E.H. Bradford so problems after surgical correction has contributed to the
prophetically noted in 1889,19 treatment of clubfoot is often wide resurgence in nonoperative treatment methods since
described in “glowing terms,” with very satisfactory results in the mid-1990s.144 Although neonatal developmental dyspla-
the short term, but in practice, recurrent or persistent defor- sia of the hip, when recognized and treated appropriately and
mity is common, having defied correction and ultimately pro- early, usually resolves completely and results in a normal hip,
ducing a less than good result. The so-called satisfactory or such is not the case for a neonatal clubfoot treated appropri-
good result after surgery, when studied objectively,b presents ately and early because a completely normal extremity and
a more contradictory picture because the affected foot invari- foot are essentially precluded by the underlying congenital
ably has restricted motion, particularly in the ankle; dimin- dysplasia.175,183
ished muscle strength and power generation of the triceps
surae, possibly secondary to the ankle dysfunction or to the Etiology
aforementioned primary dysplasia affecting all tissues of the Clubfoot has long been associated with neuromuscular
lower part of the leg; and kinetic and kinematic abnormali- diseases and syndromes, and therefore an underlying neu-
ties (recurvatum, valgus, and quadriceps and hamstring weak- romuscular or syndromic/dysmorphic etiology for all “idio-
ness) of the ipsilateral knee and thigh, which may predispose pathic” clubfeet has always been suspected. In the second
to degenerative arthritis. Recognition of these longer-term edition of this book, Tachdjian listed arthrogryposis, dia-
strophic dysplasia, Streeter dysplasia (constriction band
b References 12, 36, 80, 91, 111, 112, 190. syndrome), Freeman-Sheldon syndrome, Möbius syndrome,
and other conditions resulting from chromosomal deletions tissues that inherently resist correction of deformity.61,168
as just a few of the more recognizable systemic conditions These histopathologic findings help explain the mainte-
with associated clubfeet.188 In contrast, idiopathic clubfoot nance of a clubfoot deformity and resistance to correction,
is commonly due to a single musculoskeletal deformity in an if not the actual cause. Transforming growth factor-β and
otherwise normal infant. Because the final outcome in this platelet-derived growth factor are expressed at higher lev-
latter situation is often diminished function,7,111 the conclu- els in these contracted tissues.122 Growth factor blockade
sion that idiopathic clubfoot represents a primary but local with neutralizing antibodies is reported to have the poten-
dysplasia of all tissues of the affected extremity from the tial to lessen the severity of the contractures and ultimately
knee down is supported by the historical inability of treat- positively influence the outcome of clubfoot treatment. A
ment to completely reverse this congenital dysplasia and decreased density of nerve fibers in the synovium of club-
produce a normal foot and extremity. That is not to say that feet has been reported.4 This lack of sensory input may also
current treatment modalities, including surgery, cannot pro- be responsible for the fibrosis and contractures associated
duce a functional foot and extremity that serve the patient with clubfoot. However, the association of clubfeet with
well. It simply recognizes that treatment of true idiopathic syndromes of inherent ligamentous laxity (Down, Larsen)
clubfoot can never produce a fully normal extremity. confounds the hypothesis that fibrotic retractile tissue is
Over the past 5 years, several genetic factors have been a primary etiology. In addition, a recent report using light
implicated in population and family studies on clubfeet. and transmission electron microscopy failed to reveal any
As maternal smoking during pregnancy increases the risk myofibroblast-like cells in the capsule, fascia, ligaments, or
for clubfoot, genes that may have an impact on modulat- tendon sheaths of nine clubfoot specimens.115
ing tobacco smoke have been studied. These include the Studies of stillborn and fetal clubfeet have led some
N-acetylation genes, NAT1 and NAT2, as well as other xeno- authors to propose that a primary germ plasm defect in the
biotic metabolism genes such as CYP1A1.79,180 Following cartilaginous talar anlage produces the dysmorphic neck and
investigation, these genes are thought not to play a major role navicular subluxation.21,97,174,179 Such a proposal is consis-
in the development of clubfeet. Other genes that are involved tent with the observation that the dysmorphic talar head and
in limb and muscle morphogenesis (HOXA, HOXD, and navicular position are not seen in normal embryonic develop-
IGFBP3), involved in the development of the lower extrem- ment and thus must be present from initial limb bud differ-
ity (CAND2 and WNT7a), that encode contractile proteins entiation in an affected extremity. The association of clubfoot
of skeletal myofibers, and that are hind limb–specific genes with various neurologic entities is well known, with some of
(TBX4) have also been studied.55,126,176,201 Variation in these the most severe clubfeet being associated with paralytic disor-
genes may increase the susceptibility toward the develop- ders, such as arthrogryposis and spina bifida. Not surprisingly,
ment of clubfeet, but none are considered to be a direct a theory postulating localized neuromyogenic imbalance,
cause. Continued study in genetics may ultimately provide especially involving the peroneals, has been proposed.76,99
specific answers with regard to the etiology of clubfeet. Congenital fiber type disproportion, with an imbalance
Many other theories on the etiology of congenital club- between type I and type II muscle fibers and atrophy of type
foot have been proposed, including an arrest in embryonic I fibers, has been found in both peroneal and triceps surae
development.16 In normal fetal development of the lower histopathologic specimens.75,124,147 A study on the histologic
limb, the foot in a 6-to 8-week-old fetus has many charac- and histochemical analysis of 431 muscle specimens in idio-
teristics of a congenital clubfoot, including equinus, supina- pathic clubfeet reported that 86% showed no evidence of
tion, forefoot adduction, and medial deviation of the talar a pathologic diagnosis with normal fiber-type ratios and no
neck.114 Bohm proposed that an arrest in fetal develop- type I fiber grouping indicative of neuromuscular pathology.82
ment at this stage was responsible for the clinical deformi- Only four specimens (0.9%) showed type I fiber predomi-
ties noted at birth.16 Normally, the supinated, adducted, nance, and 12.8% revealed muscle fiber atrophy. This study
and equinus position seen in an 8- week embryo gradu- did not support the theory that a neuromuscular abnormality
ally corrects with continued development, and the fetal is responsible in the etiology of clubfoot. It is safe to conclude
foot becomes normal at 12 to 14 weeks.114 If this theory that the etiology of idiopathic clubfoot is multifactorial and
is accepted, a true congenital clubfoot has already existed modulated significantly by developmental aberrations early
for approximately 7 months in utero by the time the full- in limb bud development. Clubfoot does cluster in families
term infant is born. However, the characteristic dysmorphic but does not fit typical mendelian inheritance patterns.39,146
talar head and the medial dislocation of the navicular have Studies conducted on twins, different incidences in vari-
never been observed at any stage of normal fetal develop- ous ethnic groups, and transmission between generations all
ment.25,110,132,197 Thus, an arrest in normal fetal develop- suggest a genetic etiologic component. Investigation of the
ment fails to account for this primary dysplasia. genetic sequences of early embryonic limb development will
The innate stiffness of clubfeet was clarified by Zimny eventually yield a more unified etiologic picture, as well as
and colleagues, who identified myofibroblastic retractile possible new therapeutic avenues for interrupting or correct-
tissue in the medial ligaments.206 This finding confirmed ing these aberrations.
earlier studies by Ippolito and Ponseti, who identified an
increase in collagen fibers and fibroblastic cells in the liga- Pathologic Anatomy
ments and tendons of a clubfoot.96 Thus a second hypothesis Descriptions of the pathologic anatomy in clubfoot can
about the etiology of clubfoot proposes a retractive fibrotic be found in some of the earliest orthopaedic writings and
response, not unlike Dupuytren contracture, as a primary continue to be essentially correct today, even as we have
factor. This hypothesis is supported by studies demonstrat- more sophisticated methods of imaging to quantitate that
ing abnormal ligamentous and fascial restraints in “soft” deformity. Scarpa in 1803 reported medial and plantar
Superior talus Anterior talus Medial talus
A Normal Clubfoot B Normal Clubfoot C Normal Clubfoot

FIG. 19.39 Schematic illustration of a clubfoot talus. (A) Top view. The neck is shortened and deviated medially, so true distinction from the
body of the talus is questionable. The articulation with the navicular is on the medial side of the misshapen talar head. (B) End-on view. The
medial and plantar deviation of the navicular articulation is apparent. (C) Equinus of the neck in relation to the tibiotalar articular surface is
significant.6 (Redrawn from Shapiro F, Glimcher MJ. Gross and histological abnormalities of the talus in congenital club foot. J Bone Joint Surg
Am. 1979;61:522–530.)
displacement of the navicular, cuboid, and calcaneus around example, is generally normal, although the calcaneus is often
the talus. Displacement of the navicular and calcaneus pro- small. The sustentaculum tali is usually underdeveloped,
duces an inverted or varus hindfoot, and the entire complex consistent with dysplasia of the talar facets above,97 and the
rests in equinus. Contracture of the soft tissues (ligaments, anterior articular surface of the calcaneus is medially devi-
joint capsules, and tendons) maintains this pathologic ated and deformed because of the interosseous deformity of
malalignment of joints, described as equinovarus.152 Mul- the calcaneocuboid joint (see Fig. 19.40).53,56,158 Both the
tiple subsequent authors have added to the body of knowl- navicular and the cuboid tend to have more normal shapes
edge by describing deformities that can be separated into and are misshapen only by their interosseous relationships
intraosseous deformities, or deformities within the bone with the talus and calcaneus. The medial tuberosity of the
itself, and interosseous deformities, or deformities resulting navicular may be hypertrophied as a result of the excessively
from the relationship of one bone to another. Scarpa, Adams thick ligamentous structure tethering the navicular to the
in 1866, and Elmslie in 1920 did not implicate the talus as medial malleolus and calcaneus.90
the main pathologic structure but emphasized the midtar- Controversy exists concerning the presence or absence
sal subluxation—the navicular and cuboid displaced medi- of excessive medial or internal tibial torsion. Evidence
ally, with plantar and medial rotation of the calcaneus.53,152 for93,117,124 and against33,83,187 this deformity has been
This, as well as other deformities in the clubfoot, has been reported, and it is our experience that true medial tibial tor-
nicely demonstrated in the past several years by MRI stud- sion can exist in the presence of clubfoot but is generally
ies.108,165 Others have emphasized the talonavicular sublux- unusual. More important is the intraarticular (interosseous)
ation56 and dislocation of the head of the talus out of its deformity known as medial, or internal, spin. This defor-
“socket” (acetabulum pedis).21,23,54,199 Actual deformity mity, which involves both the talus and the calcaneus within
of the talar body and neck has been described in the more the mortise, is also a source of controversy. In the trans-
recent literature based on intraoperative observations and verse plane, the talus has been described as medially rotated
imaging studies.c Finally, Ponseti, in defining clubfoot, has and supinated within the mortise, laterally rotated in its
emphasized the cavus component, especially how it relates body, and neutrally rotated.25,69,71,135,187 The controversy
to nonoperative correction.152 has been due to the difficulty of observing the interosseous
The deformity in the talus itself includes medial and deformity at surgery. Exposure of the tibiotalar joint and
plantar deviation of the anterior end, with a short talar neck other structures of the clubfoot necessarily eliminates some
projecting medially from a dysmorphic, small body that is of the interosseous deformity because the joint capsules and
poorly placed within the ankle joint. The talar neck-body ligaments have been cut to expose these deformities. It is
declination angle is invariably decreased, with the neck axis therefore not surprising that surgical observations by differ-
approximating 90 degrees to the axis of the body in some ent investigators have been somewhat contradictory, which
specimens as compared with the normal 150 to 160 degrees underscores the need for preoperative imaging to evaluate
(Fig. 19.39).146,188 The articular surface of the talar head the interosseous deformities noninvasively and thus not dis-
may be found so close to the body that a true neck is not turb the deformity while in the process of observing it.
present (Fig. 19.40). On the inferior aspect of the talus, the The study of Herzenberg and colleagues was a landmark
anterior and medial facets of the subtalar joint are absent, in this regard.84 By digitizing multiple microtome slices
fused, or significantly misshapen, so the overall impression of normal and clubfoot fetal specimens, the investigators
of talar development is consistent with the proposed primary were able to create three-dimensional reconstructions of
cartilaginous anlage defect.21,98,174,179 The fact that the radio- the deformities by computer, similar to what would ulti-
graphic appearance of the ossification center of the talus is mately become three- dimensional CT and MRI recon-
delayed further supports the hypothesis of a primary germ struction technology. The significantly dysmorphic talus
plasm defect. Intraosseous deformity in the calcaneus, navic- (see Fig. 19.40) was found to have a neck-body axis of 60
ular, and cuboid, though similar to the dysplasia of the talus, degrees in their specimen. More important, the talar neck
is usually much less severe. The contour of the calcaneus, for was found to be internally rotated 45 degrees relative to
the tibia-fibula axis (ankle mortise), whereas the calcaneus
c References 24, 84, 90, 100, 109, 150, 186, 189. was internally rotated 22 degrees. Both these rotations were
Navicular
T
Talus
T P
A B L B1
cub
cub
Cuboid
cal
cal
Calcaneus
C C1
FIG. 19.40 (A) Normal foot, section of the talonavicular joint. N, Navicular; T, talus. (B) Clubfoot section. The navicular (N) articulates with
the medial neck of the dysmorphic talus (T). Because of the equinus, the tibia (P) and fibula (L) are included in the section. (B1) Magnetic
resonance imaging (MRI) shows the medially displaced navicular on the talus. (C) Normal and clubfoot calcaneocuboid joints. The cuboid
(cub) is displaced medially on the dysmorphic distal end of the calcaneus (cal), similar to the talonavicular alignment. (C1) MRI shows the
medially displaced cuboid on the calcaneus. (A–C, Modified from Carroll NC, McMurtry R, Leete SF. The pathoanatomy of congenital club-
foot. Orthop Clin North Am. 1978;9:225–228.)
approximately 20 degrees more than normal. Herzenberg a pronation deformity as being responsible for what is ana-
and colleagues further commented that the body of the talus tomically an inversion or varus of the heel, the presence of
appeared to be externally rotated within the mortise but this deformity in the tibiotalar joint, perhaps exacerbated
noted that the overall axis gave the impression of internal by the equinus positioning of both hindfoot bones, cannot
rotation because of the marked intrinsic deformity of the be denied because it has been observed both arthrographi-
talar neck and medial displacement of the articular surface. cally and visually at surgery (Fig. 19.41).
In the coronal plane of the ankle, deformity of the talus The navicular is consistently displaced medially and plan-
around its longitudinal axis has been found to actually be a tarward on the talar head and has a false articular relation-
pronation or “intorsion” deformity,94,104 reminiscent of the ship to the medial malleolus (see Figs. 19.39 and 19.40). The
deformity seen in embryonic specimens.114 The calcaneus, articular cartilage of the talar head may be uncovered later-
often described as inverted or supinated in surgical observa- ally as a result of medial displacement of the navicular.106
tions, has also been found to be intorted or pronated, espe- As mentioned, the cuboid is similarly displaced medially
cially its posterior segment,54 though not nearly to the same on the anterior end of the calcaneus (see Fig. 19.40C).53,58,158
degree as the talus. Although it may be difficult to visualize Because the calcaneus is also medially rotated in relation to
A B
C
FIG. 19.41 The pronation or intorsion deformity. (A) Appearance at surgery (posterior view, medial malleolus to the left). The talar articular
surface is rotated counterclockwise (“intorsion”) toward the medial malleolus. Supination and varus of the heel can be seen. (B) Arthro-
graphic documentation of talar pronation. (C) Correction after release of the most posterior connections of the talus to the medial malleolus
(“posterior” deltoid ligament). The neurovascular bundle is retracted. The nonarticular deltoid ligament between the medial malleolus and
the talar body is preserved. The talar articular surface is now perpendicular to the long axis of the tibia.
the ankle mortise in the transverse plane, this contributes to and the so-called master knot of Henry (which engages the
a significant midfoot “varus” or adductus. flexor hallucis longus and flexor digitorum longus at their
Contractures of the periarticular soft tissues must be decussation) is suspected in the pathogenesis,94,168 and all
stretched—or occasionally surgically released—to success- must be addressed by nonoperative manipulative stretching
fully restore clubfoot anatomy to a more normal appear- programs or on occasion by surgical release. Mobilizing the
ance. Thickening and contracture of tendon sheaths and navicular depends on successfully stretching the tibialis pos-
ligaments (as well as inelastic muscle tissue) have been terior and the master knot; mobilizing the talus and calca-
reported by multiple investigators. From studies of muscle, neus out of equinus often requires lengthening the Achilles
evidence of neurogenic disease has been described,99,124 as tendon; and the ability to externally rotate the calcaneus to
well as fibrotic (collagen-producing) protein synthesis.74,152 restore normal talocalcaneal divergence requires peripheral
Denervation and neuromyogenic changes in the tibialis pos- subtalar capsular stretching. The increased fibrosis and con-
terior, peroneals, triceps surae, and long toe flexors appear tractile myofibroblasts in these “soft” tissues, the interosse-
to be a result of the condition itself as opposed to being ous restraints maintaining deformity, must be successfully
the result of nonoperative or operative treatment. Short- stretched or occasionally surgically released if there is to be
ened musculotendinous units are a consistent finding at any remodeling after anatomic correction of the bony dys-
any stage of clubfoot treatment and are obstacles to correc- morphic structures.
tion of the bony deformity described earlier. In addition, A flexor digitorum accessorius longus muscle may be
fibrosis of tissues such as the plantar fascia, the calcaneo- identified in 7% of children whose deformities require sur-
navicular (“spring”) ligament, the tibionavicular ligament, gical correction.48 Children who have first-degree relatives
A B C
FIG. 19.42 Talipes equinovarus in a newborn. (A) Clinical appearance of an untreated clubfoot. (B and C) Initial radiographic appearance of
bilateral untreated clubfeet.
with clubfoot are seven times more likely to have the anom- the foot will have a propensity to be overcorrected, and
alous flexor muscle than children without first-degree rela- overcorrection will result in an equally severe and perhaps
tives with clubfoot. unreconstructable calcaneovalgus deformity if the laxity of
Finally, there have been separate reports of congenital the underlying syndrome is not taken into account. On the
deficiencies of the dorsalis pedis artery113 and the posterior other hand, patients with arthrogryposis, diastrophic dys-
tibial artery46,113 associated with idiopathic clubfeet. These plasia, Möbius or Freeman-Sheldon syndrome, spina bifida
deficiencies, though rare, are more prevalent in clubfeet and spinal dysraphism, and fetal alcohol syndrome have
with greater deformity. As a result of these abnormalities, clubfeet that are notorious for defying correction and sub-
ischemic necrosis of a portion of the foot after surgery has ject to severe recurrence. Although there have been recent
been described.35,89 reports of correction of patients with arthrogryposis and
spina bifida by Ponseti nonoperative technique, the need
Diagnostic Features and Differential Diagnosis for surgical correction should be expected.15,65,116,132 Such
It is rarely difficult to identify a true clubfoot in a new- techniques as primary bone resection (e.g., lateral column
born (Fig. 19.42). The classic appearance of the heel in shortening, talectomy) and complete division of tendons
marked equinus, with the foot inverted on the end of the rather than lengthening are often used in the management
tibia, giving the foot an upside-down appearance in more of these syndromic types of clubfeet. The importance of
severe cases, is difficult to mistake for anything else. Lack presurgical diagnosis of these conditions cannot be overem-
of correctability separates a true clubfoot from the milder phasized because it will eventually affect the technique of
postural clubfoot. The milder manifestations represent an management.
in utero postural deformity, identified by the fact that it Some evaluation of the severity of the deformity is rec-
is fully (or nearly fully) correctable passively and by the ommended, both for prognostic value and for monitoring
conspicuous absence of the significant contractures and the progress of treatment. Methods of treatment cannot be
deep skin creases of a true clubfoot. A postural clubfoot compared for efficacy if the initial severity of the defor-
exhibits none of the atrophy and rigidity of true talipes mity is not known or described. Determination of the initial
equinovarus. Postural deformity can frequently be pas- severity index is an important assessment of each compo-
sively corrected at initial evaluation by several minutes of nent of talipes equinocavovarus because it alerts the surgeon
gentle stretching. and family to the need for heel cord tenotomy or possible
In addition to distinguishing the severity, it is also essen- surgical release.161,170 Although Goldner and Fitch,69 Car-
tial to search for associated anomalies and neuromuscular roll and colleagues,25 Pirani and associates,150 and oth-
conditions that define a nonidiopathic deformity. The prog- ers66,77,128 have proposed evaluation schemes, we favor the
nosis for a nonidiopathic, syndromic clubfoot is generally method of Dimeglio42,59,195,196 because of its more objective
worse than that for an idiopathic clubfoot, although there and reproducible method of scoring (Fig. 19.43). In fact,
are certain exceptions, such as Down syndrome or Larsen rating the severity of the clubfeet before nonoperative treat-
syndrome. In these syndromes, because of the significant ment using this method is predictive of the outcomes at 2
ligamentous laxity underlying the syndrome itself, cor- years old (Fig. 19.44).205
rection may be achieved with nonoperative treatment. If The overall rate of hip dysplasia in those with idiopathic
surgical release of a clubfoot is needed, it must be done clubfeet is less than 1%.200 Thus, screening hip radiographs
judiciously rather than aggressively or completely because are probably not warranted.
Assessment of Clubfoot by Severity
= 4 points
–20° = 3 points
= 2 points
= 1 point
0°
90°
20°
45°
–20° 0° 20°
45°
90°
Sagittal plane evaluation of equinus Frontal plane evaluation of varus
0°
20° –20°
90° 45°
45°
90°
20° –20°
0°
Horizontal plane evaluation of derotation Horizontal plane evaluation of forefoot
of the calcaneopedal block relative to hindfoot
Reducibility Points Other parameters Points
90° to 45° 4 Posterior crease 1

45° to 20° 3 Medial crease 1
20° to 0° 2 Cavus 1
<0° to –20° 1 Poor muscle condition 1
A
Classification of Clubfoot
Classification grade Type Frequency (%) Score
I Benign 20 <5
II Moderate 33 5 to <10
III Severe 35 10 to <15
IV Very severe 12 15 to <20
B
FIG. 19.43 Classification of clubfoot according to Dimeglio. (A) Assessment of clubfoot by severity. Each major component of clubfoot
(equinus, heel varus, medial rotation of the calcaneo-pedal “block,” and forefoot adductus) is graded clinically from 4 to 1 (most severe to
most mild). Additional points are added for deep posterior and medial creases, cavus, and poor muscle function. (B) Classification of club-
foot. The total score is stratified into four groups of severity (benign to very severe, grades I–IV).
Equinus: 3 points
Equinus: 2 points Varus deviations, reducibility to 00: 2 points
Derotation of calcaneopedal block: reducibility to –100: 1 points Adduction of forefoot,

reducibility to 00: 2 points
Posterior crease: 1 point Medial crease: 1 point Cavus foot: 1 point (for this foot,
1 more point for the medial crease
and another point for the posterior
C crease)
FIG. 19.43, cont’d (C) Clinical photographs showing assessment of clubfoot. (A and B, Adapted from Dimeglio A, Bensahel H, Souchet P,
et al. Classification of clubfoot. J Pediatr Orthop B. 1995;4:129–136; and Dimeglio A, Bonnet F. Reeducation du Piet Bot Varus Equin. Paris:
Elsevier; 1997.)
1.0 achieved with the Ponseti method, and the less frequently
Estimated probability of a good outcome 0.9
used French physiotherapy technique.d
0.8
Ponseti Method
In the early 1940s, Ignacio Ponseti developed his nonopera-
0.7
at age 2 years
tive approach to the treatment of clubfeet.152 Similar to Kite,

0.6 he was stimulated to investigate a less aggressive correction
than that used by surgeons with their attendant high rates of
0.5 complications, stiffness, and overcorrection. Careful anatomic
Estimated probability
0.4 Lower 95% confidence limit dissection of stillborn babies with clubfeet was critical for Pon-
Upper 95% confidence limit seti to define the pertinent pathoanatomy and to rationalize a
0.3 mechanism for correction. In addition, detailed investigations
0.2 into the biology of collagen were fundamental in supporting a
6 7 8 9 10 11 12 13 14 15 16 17 18 19 gradual correction. His method of weekly manipulation and
Initial Dimeglio numerical severity rating cast application to hold correction allows relaxation of the col-
lagen and atraumatic remodeling of joint surfaces without the
FIG. 19.44 Logistic regression provides an estimate of the prob-
ability of a good outcome (plantigrade foot with or without a fibrosis and scarring associated with surgical release.
tendoachilles lengthening) as a function of the initial Dimeglio In general, the ability to obtain full correction via this
numerical severity rating. approach is enhanced when treatment is instituted within
the first month of life. In these instances, Ponseti reports
that the need for posterior medial and lateral release is
Nonoperative Treatment avoided in more than 95% of cases. Although the success
Almost all orthopaedists agree that the initial treatment of rate in older infants (7–10 months old) is lower than that in
idiopathic clubfoot should be nonoperative. Most also agree younger ones, there is some merit in attempting to obtain as
that the earlier the treatment is begun, the more likely that much correction as possible before surgical release.
it will be successful because of the relatively viscoelastic For this method to be successful, correction of deformity
character of the newborn foot. The underlying philosophy should proceed in an orderly fashion. The acronym CAVE
of advocates of nonoperative treatment is that this should (cavus, adductus, varus, equinus) is helpful because it not
be a definitive method, thereby eliminating or significantly only describes the clinical position of the clubfoot, but it
reducing the incidence and amount of surgery that might also outlines the general order of deformity correction via
eventually be required. Doing so avoids the scarring and the Ponseti method.
stiffness that develops after surgery. Much of this philoso-
phy is predicated on observations in earlier surgical experi- Technique. The protocol consists of stretching and manipu-
ence that neonatal clubfoot surgery almost always produces lating the foot and applying holding casts until the next ses-
a more scarred and stiff foot.43,154 With this in mind, nonop- sion 5 to 7 days later. To stretch the ligaments and gradually
erative treatment proposes to gradually correct the clubfoot correct the deformity, the foot is manipulated for 1 to 3
deformity without producing the scar tissue that inevitably minutes. The correction is maintained for 5 to 7 days with
diminishes the result. The detrimental role of retracting a plaster cast extending from the toes to the upper third
fibrosis and the observations of myofibroblasts in retractile of the thigh and the knee at 90 degrees of flexion.184 Five
tissue61,152,168,206 certainly add histologic confirmation to or six cast changes are sufficient to correct most clubfeet.
the clinical observations concerning the results of neonatal Casting is usually timed to coincide with routine feedings;
surgery. after manipulation, the infant is fed a bottle, which tends to
Perhaps the most determined early protagonist of non- relax the infant and allow easier cast application.
operative treatment was J.H. Kite, who in the period The first goal is correction of the cavus deformity by fore-
from 1924 to 1960 nonoperatively treated more than 800 foot supination relative to the hindfoot. This manipulation
patients at the Atlanta Scottish Rite Hospital. In his 1964 seems counterintuitive because it tends to exaggerate the
monograph The Clubfoot, Kite described in great detail the appearance of overall foot inversion. Elevation of the first
method of manipulation and cast correction that had served metatarsal and supination of the forefoot is in contradistinc-
him well over many years.116 Kite corrected each compo- tion to other methods of manipulation that propose correction
nent of the clubfoot deformity separately and in order, of the cavus by pronation of the first metatarsal. At the first
beginning with forefoot adduction and proceeding to cor- session the forefoot is simultaneously supinated and abducted.
rection of heel varus (inversion) and finally to correction The cavus is almost always corrected with the first cast.60
of equinus. He was adamant that one could not proceed At successive manipulation and casting sessions, metatar-
to correct the next deformity until the previous one had sus adductus and hindfoot varus are simultaneously corrected
been corrected. Ideally, Kite believed, the forefoot should by abducting the foot while counterpressure is applied later-
be slightly overcorrected into a mild flatfoot position before ally over the talar head. With this technique, the calcaneus,
the foot was brought up out of equinus. Today, the Kite navicular, and cuboid are gradually displaced laterally. This
method is rarely used because of the inability of others to key maneuver corrects the majority of the clubfoot deformity
match his results and the excessive amount of time (26–49 and must be performed at each session with attention to three
weeks) required for infants to remain in casts. However,
enthusiasm for nonoperative treatment remains at an all- d References
17, 18, 30, 34, 45, 51, 57, 60, 81, 85, 101, 107, 121,
time high on account of the success that is currently being 139–141, 144, 159, 161, 163, 170, 181, 184, 208, 209.
A B
FIG. 19.45 Technique of a nonoperative Ponseti correction of clubfoot. (A) The thumb is positioned over the lateral aspect of the head of
the talus and the fingers correct the forefoot. No counterpressure should be applied at the calcaneocuboid joint because the entire foot
must be abducted under the talus. (B) The cavus and adduction are corrected by slight supination of the forefoot in relation to the hindfoot.
The forefoot is never everted; rather, it is displaced as a unit.
A B
FIG. 19.46 (A) Thin cataract knife blade used for percutaneous heel cord tenotomy. (B) Little scarring is left.
points (Fig. 19.45). First, forefoot abduction should be per- Equinus is the last deformity that is corrected, and cor-
formed with the foot in slight supination. As such, correction rection should be attempted when the hindfoot is in neutral
of the cavus deformity is preserved, but collinearity of the to slight valgus and the foot is abducted 70 degrees relative
metatarsals is also maintained, thereby producing an efficient to the leg. This degree of abduction seems excessive but is
lever arm for abduction. Second, the heel should not be con- needed to prevent recurrence of deformity. Equinus may
strained by premature dorsiflexion. It is important that abduc- be corrected by progressively dorsiflexing the foot after the
tion be accomplished with the foot in equinus to allow the varus and adduction of the foot have been corrected. The
calcaneus to abduct freely under the talus and evert to a neu- foot is dorsiflexed by applying pressure under the entire
tral position without touching the heel. It is also important to sole of the foot and not much under the metatarsal heads
avoid forceful dorsiflexion before correction of hindfoot varus to avoid a rocker bottom deformity. Equinus may be com-
because a rocker bottom deformity could develop. Third, care pletely corrected through further progressive stretching
is taken to locate the fulcrum for counterpressure on the lat- and casting. However, to facilitate more rapid correction,
eral head of the talus. Correction of hindfoot varus and cal- subcutaneous heel cord tenotomy is performed in the vast
caneal inversion would be hindered if counterpressure were majority (at least 85%) of patients. In this procedure the
applied to the lateral column of the foot or at the calcaneo- entire Achilles tendon is transected. Heel cord tenotomy
cuboid joint as opposed to the talar head.153 In general, three has been performed in children up to 1 year old without the
or four weekly manipulation and casting sessions are required occurrence of overlengthening or weakness. Tenotomy may
to loosen the medial ligamentous structures of the tarsus and be performed with a thin cataract knife in the clinic under
partially mold the joints. After each cast, foot supination is sterile technique (after lidocaine/prilocaine cream has anes-
gradually decreased to correct the inversion of the tarsal bones thetized the skin locally for 30 minutes; Fig. 19.46). Though
while the foot is further abducted under the talus. the procedure is done this way in the majority of patients,
A B C
D E
FIG. 19.47 (A–F) Ponseti casts show serial correction of the patient (see Fig. 19.42). (E and F) The last cast was applied after percutaneous
heel cord tenotomy.
some physicians elect to perform tenotomy in the operating sural nerve at risk.47 Successful tenotomy is heralded by a
room in children older than 3 months. It is easier to apply a palpable pop and immediate ability for further dorsiflexion
better cast without the resistance encountered in older and of approximately 15 to 20 degrees. No stitches are needed
therefore stronger infants. and sterile cotton cast padding is applied, followed by the
Certain techniques should be adhered to when perform- application of a long-leg cast in maximal dorsiflexion with
ing a percutaneous heel cord tenotomy. After standard ster- abduction to 70 degrees. The foot is immobilized for 3 to 4
ile preparation, the foot is held by an assistant with mild weeks; most infants require immobilization for 3 weeks, the
to moderate dorsiflexion pressure. Excessive pressure may slightly longer immobilization being reasonable in children
tend to tighten the skin and hinder the ability to palpate older than 6 months.
the tendon well. The blade enters the skin along the medial An alternative to percutaneous heel cord tenotomy
border of the Achilles tendon. Because the calcaneus is usu- has been suggested by Alvarez and colleagues.5 Botulinum
ally elevated in the fat pad, it is important to cut the ten- A toxin is injected into the triceps surae muscle complex
don 0.5 to 1 cm proximal to its insertion, where it tends to to weaken its function. Very short-term success with this
fan out onto the tuberosity of the calcaneus. After inser- approach, as opposed to tenotomy, was reported in 50 of 51
tion, the blade is pushed medial to the tendon and rotated infants with clubfeet.
underneath it. Counterpressure with the opposite index fin- Well-molded long-leg plaster casts are applied over a thin
ger will push the tendon onto the blade and prevent inad- layer of cotton padding at all steps during the treatment
vertent and unnecessary skin laceration. Excessive motion (Fig. 19.47). Benzoin is not applied to the skin and fiber-
of the blade laterally places the lesser saphenous vein and glass is not used because of poor molding characteristics.
has confirmed that children with recurrent deformity were

The Ponseti Brace in their orthoses for a significantly lower number of hours
each day then children without relapse.167
Gait analysis on 2-year-olds who were treated successfully
with this method have shown normal kinematic ankle motion
in the sagittal plane in 47% of cases.51 The most common gait
abnormality encountered was mildly increased dorsiflexion in
the stance phase. Although the rate of calcaneus gait abnor-
FIG. 19.48 The Mitchell abduction orthosis. (Courtesy MD Ortho- mality was less than 15%, patients with this objective informa-
paedics.) tion appeared to ambulate well at this early age. More recent
gait analysis studies have identified decreased total arc of ankle
Casts extending above the knee are necessary to maintain motion, plantar flexion, and push off strength in feet managed
the foot in abduction and external rotation, and to improve with Ponseti casting when compared to normal feet.137
results. The casts are molded with care taken to avoid pres- Partial recurrence of clubfoot deformity occurs in the
sure spots directly over the heel or malleoli. The plaster on first 2 to 3 years in approximately one third of feet and
top of the toes may be trimmed off, but a platform of plas- is often due either to poor compliance with the abduction
ter is left under the toes to favor stretching of the toe flex- orthosis or to delayed onset of treatment.29,57,155,159 Early
ors. As previously mentioned, it is advantageous to cast the recurrence of deformity (within the first year) may be suc-
infants when they are feeding. This may distract the child cessfully salvaged in one third of the relapsed cases by repeat
and facilitate application of the cast (Video 19.4). manipulation and application of casts to stretch and correct
After removal of the last cast, a foot abduction orthosis any residual deformity. It can be difficult to apply casts in
(often called a Denis Browne bar and shoes) is prescribed older infants; however, surprising correction of residual
to prevent recurrence of the deformity, to favor remodel- deformity can be obtained and subsequently maintained
ing of the joints with the bones in proper alignment, and to with the abduction orthosis. Again, compliance with ortho-
increase leg and foot muscle strength. The orthosis consists sis wear is mandatory for a successful outcome. In approxi-
of two straight-last open-toe shoes, or alternatively more mately two thirds of the feet that relapse, the recurrence of
flexible leather shoes with rubber inserts, connected by a deformity in infants does not respond sufficiently to repeat
bar that allows the shoes to be placed at shoulder width casting, and surgical intervention is therefore indicated, but
(Fig. 19.48). The bar should hold the shoes at 70 degrees usually not before 18 months old. Selective surgery consist-
of external rotation and 5 to 10 degrees of dorsiflexion. In ing of repeat heel cord lengthening, posterior ankle release,
unilateral cases, the normal foot should be in 40 degrees of or plantar fascia release (or a combination of these inter-
outward rotation. Maintaining the feet at shoulder width ventions) will be successful in restoring a plantigrade foot.
facilitates foot abduction. The orthosis is worn full time for Repeat casting prior to surgical intervention may limit the
at least 3 to 4 months, and afterward it is worn at nap and surgery required to obtain a satisfactory result.49 Extensive
nighttime for 2 to 4 years. A flexible abduction bar may posterior medial and lateral release is not usually needed
increase wear compliance.27 In patients older than 2 to 3 years, a dynamic swing
phase supination deformity may develop as a result of
Results. The results of treatment with the Ponseti method medial overpull of the anterior tibialis tendon. Incomplete
depend both on the outcome parameter used to judge results reduction of the navicular onto the head of the talus con-
and on the length of follow-up. Most current studies report verts the function of this tendon to a foot supinator instead
a high degree of success over the short term.51,57,101,107,181 of a dorsiflexor. If uncorrected, this can lead to recurrence
Following the completion of casting, satisfactory initial of hindfoot varus. In these patients, transfer of the anterior
correction can be expected in approximately 95% of idio- tibialis to the third cuneiform is performed after a short
pathic clubfeet. To maintain this correction, consistent use period of repeat casting.40,120,191 To prevent bowstringing,
of the foot abduction orthosis is mandatory. Unfortunately, the tendon should be left under the anterior retinaculum of
difficulty can be encountered in maintaining compliance the ankle. It is important to assess for any recurrent equinus
with orthosis wear. Every effort should be made to assist deformity that may require Achilles tendon Z-lengthening
families in this endeavor because lack of compliance with at the time of anterior tibialis transfer. Gait analysis has
brace wear is the primary reason for recurrence of defor- demonstrated significant decreases in the lateral midfoot
mity and failure of this treatment method.45,207 Infants are and forefoot contact time, contact area, and peak pressures
often irritated when transitioned from casts to the shoes following anterior tibial tendon transfer indicating efficacy
because their feet are not used to being touched. Because of the procedure at improving pressure distribution dur-
poorly fitting shoes can cause blisters, we recommend that ing stance.102 Despite the usual success of this procedure,
the shoes be removed and the feet examined several times a transfer of the tibialis anterior tendon does not guarantee a
day for the first week. In young infants, fit of the shoes can successful plantigrade outcome.120,130
be improved with application of a Plastazote heel counter In recent reports of patients with 5-year follow-up, the
and tongue liner. It is necessary to reassure parents that the overall number of patients who experience a relapse requir-
initial sensitivity soon resolves. Newer generation shoes, and ing some surgical intervention increases, and is reported
flexible abduction bars, may have a significant impact on to be in the range of 32% to 35%.17,157 The most common
improving compliance.27 Without the proper use of ortho- procedure performed is the tibialis anterior tendon trans-
ses following successful casting, recurrence of the clubfoot fer, which corrects swing phase supination. Those who
deformity is inevitable. An analysis of brace use adherence clearly fail the nonoperative treatment program and require
complete posteromedial releases are usually identified and plantar pressure patterns were normal in their intensity
early, and have undergone their surgical intervention before and distribution. For those still requiring surgery, operative
2 years old. Longer-term studies have also reported recur- procedures were usually limited to the posterior structures
rence in approximately one third of feet.32,95 Interestingly, only.
radiographic parameters such as the talocalcaneal angle and Although results were encouraging, this method of treat-
tibiocalcaneal angle on weight bearing films following good ment raised some concern.10,41 It consumed considerable
clinical correction with non-operative treatment do not pre- time and expertise, with success dependent on physical
dict the chance of future relapse in children aged 18 to 24 therapists’ skills.11 Cooperation and availability of families
months.160 were essential for this program to be effective. When the
It is not known with certainty the differences in long- family lived too far from the treatment center, successful
term foot function between feet treated with this method outcomes were less likely. In addition, economic concerns
and those treated with extensive surgical release. Primar- were involved because the daily specialized care was not
ily, no prospective randomized studies comparing these covered by all health care systems.41
two groups with long-term follow-up exist. Secondarily, it During the mid-1980s a new comprehensive French clas-
is important to realize that with this method one third of sification system for clubfeet was developed. It was refined
patients may require tendon transfer, tendon lengthening, through the years and eventually published in English medi-
or selective release as time goes on. As such, it would be cal literature in 1995.42 It achieved three goals: (1) estab-
inaccurate to compare only those who did not require any lished objective reproducible parameters that are easy to
surgery with those who failed other nonoperative methods measure even for those who have limited experience with
and required posterior medial and lateral release. However, clubfeet, (2) defined a reproducible 20- point value and
it seems intuitive that feet treated with less surgery would severity scale, and (3) made clinical assessment simple by
function better over the long term with less pain and greater providing a complete and strict checklist illustrated with
strength, mobility, and function. drawings to avoid approximate examinations. This classifi-
Cooper and Dietz published long- term results from cation system has become assimilated into this method of
an Iowa study in 1995.32 In this retrospective review, 45 treatment (see Fig. 19.43). Dimeglio introduced the French
patients with 71 clubfeet were evaluated an average of 34 method of clubfoot treatment in North America in 1996.
years after treatment. Thirty of the 71 feet required tibialis With this method of clubfoot treatment, the orthopae-
anterior transfer. Sixty-two percent of clubfeet were nor- dist evaluates the newborn, grades the severity of the foot
mal, 16% were good, and 15% were poor. Physical exami- with the Dimeglio classification system, and then refers the
nation documented very good strength and decreased foot family to a physical therapist experienced with this tech-
motion in comparison to those whose contralateral foot was nique. The family’s cooperation in regularly attending the
normal. Subjective evaluation was based on age-matched daily sessions must be emphasized and clearly understood.
controls and failed to denote any differences in functional The time requirements for this technique effectively elimi-
outcome. Only with time and longer-term follow-up of sur- nate the orthopaedist from being the primary individual who
gical patients will we be able to compare these results with performs the daily manipulations. Instead, the orthopaedist
those that required extensive surgery. works closely with the physical therapist. Specialized train-
ing and, with time, experience are required if successful out-
French Physiotherapy (Functional) Method comes are to be expected. Decisions regarding the frequency
The French physiotherapy method is another method for of physical therapy visits and need for splinting are made
nonoperative correction of clubfeet. It is used today mainly primarily by the therapist. Physician follow-up is undertaken
in Europe, and in several North American centers. every other month to monitor improvement in the foot and
determine whether operative intervention will be necessary.
Origin of the Procedure. The French method for nonopera- Open communication between the orthopaedist and physi-
tive correction of clubfeet was conceived in the early 1970s cal therapist is essential for success of this program.
by Masse131 and by Bensahel and colleagues.11 Known as the The French method aims specifically at relaxing the tibi-
“functional method,” it consisted of daily manipulations of alis posterior and medial fibrous zone through a combination
the newborn’s clubfoot, stimulation of the muscles around of progressive passive manipulations, active muscle work,
the foot (particularly the peroneal muscles) to maintain the taping, and splinting.8,10 Bensahel believed that plaster cast
reduction achieved by passive manipulations, and temporary immobilization after reduction of this deformity (by any
immobilization of the foot with nonelastic adhesive strap- means of forced stretching) was detrimental. He thought
ping. The daily treatments were continued for approximately that forced stretching of muscles in a child (even under
2 months and were then progressively reduced to three ses- anesthesia) would lead to a defense reaction with resulting
sions per week for an additional 6 months. After this period, contraction of the stretched muscles.
taping was continued until the child became ambulatory, and The infant must be relaxed; otherwise, resistance makes
then nighttime splinting was used for 2 to 3 years. this technique difficult. Sessions last approximately 30
Intermediate-term results of patients treated from the minutes per foot. The process is no more difficult than any
mid-1970s to the early 1980s were first reported in English other form of nonoperative treatment but must be well
medical literature in 1990.11 In nearly 50% of infants with assimilated because it is detailed and very precise in all its
clubfoot treated by this “functional” method, the outcome steps, including finger placement, hand position, and sens-
was favorable in that the feet were well aligned clinically ing of the infant’s response. Manipulations are performed
and radiographically, range of motion was within normal gently and smoothly and must be progressive in reduction
limits, gait was normal with normal wear patterns on shoes, of the deformities. The first few weeks of life are the best
A B C
D E F
G H I
J
FIG. 19.49 French technique of manipulation and taping. (A) Manipulation to correct forefoot adductus and heel varus. (B and C) Derota-
tion of the calcaneo-pedal block and reduction of talonavicular displacement. (D) Manipulation of heel varus. The calcaneus is then rotated
medially away from the fibula while the forefoot is externally rotated (as in B and C). (E) Manipulation of equinus. The taping technique
maintains correction of the forefoot. (F–H) Taping to maintain forefoot eversion and midfoot dorsiflexion. (I and J) Additional taping main-
tains external rotation and dorsiflexion.
time to initiate functional treatment because it allows the cuneiform-metatarsal, and MTP. As this is performed and
best chance of success. after all joints of the foot have been loosened, forefoot
adduction is further decreased by continuing to stretch the
Current Procedure. The goal of this treatment is to reduce medial skin crease. To maintain the new passive range of
the talonavicular joint, stretch out the medial tissues, and motion, the toe extensors and peroneals must be strength-
then sequentially correct forefoot adduction, hindfoot varus, ened. To do this, the therapist elicits cutaneous reflexes by
and equinus of the calcaneus (Fig. 19.49). In the first step, tickling the fifth ray and along the lateral border of the foot.
the navicular bone is progressively released from the medial The third step is progressive reduction of hindfoot varus.
malleolus and from its medial position on the head of the This begins after the talonavicular joint has been reduced
talus. Early on, this relaxation will be incomplete because the and can be performed in conjunction with correction of the
talus retains its pathologic position. Gradually, this improves. forefoot adduction. The calcaneus gradually moves to a neu-
The second step is to correct forefoot adduction by tral position and eventually into valgus. The ankle is exter-
stabilization of the global adduction of the calcaneus- nally rotated at the same time that the calcaneus is being
forefoot block. This maneuver stretches all the joints of mobilized into valgus. The knee is kept flexed to 90 degrees
the medial ray of the foot progressively: naviculocuneiform, during these maneuvers.
The final step of this treatment program corrects the that similar rates of surgery were required by both groups
equinus of the calcaneus, which is often difficult because (16%–21%), but that the Ponseti-treated patients required
contracture of the posterior soft tissues may not be easily less extensive surgery compared with those treated by the
elongated by manipulations. The calcaneus is progressively French method.28
brought from plantar flexion to dorsiflexion while the knee We agree with Dimeglio that selective, less- extensive
is kept in flexion. The knee is then very cautiously extended. surgery should now be considered a part of both the Pon-
This maneuver is performed repeatedly. The lateral arch is seti method and the French method (surgery “à la carte”).44
carefully supported in an effort to protect the midfoot from Some patients will also benefit from use of both methods
being stretched (midfoot break). in their treatment program, particularly when difficulty
These phases of the manipulation sessions should be per- with correction is encountered using one of the methods.
formed by the physical therapist in the order described.8 By combining the advantages of both methods, optimal out-
Once the manipulations are concluded, taping is applied to comes may be maximized. Dimeglio has referred to this as
maintain the passive range of motion achieved during the the “hybrid method” or the “third way.” It may come to be
session. Supplies needed include M-wrap, Elastoplast, and considered the best approach in the future.
Hypafix. M-wrap is a very thin layer of foam underwrap
that protects the leg from the adhesive. Elastoplast tape Surgical Treatment
holds the foot in position but, because it stretches, permits Surgical management of a resistant, persistent, or relapsed
exercise of the taped foot. Eight-inch lengths of Elastoplast clubfoot deformity (that does not respond to further non-
tape are specifically applied to maintain the correction. operative treatment) will be required to obtain a plantigrade
Hypafix tape keeps the proximal edges of the M-wrap and foot. The surgical release must address all pathoanatomic
Elastoplast from sliding distally. structures in a resistant clubfoot, including a complex release
of the hindfoot and midfoot, possibly one of the more com-
Results. Most of the clubfoot improvement achieved with plicated procedures performed in all orthopaedics. Mov-
the functional method occurs during the first 3 months. ing ahead with this treatment requires more judgment and
After this period, only modest amounts of further improve- skill from the surgeon than any other orthopaedic condition
ment should be expected. The stretching, taping, and splint- amenable to surgical correction. The decisions that have to
ing program continues to be performed on a daily basis by be made preoperatively and intraoperatively—the timing
the parents. Visits with the physical therapist decrease in of surgery, its extent, and regretfully, how to plan a salvage
frequency. If successful, this program continues until the procedure—compose a challenging treatment algorithm for
child is walking and is then discontinued (at 2 to 3 years old) which there is no “standard” method or reference.
as the foot position is stabilized. Follow-up continues until Surgical correction is the last resort for a deformity
the end of adolescence. that is resistant to nonoperative treatment. Although many
If the program is not successful, surgery may be needed. orthopaedists believe that surgery will most likely correct a
Percutaneous heel cord tenotomy may be performed in the first severe clubfoot, one cannot discuss this as the most effec-
several months and is now becoming more commonly used with tive method of treatment without again recalling the warn-
this treatment method. Physiotherapy is started again after the ing of E.H. Bradford19 that “the literature on the treatment
plaster cast is removed. If further surgery is anticipated, such as of clubfeet is, as a general rule, that of unvarying success
a posterior release, it is usually delayed until walking age. … yet in practice there is no lack of half-cured or relapsed
Bensahel and associates first reported the results of treat- cases, sufficient evidence that methods of cure are not uni-
ment with the French physiotherapy method in 1990. Good versally understood.” Certain principles of surgery are self-
results (without continuous passive motion [CPM]) were evident yet bear repeating because of Bradford’s warning.
attained in nearly 50% of patients.11 When complementary Multiple operations are to be avoided because increasing
surgery was performed in the remaining patients, the overall stiffness, deepening of scars, and hardening of tissue from
good outcomes increased to 86%. In more recent reports, repeated surgery, as well as atrophy introduced by immobi-
good results from exclusively nonoperative treatment were lization, are common after repeat surgery. The surgeon who
achieved in 63% (mean follow-up of 10 years)9 and 77% performs the first operation has the best chance of achieving
of patients.181 With these reports, emphasis was placed on permanent correction, and thus this surgeon’s responsibility
the importance of using experienced, well-trained physical is increased. The most frequent cause of repeat surgery for a
therapists. A significant difference in outcomes depended severe clubfoot is incomplete or inadequate correction, thus
on their degree of training and experience. revealing that the so-called limited release is often a euphe-
Our success treating idiopathic clubfeet with the French mism for an incomplete or inadequate operation. Both the
physiotherapy method has been similar to that found using French physiotherapy treatment and Ponseti method allow
the Ponseti method.57,159,162 The initial correction rate was improved results with limited releases when relapses occur
95%, and relapses occurred in 29%. All relapsed feet required or when incomplete correction is achieved. The amount of
surgical intervention, with approximately half undergoing release that is performed is a measure of the practitioners’
selective surgery and half requiring posteromedial release skill and experience in knowing how much surgery, short
before the age of 2 years. Gait analysis at 2 years old com- of a comprehensive release, is necessary to produce appro-
paring the French method and Ponseti method found that priate correction that is additive to the correction achieved
normal kinematic ankle motion was present more often in by the nonoperative manipulation. Frequently, a posterior
the Ponseti group, and that residual intoeing was seen in one release consisting of Achilles tendon lengthening and poste-
third of children treated by both methods.70 A French study rior capsulotomies of the tibiotalar and subtalar joints will
comparing the two methods at 5-year follow-up reported be sufficient to correct the equinus and, if present, minimal
a program because of excessive scarring and recurrent fibro-

sis, which was attributed to the hypermetabolic reaction of
the connective tissue in such a young infant.154 Turco rec-
ommended surgery at the age of 1 year or older, primarily
because of the advantages that the structures were larger,
the anatomy more easily evaluated and corrected, and the
tendon lengthening repairs more secure.192 Consensus
indicates that although surgery can be performed as early
as 5 months old by an experienced surgeon, there is little
advantage to doing it at that time because weight bearing
and achieving the standing position will be delayed by the
postoperative immobilization. The lack of weight bearing in
a 6-month-old infant requires that the plantigrade position
be maintained in retention braces or some other external
device to prevent recurrence until such time as the child
achieves the standing position. There is therefore little
advantage to performing the surgery before 9 to 10 months,
A B an age that ensures that the child will be weight bearing
when the postoperative cast immobilization is completed.
Various Techniques
A variety of surgical procedures and techniques have been
described to achieve the goal of complete anatomic restora-
tion. Turco is credited with describing the first complete
one-stage posteromedial release.192 He emphasized cor-
recting the deformity of the calcaneus beneath the talus,
which required complete subtalar release (lateral, poste-
T rior, and medial), as well as release of the calcaneofibular
ligaments. The surgery is performed with patient supine,
through a curved posteromedial incision beginning along-
side the Achilles tendon above the ankle joint. All medial
neurovascular structures and tendons are identified, with
the posterior tibialis tendon being lengthened or released,
C the talonavicular joint opened dorsally, medially, and inferi-
orly, and the calcaneonavicular spring ligament released.
FIG. 19.50 (A and B) Pinning of the talonavicular joint. The pin is The Achilles tendon and long toe flexors are lengthened and
drilled from the posterolateral corner of the talus and, once firmly repaired. The talonavicular joint is reduced and pinned (Fig.
in the body of the talus, can be used as a joystick to rotate the talus 19.50).
medially while the forefoot is abducted to effect reduction. Parallel-
Release of the interosseous talocalcaneal ligament so
ism of the talus and calcaneus, indicative of hindfoot deformity, is
corrected by the rotation with the axis at the interosseous ligament.
that the calcaneus can be everted and rotated by moving
(C) The pin is drilled across the talonavicular joint under direct the anterior end laterally and the posterior tuberosity down-
vision. The interosseous ligament (arrow), which is usually released ward was part of Turco’s original description, although it is
as part of several published techniques (Turco, McKay, Simons), is generally avoided in other techniques. Turco immobilized
preserved. The anterior talocalcaneal ligaments connecting the talar his patients for a total of 4 months and removed the K-wires
neck and the anterior end of the calcaneus are released to allow at 6 weeks. Night splints were used for an additional year
complete talocalcaneal divergence. (Note the space between the after the end of cast immobilization.
interosseous ligament and the talar head [T].) (A and B, Redrawn Other surgeons modified Turco’s basic procedure to
from Carroll NC, McMurtry R, Leete SF. The pathoanatomy of con address different pathoanatomic aspects that were also con-
genital clubfoot. Orthop Clin North Am. 1978;9:225–228.)
sidered important. Carroll emphasized plantar fascial release
and capsulotomy of the calcaneocuboid joint24,25 because
hindfoot varus. In approximately 15% of idiopathic club- forefoot adduction and supination (actual cavus) were not
feet, a complete posteromedial release will be needed, and addressed by Turco’s procedure. Thus, through a medial
the remainder of this section addresses this procedure.28,159 incision with the patient prone (or supine), the abductor
hallucis is identified and released, and deep to it, the plantar
Timing of the Procedure fascia is divided; after sufficient dissection of the inferior
For an infant in whom nonoperative treatment fails, surgery talonavicular and anterior talocalcaneal area, the peroneus
should be performed before the age of 12 months (once longus tendon is protected and the calcaneocuboid joint is
the child has achieved walking status).66,128,152,173,192 In opened from the medial side and fully released (Fig. 19.51).
the past, Pous and Dimeglio performed surgical releases This follows posterolateral release through a posterior lon-
between 1 and 6 weeks old under the reasoning that the gitudinal incision paralleling the lateral edge of the heel
earlier the fibrous medial and posterior contractures were cord, through which the Achilles tendon is Z-lengthened.
released, the better.154 They subsequently abandoned such A posterior capsulotomy of the ankle joint, including the
calcaneonavicular impingement preventing midfoot abduc-

tion (“the rug in front of the door”) is assessed. A lateral
talonavicular capsulorrhaphy to obviate internal fixation is
then performed. De-emphasizing the subtalar circumferen-
tial release and replacing it with the more complete tibio-
talar and midfoot release make Goldner’s approach unique
among modern clubfoot procedures. The results of club-
foot release without formal subtalar release indicate more
undercorrection (residual internal foot progression angle),
but rarely valgus overcorrection, a more difficult deformity
to reconstruct.204
More extensive procedures are performed by McKay134
and Simons,178 who used the Cincinnati incision31 with the
patient supine. The majority of peritalar structures, includ-
ing all hindfoot and midfoot joints, are released. A medial and
lateral circumferential talocalcaneal release is performed,
with the lateral talocalcaneus ligament being released from
the attachment of the calcaneocuboid joint laterally to the
sheath of the flexor hallucis longus posteromedially. Com-
A plete release of the talonavicular and calcaneocuboid articu-
lations is included, and both these structures are pinned.
The subtalar release includes the interosseous ligament.
Once the calcaneus has been adequately derotated by push-
ing the anterior end laterally and the posterior tuberosity
medially and downward, the interosseous ligament is inter-
nally fixed. McKay also introduced the concept of an articu-
lated “cable cast” in which the hinge is centered at the ankle
joint for immediate postoperative movement, with the con-
nection between the foot and leg portions of the cast being
a large-gauge telephone wire. This was intended to increase
hindfoot (ankle) motion, with 30 to 60 degrees of total
motion being reported,135,178 although dorsiflexion is usu-
ally limited to 10 to 15 degrees. Wound complications from
early motion of the cable cast have decreased acceptance of
this method of postoperative management. Despite the use
of multiple K-wires to internally fix the three joints, late
motion does not appear to diminish if early motion is com-
menced, a theme more emphatically repeated as long-term
B outcome studies are completed.
FIG. 19.51 (A) Calcaneocuboid deformity; release from the medial Suggested Operative Technique
approach (arrow). (B) Fluoroscopic confirmation of calcaneocuboid
release from the medial side. The comprehensive procedure favored at our institution
includes portions of all the aforementioned procedures
(Video 19.5). Prone positioning allows better assessment
medial and lateral ligaments, is performed to mobilize the of hindfoot release, whereas a supine position probably
talus and reduce the talonavicular joint, which is done by improves medial and plantar exposure. We use the Cin-
internally rotating the talus with a longitudinal K-wire as cinnati incision and do not hesitate to add a longitudinal
the “handle” to perform this derotation (see Fig. 19.50).25 arm paralleling the Achilles tendon, placed perpendicular
This maneuver is consistent with three-dimensional analysis to the transverse portion of the Cincinnati incision over
showing that the body of the talus is externally rotated in the calcaneal tuberosity, if additional proximal exposure
the ankle mortise and must be internally rotated to produce for Achilles tendon lengthening is needed.
correction. As in any procedure involving multiple anatomic steps,
Goldner, also emphasizing correction of the talar rotation exposure is key to a successful comprehensive release, and
as the primary deformity, performs complete release of the there is no better place to begin emphasis of exposure than
tibiotalar joint, including the deep medial deltoid ligaments, with the posterolateral corner of the ankle, where after the
and subsequently repairs these ligaments if necessary to cor- sural nerve and lesser saphenous vein have been identified
rect the talar rotation through the ankle joint.68 Subtalar and protected, the peroneal sheath is opened to allow full
capsulotomy is minimized to protect against valgus over- anterior retraction of the two tendons (Fig. 19.52). This
correction. The medial and plantar structures (all tendons) permits a precise and complete release of the calcaneofibular
are lengthened, as is the Achilles tendon, through a medial and lateral subtalar ligaments anteriorly to the sinus tarsi
incision, and via a separate lateral incision in the sinus tarsi area135 under direct vision, thereby avoiding blind peroneal
region, a calcaneocuboid capsulotomy is performed and tendon injury. The opening of the tendon sheath ends above
A B
Posterior tibial
artery and nerve
Talus Fibula
B
Flexor hallucis
longus muscle
C D
A
C
B FIG. 19.52 (A) Posterolateral corner. The peroneal tendons are

retracted to allow complete calcaneofibular and lateral subta-
lar release (elevator in the subtalar joint; T, talus; F, fibula). The
Achilles tendon and sural nerve are preserved.
(B) Deep calcaneofibular (arrow) release. Improved exposure
by peroneal retraction makes complete posterolateral release
feasible under direct vision. The Achilles tendon already has
E
been lengthened in this example. (C) Z-lengthening of the
Achilles tendon in the coronal plane. (D) Retraction of the
flexor hallucis longus tendon allows exposure for posteromedial
release of the tibiotalar (A) and subtalar (B) joints. (E) Release
of the posteromedial ankle (A) and medial subtalar (B) joints
(neurovascular bundle and tendons removed). The stump
of the lengthened tibialis posterior remains attached to the
navicular, which acts as a guide to continue subtalar release
distally into the talonavicular joint (C).
the tip of the fibula to avoid subluxation of the tendons bones being the interosseous ligament, the center of rota-
anterior to the fibula. Longitudinal exposure of the Achil- tion. Failure to release the talar neck from the anterior end
les tendon permits a long Z-lengthening in either the coro- of the calcaneus means that the rotatory divergence nec-
nal or sagittal plane (see Fig. 19.52C) so that two strips are essary to correct hindfoot inversion and medial rotation is
created for later competent repair under tension. Because impaired because the calcaneus is still “locked” to the talus
of concern over late triceps surae insufficiency, Achilles anteriorly (see Fig. 19.53). Division of the calcaneonavicu-
tendon lengthening can be deferred until late in the proce- lar (spring) ligament completes the medial release. After
dure, when it can be definitively determined that Achilles the navicular is retracted distally with a two-pronged rake,
tendon lengthening is required to achieve neutral dorsiflex- blunt dissection distal to the end of the calcaneus will lead
ion. Extensile longitudinal exposure of the Achilles tendon to the calcaneocuboid joint, which is incised and mobilized
allows it to be mobilized and retracted without lengthening, with a Freer elevator, and the capsule is then stripped and
but we do not hesitate to lengthen it to aid exposure if it opened to allow reduction of the cuboid laterally (see Fig.
is undeniably contracted. The flexor hallucis longus sheath 19.51).
medially is opened so that the tendon can be retracted. Pos- If cavus is a significant component of the foot defor-
terior and medial release of the subtalar and tibiotalar joints mity, the plantar fascia should be divided transversely by
can be performed at this stage (see Fig. 19.52D). The neu- returning to the plane superficial to the plantar edge of the
rovascular bundle is mobilized and protected with a Penrose abductor hallucis. The muscle belly is bluntly dissected and
drain, and the posterior tibialis and flexor digitorum lon- retracted dorsally to locate the fascial edge. An elevator is
gus sheaths are also incised for retraction or lengthening, or passed deep and superficial to the fascia to clear all soft
both. In mobilizing the bundle, it is elevated off the medial tissue before the fascia is cut with scissors. If the first ray
subtalar area completely, and release of the flexor hallu- remains tethered and resists dorsiflexion and abduction, the
cis longus sheath all the way to the decussation with the tendon of the abductor hallucis can be released distally.
flexor digitorum longus distally provides easy visual access The talonavicular joint is now reduced and pinned using
to release the medial subtalar capsule peripherally to the the Carroll technique of passing a K-wire from the posterior
sustentaculum without cutting the interosseous ligament lateral corner of the talus (in the posterior part of the inci-
(see Figs. 19.50C and 19.52E). sion) longitudinally toward the talar head (see Fig. 19.50).
Moving medially, the key to wide exposure is to dissect The pin is used as a joystick to rotate the talar body inter-
the plane dorsal to the abductor hallucis and effectively nally while the navicular is pushed into abduction and onto
release it from its origins on the flexor tendon sheaths. The the true talar head. The reduced joint is pinned, and the pin
plantar exposure depends on this and on incision and release is pushed out onto the dorsal aspect of the foot (for later
of all tibialis posterior insertions in the plantar aspect of the removal). The forefoot is now reduced to the talus. The sur-
foot, with only the insertion on the navicular remaining. geon must ensure that the reduction is anatomic and that no
The tibialis posterior is usually Z-lengthened at this stage rotation of the navicular has occurred as a result of pivoting
for exposure, as well as to allow navicular reduction later. on lateral soft tissue or calcaneal obstruction. Otherwise,
The two long flexors and the neurovascular bundle can then dorsal subluxation of the navicular will ensue and lead to
be retracted as a group in the Penrose drain and the most recurrent cavovarus.119
anterior part of the medial subtalar joint incised, leading Normally, accurate talonavicular reduction produces
dorsally to the talonavicular capsule and laterally under the calcaneocuboid reduction, which is recognized from the
neck of the talus for release of the anterior talocalcaneal flattened or overcorrectable lateral column and border of
attachments (see Fig. 19.50C). The flexor tendon sheaths, the foot. If the lateral border is not straight but remains
now empty, should be incised transversely at the level of with forefoot-medial curve, a calcaneocuboid capsulotomy
the medial malleolus to the posterior edge of the tibialis from the lateral side and a Lichtblau123 or other resection
posterior to eliminate them from functioning as a supinating to shorten the lateral column must be considered (Fig.
contracture. 19.54). Similarly if dynamic forefoot cavovarus is pres-
Talonavicular release must be done carefully because ent, long flexor tendon lengthenings should be performed.
of medial displacement of the navicular. The dorsal struc- Once these tendons are lengthened (typically 1–1.5 cm),
tures should be elevated close to bone off the talar neck the forefoot can be passively corrected. The lengthened
and navicular, with complete release of the tibionavicular and repaired tendons are replaced in their original sheath
(superficial deltoid) ligament (see Fig. 19.52E). The tibialis grooves (the flexor hallucis longus posterior to the bundle,
anterior tendon should be identified and followed partially the flexor digitorum longus anterior), and the sheaths are
to its cuneiform insertion to aid in directing dissection to the partially repaired with 5-0 suture to act as a checkrein and
talonavicular joint and avoid misrecognition of the naviculo- keep the tendons in place (Fig. 19.55).
cuneiform joint. With the distal stump of the Z-lengthened The tibialis posterior is repaired with tension and
tibialis posterior used as a guide, talonavicular capsulotomy replaced in its sheath. Repair of a checkrein here is helpful
is performed medially, dorsally, and plantarward. With a to avoid adhesions. Finally, the Achilles tendon, if length-
curved elevator, the lateral talonavicular capsule is stripped ened, is repaired with the foot in slight (“gravity”) equinus
from the talus and the navicular is mobilized so that it can to encourage maximal triceps function. Several interrupted
be accurately reduced on the talar head. The elevator is then sutures between the overlapped surfaces of the tendon are
passed under the neck of the talus to strip and incise any tied to prevent stretching or rupture of this most important
anterior calcaneal connections with the talus (Fig. 19.53). of tendons.
This will ensure full rotatory mobility of the talocalcaneal Skin closure is done with minimal tension; the wound is
joint, with the only remaining structure between the two allowed to gap open, if necessary, to avoid necrosis of the
A B
C D
FIG. 19.53 (A) Uncorrected deformity (right). To gain rotatory divergence of the talus and calcaneus, all peripheral connections between
the two bones, except the interosseous ligament (x), must be released, including the anterior talocalcaneal ligaments. (B) Release of anterior
talocalcaneal structures dissected by the hemostat (heel to the left, toes to the right). The talonavicular joint is distracted by the two-prong
rake. The talar head is visible. (C) Intraoperative radiograph obtained after posterior and talonavicular release but before complete medial
and anterior talocalcaneal release. As evidenced by the shortened-appearing calcaneus and posterior displacement of the fibula, the talus
and calcaneus are still medially rotated together with inadequate rotatory divergence. The fibula appears more posterior because the hind-
foot remains medially rotated, and the foot and ankle are positioned for a true lateral view of the foot. (D) Radiograph obtained after medial
and anterior talocalcaneal release and reduction of the talonavicular joint. The calcaneal projection now shows normal length and pitch, in-
dicative of a true lateral rather than a medially rotated position. This is confirmed by the normal lateral view of the fibula, which is no longer
posteriorly displaced in external rotation. The talocalcaneal relationship has now diverged appropriately.
skin edges. If the original deformity was severe, the foot the other components of the deformity must be correctly
must be left with residual equinus in the immediate post- positioned to avoid early recurrence. Thus the foot should
operative splint and the splint changed to a cast in 7 to 10 be externally rotated by simultaneously abducting the fore-
days (usually under anesthesia) to correct the residual equi- foot and pushing the posterior calcaneus away from the
nus once the wound has healed partially. An above-knee cast fibula. The surgeon holding the correction must immobilize
is used. Regional fasciocutaneous flap closures have been the tibia-fibula unit in internal rotation by grasping just dis-
described for very severe clubfeet.127 In older children, the tal to the knee and externally rotating the foot against the
use of soft tissue expanders before surgical treatment of a tibia-fibula position while the plaster hardens. As the cast
very severe clubfoot has been successful in achieving pri- or splint hardens, additional molding against the first meta-
mary wound closure.162 tarsal medially helps correct forefoot adduction, and addi-
Immobilization of a freshly operated clubfoot is as tional molding against the cuboid plantar surface everts the
important as the operative technique itself inasmuch as a midfoot. At the 10-day cast change, the foot is dorsiflexed
foot poorly positioned in a cast or splint will heal in that to neutral by pushing the first metatarsal upward (to correct
position. Although it may be necessary to temporarily leave cavus) while maintaining the externally rotated position of
some residual equinus because of skin tightness posteriorly, the entire foot.
FIG. 19.55 Replacement of the lengthened flexor hallucis longus

tendon in its original sheath location at the posterior margin of the
talus. A checkrein repair (arrow) maintains the biomechanical func-
tion of the lengthened tendon. (The neurovascular bundle is under
the retractor to the right.)
FIG. 19.54 Incomplete correction of the midfoot despite calcaneo-

cuboid capsulotomy. The lateral column remains too long. Lateral window created. By maintaining foot position during reso-
column shortening is indicated. lution of the wound problems, recurrent deformity and an
even more difficult revision operation may be avoided.
Pin tract infection can be a dilemma because premature
Because of concern about immobilization stiffness and pin removal can lead to loss of correction. Dorsal sublux-
atrophy, above-knee casting is continued only until the ation of the navicular can be traced to premature talonavicu-
soft tissues have healed, generally in 4 to 6 weeks. Pins lar pin removal, especially if lateral tethers to the navicular
are removed at approximately 4 weeks, with ambulation have not been adequately released.119 The ensuing shorten-
encouraged immediately in a short-leg walking cast. ing of the medial column, forefoot equinus, and supination
usually produce a cavovarus deformity that will need revi-
Postoperative Complications sion. Thus, if a pin tract becomes infected within the first
Loss of Correction. Loss of correction with recurrence 4 weeks of postoperative management and retention of the
of deformity is a recognized scenario in clubfoot sur- pin is thought to be critical for maintenance of correction,
gery.78,151,194 Wound or cast complications may necessitate vigorous pin care should be ensured and antibiotics adminis-
a change in the postoperative plan of treatment. Most com- tered in an attempt to maintain the fixation until the normal
monly, loss of correction involves inadequate postoperative time for removal.
position as a result of the cast’s becoming too loose once
the postoperative swelling has resolved. Failure to recognize Dorsal Subluxation of the Navicular. This condition, which
and change a loose or inadequate cast—usually with equi- produces a shortened cavovarus foot, has been reported fre-
nus positioning—will invite recurrence. The surgeon must quently after Turco procedures.136,171 Simons177 and Tachd-
be prepared during the first 3 to 4 postoperative weeks to jian188 blamed failure to release the tibionavicular ligament
change the cast, under anesthesia if necessary, to maintain and dorsolateral talonavicular capsule for the complication.
the corrected position. After the first 4 weeks, cast changes Kuo and Jansen, however, found this complication to occur
will probably be ineffective in regaining any dorsiflexion or just as frequently after a Carroll-type subtalar and calcaneocu-
external rotation that has been lost, and thus if a cast change boid release as after Turco procedures.119 It should be appar-
is done in an attempt to regain position successfully, it must ent that failure to release the important tethering structures of
be done early. the navicular, failure to accurately reduce the navicular head of
Maintaining the corrected foot position despite wound the talus, and loss of talonavicular reduction as a result of pre-
complications follows the principle of obtaining maximum mature pin removal are technical errors that have nothing to
correction by the first cast change. Although wound dehis- do directly with the type of procedure performed. Anatomic
cence and infection (including infection of the pin tracts) analysis of the deformity has shown it to be a rotatory sublux-
are uncommon in a first-time operation, if wound access is ation, with the medial edge of the navicular rotated superiorly
needed for dehiscence with secondary infection, foot posi- while the lateral edge is tethered (by the talonavicular, navicu-
tion must be maintained while wound healing by secondary locuneiform, and cubonavicular ligaments).
intention proceeds. If a cast window threatens the integrity Should revision surgery be indicated for the resulting
of foot positioning, the cast should be replaced and a new cavovarus foot, an attempt at reduction of the navicular is
A B
C D
FIG. 19.56 (A–C) Valgus overcorrection. Because of hyperpronation and abduction of the midfoot and forefoot, weight bearing is excessive
on the medial border of the foot. Lateral ankle impingement at the fibula is caused by horizontal translation of the calcaneus under the talus.
The resulting loss of normal heel height produces additional triceps surae weakness over that caused by lengthening of the Achilles tendon.
(D) Three-dimensional reconstruction (from computed tomography images) of the right foot valgus overcorrection (posterior view). The loss
of heel height and horizontal translation of the calcaneus laterally are obvious. Note that the talus vertical moment of inertia (arrow points
to the axis) indicates persistent pronation-intorsion; that is, the tibiotalar clubfoot deformity is uncorrected. Similarly, the longitudinal axis of
the calcaneus (double arrows) is internally rotated, an uncorrected clubfoot position exacerbated by eversion/valgus corrective force applied
during casting, with the calcaneus pushed toward the fibula rather than rotating the posterior tuberosity away from it.
appropriate in children younger than 6 years old. A midfoot of forefoot adduction or heel inversion, and aggressive cast-
release, beginning on the lateral side (calcaneocuboid, cubo- ing to evert the hindfoot and abduct the forefoot is carried
navicular, and lateral, dorsal, and medial talonavicular) and out to redress the unsatisfactory position. Plantar release in
combined with repeat plantar release and possibly tibial ante- the absence of fixed cavus will likewise contribute to this
rior lengthening, will be necessary to mobilize the navicu- finding. Overcorrection has also been seen in feet treated
lar for reduction. Derotation after dorsolateral release with by external fixation, with which powerful deforming force
inferior pressure may allow reduction, and talonaviculocu- could be applied. In our opinion, an overcorrected foot
neiform alignment should be maintained by internal fixation. generally results from a horizontal breach in the foot, pri-
In an older child, reduction and concomitant medial column marily through the subtalar joint, where the talus is still
lengthening may not be possible without more extensive sur- relatively tethered in internal rotation because of incom-
gery, including bone resection laterally for shortening. plete posterolateral and posteromedial talofibular and del-
toid release, and the subtalar joint is completely released
Valgus Overcorrection. A so- called overcorrected foot, and unstable. The calcaneus is then excessively translated
with excessive hindfoot valgus and usually forefoot abduc- laterally during improper cast maneuvers postoperatively,
tion and pronation, is a significant complication of surgical and the heel is everted only by medial molding rather than
release that unfortunately leads to further surgery because derotated by pushing the tuberosity away from the fibula
of pain (Fig. 19.56). The typical background for this com- from a lateral position (see Fig. 19.56D). Additional defor-
plication involves two scenarios, both of which illustrate mity is produced by vigorous abduction molding in which
what not to do in clubfoot treatment. First, the surgeon is the midfoot is subluxated laterally, especially when the talo-
unable to obtain or is dissatisfied with the intraoperative navicular joint has not been internally fixed or when one
correction and cuts the interosseous ligaments in the pres- final aggressive cast is applied after pin removal. Finally, in a
ence of severe internal talar rotational persistence; second, very severe clubfoot in which the surgeon is desperately try-
the postoperative position is deemed unsatisfactory because ing to obtain more equinus correction, the forefoot may be
Bone graft
A B
C Bone graft
FIG. 19.57 (A–C) Triple arthrodesis for an overcorrected valgus deformity. For an overcorrected clubfoot, opening wedge bone grafts in the
lateral column and subtalar joints may be required to restore heel height and lateral column length.
dorsiflexed selectively, thereby adding dorsal subluxation to pseudarthrosis is not common for valgus triple arthrodesis,
the horizontal breach. The result is a valgus, hyperabducted there is a definite tendency to undercorrect a valgus triple
foot, with weak plantar flexion caused by possible heel cord arthrodesis,31,172,203 probably because of conscious avoid-
incompetence or weakening as a result of loss of height of ance of overcorrection into varus and “settling” of opening
the heel in a laterally subluxed, breached subtalar joint. wedge grafts as they incorporate. Despite a tendency to be
Surgical intervention is generally required for an over- undercorrected, however, most patients are improved with
corrected foot because of pain from excessive medial arch relief of weight bearing on the medial arch and decompres-
weight bearing, lateral ankle impingement, or a weakened sion of the lateral impingement.
triceps. Restoration of heel height and triceps function can Ultimately, any foot subjected to triple arthrodesis will
be attempted by a varus osteotomy of the calcaneus or an exhibit radiographic degenerative changes in adjacent joints,
opening wedge lateral subtalar fusion. Forefoot realign- particularly the ankle,3,6 after 10 or more years of follow-up.
ment requires medial column shortening and lateral column For this reason, extraarticular correction of valgus deformity
lengthening through the subluxed joints, and thus the entire has been recommended by Rathjen and Mubarak; medial
procedure may best be accomplished by a triple arthrod- column shortening, lateral column lengthening, and medial
esis. Through a traditional lateral approach, a bone graft is translation of the calcaneus are combined in an effort to
required to prop open the subtalar joint and restore heel avoid fusion of any joints.156 Although radiographic cor-
height and alignment. The navicular is usually in a fixed rection was noted, functional follow-up was insufficient to
position lateral to the talar head. Thus a second medial inci- determine whether joint-sparing surgery was beneficial as
sion over the prominent talar head is recommended so that hypothesized. Interestingly, varus foot correction was not
adequate exposure can be obtained to shorten the medial as successful when the same three sites of osteotomy were
column by resecting part of the talar head and reducing used in reverse (medial column lengthening, lateral column
the navicular by medial displacement. Because the lat- shortening, and lateral translation of the calcaneus; Fig.
eral column may also need lengthening to correct midfoot 19.58) because of the relative stiffness of varus feet ver-
abduction, a bone graft in the calcaneocuboid joint may be sus the relative flexibility in valgus deformities. The valgus
required as well. Internal fixation of all three joints is rec- deformities addressed successfully by extraarticular oste-
ommended, especially if significant opening wedge grafts otomies were less rigid than the stiff, symptomatic, over-
are being used (Fig. 19.57). corrected clubfeet discussed here, which may still be best
Triple arthrodesis for valgus deformity is required when managed by triple arthrodesis.
the midfoot is stiff and simple hindfoot correction or lateral Ankle valgus may be present and is an often overlooked
column elongation will not correct the excessive forefoot problem that evolves with growth.185 If it is mistaken for
abduction and pronation. Symptomatic weight bearing on hindfoot valgus (“overcorrected clubfoot”), inappropri-
the medial arch should have failed with nonoperative meth- ate hindfoot surgery may ensue. Ankle valgus may result
ods before the surgeon resorts to triple arthrodesis. Although in prominence of the medial malleolus, lateral shift of the
ground reactive forces, compression of the lateral portion a result of overpull of the long and, especially, the short great
of the distal tibial epiphysis, fibular impingement, and toe flexors in the foot with weak plantar flexion (calcaneus
excessive shoe wear. If severe enough, definitive treat- gait). McKay has emphasized the flexor hallucis brevis and
ment options include medial malleolar epiphysiodesis or, if abductor hallucis as being responsible for the hallux flexus.134
mature, supramalleolar osteotomy. Thus, in a postoperative clubfoot with weak triceps, the
flexor hallucis longus and brevis overact as part of an effort
Dorsal Bunion. This deformity can be considered a com- to compensate for weak plantar flexion, and with a sectioned
plication of clubfoot surgery because the underlying muscle or scarred peroneus longus, the flexed great toe MTP joint
imbalance required to produce the deformity is caused by worsens if the tibialis anterior is functioning unopposed by
some of the surgical maneuvers for clubfoot correction gone adequate plantar flexors and the first metatarsal depressor.105
awry. Traditionally, a dorsal bunion (hallux flexus) is thought In the clinical scenario of calcaneus gait, a dorsal bunion
to occur when the depressing strength of the peroneus lon- is often manifested in an overcorrected valgus foot as a poor
gus on the first metatarsal is lost, either through disease (e.g., triceps and a horizontal breach deformity. The peroneus
poliomyelitis) or iatrogenically (scarring or division), in the longus may be functionally inadequate in a rigid abducted
presence of unopposed first metatarsal elevation by the tibi- foot because of lack of excursion. Alternatively, it may have
alis anterior. In clubfoot, a dorsal bunion probably occurs as been inadvertently divided during an earlier procedure
when the posterolateral release was performed through a
posteromedial incision. In fixed hallux flexus, abnormal
pressure on the tip of the flexed great toe or a painful callus
on the dorsum of the first metatarsal head (the “bunion”) is
likely to produce symptoms before such problems as exces-
sive medial arch weight bearing, lateral impingement, or calf
weakness become symptomatic.
Treatment of a dorsal bunion involves realignment of
the first ray, both proximally and distally. The flexed MTP
joint is released by volar, medial, and lateral capsulotomy,
lengthening of the flexor hallucis longus tendon, and release
or dorsal transfer of the flexor hallucis brevis (to become an
MTP extensor; Video 19.6). The elevated metatarsal shaft
is depressed by a proximal plantar closing wedge osteotomy
(Fig. 19.59). The tibialis anterior, if obviously contracted or
overpulling, is either lengthened or transferred laterally to the
second metatarsal. This first ray realignment must be done in
conjunction with whatever reconstruction may be necessary
for the rest of the foot because it is likely that there will
A B be other postoperative residua (calcaneus, hyperpronation,
FIG. 19.58 Cuboid wedge removal/reversal to the first cuneiform horizontal breach with valgus) that will need to be addressed.
can be combined with calcaneal osteotomy for correction of varus
Revision and Secondary Procedures
deformities in those older than 6 years old. (A) Osteotomy lines and
wedge to be removed. (B) Insertion of wedge and resulting correc- Recurrence of clubfoot deformity after what initially
tion of deformity (arrow). appeared to be a satisfactory outcome is discouraging for all
Joint
capsule
Cut
A
FIG. 19.59 Dorsal bunion correction. (A) The

metatarsophalangeal joint is released to reduce
the phalanx on the first metatarsal head. (B) The
first ray is corrected by a plantar closing wedge B
osteotomy.
concerned. Faced with what seems to be true recurrence, must be corrected before consideration of anterior tibial
the surgeon must candidly assess the original procedure tendon transfer.63,64
because of the generally accepted belief that the majority If a split transfer is used, the lateral arm of the transfer
of “recurrences” are merely a persistence of deformity that should be rerouted subcutaneously from the ankle retinacu-
was never completely corrected in the first place. If this lum at the distal end of the tibia, reinserted in the cuboid
assessment concludes that there was complete correction or lateral cuneiform area through a drill hole, and anchored
followed by true recurrence, nonidiopathic causes such as a over a button on the plantar surface.86 Tension in the lat-
neurologic disorder (e.g., occult spinal dysraphism) must be eral arm should be sufficient to produce slight eversion and
considered and a diagnostic workup undertaken in an effort pronation statically. If the entire tendon is transposed, the
to prognosticate and even correct the neurologic imbalance insertion should be moved to the midline or just slightly
responsible. Electrophysiologic testing and MRI of the spi- lateral to midline (into the third cuneiform) to attain dorsi-
nal cord are two such tests to be considered if true recur- flexion without excessive abduction. Transfer of the entire
rence is present. tendon theoretically produces a loss of dorsiflexion strength
The prevalence of repeat surgery after the initial soft tis- of one grade, although this was not found in Ponseti’s long-
sue release in infancy is estimated to be in the range of 10%. term follow-up study. If it is weakened, it may become
Obviously, not all feet with residual deformity or muscle functionally important if there is residual equinus, and thus
imbalance undergo additional surgery because the surgeon’s assessment of posterior ankle contracture and the need for
and parents’ perception and acceptance of the postoperative release must be made or else a more significant drop foot
result can differ. In selecting revision procedures, the sur- may result.
geon must strongly consider the inevitable additional stiff- Anterior tibialis transfer with lengthening may be indi-
ness and muscle weakness that result from repeat surgery cated as part of revision for a postoperative dorsal bunion
and immobilization, and thus the primary goal of additional when the first ray is excessively dorsiflexed. In this situa-
procedures must be to achieve the eventual realistic foot tion, the overpull of the tibialis anterior must be balanced
position with the least possible number of procedures. It is with the plantar flexing strength of the peroneus longus on
therefore justified to accept, for example, recurrent defor- the first ray, which will most likely be weak or absent. See
mity in a 3-year-old for several years and, if possible, delay the previous discussion of dorsal bunion.
one definitive final surgery until 10 years old, when a bony
correction can be accomplished without significant further Transfer for Insufficient Triceps Surae (Calcaneus
soft tissue dissection and immobilization. Gait). Overlengthening of the Achilles tendon or triceps
In general, revision surgery should address a specific insufficiency secondary to inadequate excursion from scarring
problem or deformity that has become unacceptably symp- is notoriously difficult to reconstruct and is best prevented
tomatic and is producing functional problems and pain. rather than reconstructed. Careful attention to the technique
Functional problems include poor foot position (such as of heel cord lengthening and tensioning for repair at the index
supination/inversion) or an excessive internal foot progres- procedure and avoidance of heel cord rupture during postop-
sion angle (producing painful lateral ray weight bearing) and erative manipulation and casting are essential to avoid this com-
muscle imbalance or weakness, such as triceps surae incom- plication. However, as long-term functional evaluations have
petence (producing a calcaneus gait and calf pain). Revision shown,7,111,128 plantar flexion weakness is universal after even
surgery has a greater likelihood of success if a single problem the most meticulous technique in an otherwise “good” result.
can be identified and addressed rather than simply taking The plantar flexion insufficiency may not be apparent for years,
the patient to the operating room for the nebulous “repeat until the child has grown sufficiently so that the weakness is
clubfoot release.” clinically exposed, at which time the strength of the muscles
available for tendon transfer may be inadequate to replace the
Soft Tissue Surgery missing triceps. The surgeon must diagnose plantar flexion
Anterior Tibial Tendon Transfer (Video 19.7). Transfer of weakness as early as possible if muscle transfer is to have any
the tibialis anterior insertion—either the entire tendon or chance of being effective.
a split transfer—is indicated when there is dynamic inver- Muscles available for transfer to reconstruct the triceps-
sion or supination of the midfoot, especially in the swing Achilles complex should be phasic with the latter and should
phase, that produces weight bearing on the lateral aspect thus include the peroneals, tibialis posterior, and long toe
of the foot upon initial stance.118 The goal is to eliminate flexors. Laterally, the peroneus brevis can be divided distal
the supinated position for the initiation of stance. Ponseti to the fibula and the proximal end rerouted to the calcaneus
and Goldner have advocated that this technique be rou- tuberosity (Fig. 19.60A–C). Tendon-to-bone transfer is pre-
tinely performed as part of the index operative procedure, ferred, with the tendon anchored through a drill hole in the
as well as using it as a secondary procedure after a non- calcaneal tuberosity to a button on the plantar surface of the
operative correction in which there is persistence of mild heel. The distal stump of the brevis should be tenodesed
midfoot supination.152 The dynamic deformity should be side to side to the longus to maintain eversion power. Medi-
demonstrated statically by observing midfoot supination or ally, the tibialis posterior or flexor hallucis longus should
excessive first ray elevation when the patient attempts to be rerouted in a similar fashion and interwoven with the
dorsiflex the foot voluntarily, and it can be further identi- residual Achilles tendon, if present, or anchored to bone
fied by formal gait analysis. If the foot is otherwise mobile (see Fig. 19.60D–F). The tibialis posterior is often scarred
and can be placed plantigrade for stance, this may be the and nonfunctional as a result of the index procedure, and a
only procedure necessary. A fixed deformity of the foot discrete tendon may not be discernible. However, we have
Peroneus brevis
Achilles
muscle cut and
tendon
retracted
Inferior
extensor
retinaculum
Joint
capsule
A B
Peroneus Peroneus
longus muscle brevis muscle
C D
Line of
incision Achilles tendon
Tibialis
posterior
muscle
Tibialis
anterior
muscle
E F
Flexor
Flexor
hallucis
digitorum
longus muscle
longus muscle
FIG. 19.60 Muscle transfers for calcaneus gait (triceps insufficiency). (A–C) The peroneus brevis is exposed distal to the fibula, released from
its insertion, mobilized proximally and rerouted through a drill hole in the calcaneal tuberosity, and sutured under tension to a button on
the heel. (D–F) The tibialis posterior (or flexor hallucis longus) is identified above the medial malleolus in relatively unscarred tissue. It is dis-
sected distally as far as possible, cut, and transferred to the Achilles tendon, where it is sutured under maximum tension.
found that by dissecting proximally above the medial mal- excessive length of the lateral column, where the cuboid
leolus, the original tibialis posterior tendon can in fact be may be displaced medially on the anterior end of the cal-
located, mobilized, and transferred distally toward the calcaneus. Evans suggested that this obstruction to forefoot
caneal insertion of the original Achilles. If the tibialis pos- positioning by the length and adaptive obliquity of the cal-
terior is unavailable, the flexor hallucis longus is rerouted caneocuboid joint was the essential lesion of clubfoot and
from above the medial malleolus to the Achilles insertion. described the use of a wedge resection of the calcaneocu-
Because of the intertendinous connections between the boid joint to shorten the lateral column as part of treatment
flexor hallucis and flexor digitorum longus distally at their of the relapsed deformity.56 This approach, which combines
decussation, flexion power of the great toe does not appear posteromedial release and lateral column shortening in one
to suffer greatly from this transfer. stage, is probably the most common procedure for recur-
Traditionally, the tibialis anterior has been transferred rent clubfoot. Evans’ procedure relies on concepts of mid-
to the heel (through the interosseous membrane) in cases foot (talonavicular and calcaneocuboid) dislocation,41,103
of paralytic or neuromuscular calcaneus.14,149,193 In club- and by allowing reduction of the navicular on the talar head
feet, this procedure has been reported sparingly but with by lateral column shortening, further relapse or recurrence
some success.202 We have found, however, that although was avoided. Heel varus was also corrected adequately in
the calcaneus gait is improved by such a transfer in club- Evans’ original series, although most investigators find that
feet, the resulting foot drop from the lack of active dorsi- heel varus must often be formally corrected by either repeat
flexion becomes an unacceptable secondary problem that subtalar release or a calcaneal osteotomy.
often makes the patient brace dependent to avoid tripping The Evans procedure has become a standard technique
and awkward because of the steppage gait (increased hip and for recurrent clubfoot deformity in which the midfoot is
knee flexion in the swing phase). Consequently, transfer of clearly in varus as a result of talonavicular and calcaneocu-
the tibialis anterior in nonparalytic conditions such as club- boid medial displacement. It is also an ideal index procedure
foot is not recommended. for a clubfoot initially seen at a later stage. Other reviews1,2
If no other procedures (for other residual deformities) have confirmed it to be the procedure of choice between 4
are to be performed, transfer of the peroneal and tibialis and 8 years old. Before 4 years old, calcaneocuboid fusion
posterior or flexor hallucis longus tendons to the heel is best is more difficult to achieve because of the large amount of
done through one longitudinal incision centered over the cartilage in the two bones. In this instance, simple resec-
Achilles, or alternatively through separate posterolateral and tion of the anterior end of the calcaneus as described by
posteromedial incisions spaced appropriately. Anterior ankle Lichtblau123 or shortening of the calcaneal neck proximal
capsulotomy and lengthening of a contracted tibialis anterior to the calcaneocuboid joint will achieve the desired short-
may be necessary if passive plantar flexion to 20 degrees is ening. Lichtblau’s operation, essentially a calcaneocuboid
not present. The transfers should be tensioned so that the arthroplasty, can be used whenever the lateral column is
foot is passively held in equinus and immobilized for 6 to 8 too long. Alternatively, cuboid decancellation103 or wedge
weeks of non–weight bearing. Thereafter, a solid ankle-foot resection of the body of the cuboid will preserve the joint,
orthosis with dorsiflexion stopped at neutral should be con- but it limits the amount of lateral column shortening if
tinued for an additional 4 months in an attempt to prevent the cuboid is small. The actual amount of lateral shorten-
the transfers from stretching out, and active plantar flexion ing is determined intraoperatively and should be sufficient
exercises should be performed non–weight bearing with the to allow talonavicular reduction, after adequate medial or
brace off. Although normal plantar flexion strength can never posterior release (or both), with little effort. The lateral
be realized by tendon transfer, several patients have devel- edge of the foot should become a straight border rather
oped toe-up ability, especially when triceps reconstruction than the rounded, “kidney bean” shape of a varus forefoot
has been performed before 6 years old. Usually, a transfer (see Fig. 19.54) after lateral column shortening. The lat-
performed after this age must also be accompanied by bone eral wedge can be removed through a separate longitudi-
procedures, such as a calcaneal osteotomy or subtalar fusion nal incision over the calcaneocuboid joint (Fig. 19.61) or
for hindfoot valgus, which frequently accompanies calcaneus by simple extension of the lateral extent of the Cincinnati
deformity. Combining some posterior displacement of the incision. Closure of the lateral wedge should be maintained
calcaneal tuberosity,138,166 where the transferred tendons by internal fixation, either with longitudinal pins that are
will be anchored, with the medial displacement to address removed or with staples or lag screws for a formal calcaneo-
heel valgus is an additional feature that will theoretically cuboid fusion. Although formal fusion is generally believed
increase the plantar flexion moment arm of the transferred to result in better long-term maintenance of correction,72
muscles (see “Calcaneal Osteotomy”). the long-term results of the Lichtblau procedure have also
been gratifying, with the additional benefit of maintaining
Bony Surgery some calcaneocuboid motion in the majority of patients.67
Lateral Column Shortening (Video 19.8). “Recurrence” Some patients with recurrent deformity have sufficient
of clubfoot deformity after earlier surgical release requires scarring that medial soft tissue release and subtalar release
analysis of the deformity. Frequently, all components of will be ineffective. In a patient older than 6 years with a
the equinovarus deformity seem to have recurred, but varus forefoot position, lateral column shortening has been
the “essential” deformity may consist of a length dispar- combined with medial column lengthening by removing a
ity between the medial and lateral borders of the foot. Any wedge of bone from the cuboid and transferring it to an open-
attempt to abduct and externally rotate the forefoot in rela- ing wedge osteotomy in the first cuneiform (Fowler proce-
tion to the hindfoot, as well as any attempt to correct fore- dure; see Fig. 19.58).87,125,133,142,169 This approach has the
foot supination, is resisted by the medial contracture and advantage of avoiding formal fusion of joints and maintaining
Skin incision centered over

anterolateral calcaneus and
Foot in 20° varus deformity posterolateral cuboid
A 2 1 B
4 3
Calcaneus
Cuboid Incision
Lichtblau
C D
3/8"wedge resection of anterior end 3/8" wedge resection of anterior end
of calcaneus; articular cartilage not of calcaneus including calcaneal
disturbed articular cartilage
Evans Cuboid decancellation
E F
Resection and fusion of Wedge to be resected
calcaneocuboid joint
FIG. 19.61 Shortening of the lateral column of the foot in a 6-year-old child. (A) Lateral view of the foot showing different levels of oste-
otomy: 1, vertical osteotomy of the anterior part of the calcaneus; 2, excision of the anterior end of the calcaneus (Lichtblau procedure); 3,
excision of the calcaneocuboid joint and fusion (Evans operation); 4, wedge resection and enucleation of cuboid bone. (B) A 4-cm incision
is centered over the dorsolateral aspect of the calcaneocuboid joint. The peroneus brevis tendon is identified and retracted plantarward. The
extensor digitorum brevis muscle is elevated off the cuboid bone and retracted dorsally and medially. (C) Vertical osteotomy with a wedge
resection of bone based laterally for shortening the calcaneal neck. The calcaneocuboid joint is preserved. (D) Calcaneocuboid arthroplasty
(Lichtblau procedure). This procedure is indicated in children younger than 6 years old who need lateral column shortening. (E) Wedge re-
section and fusion of the calcaneocuboid joint (Evans procedure). (F) Cuboid decancellation with wedge resection in older children preserves
the articular surfaces. Lateral column shortening procedures should be internally fixed with smooth pins or staples to maintain alignment
until healing.
Turco
Cincinnati
Incision Graft being placed in

"open-up" wedge
A
Line of osteotomy
Neurovascular
bundle and
tendons retracted
Division of
medial insertion
of Achilles
tendon
Laminectomy retractor
B opening and holding apart
osteotomized fragments
C
FIG. 19.62 Medial osteotomy of the calcaneus with a bone graft wedge for correction of varus hindfoot—Dwyer technique. (A) The skin
incision is usually made perpendicular to previous incisions because of closure problems if made parallel (Cincinnati, Turco). The posterior
extent should be to the superior edge of the calcaneal tuberosity (to allow lengthening of the Achilles tendon if necessary). The calcaneus is
osteotomized roughly parallel to the subtalar joint. (B) The osteotomy is opened with the aid of a lamina spreader. Achilles tendon lengthen-
ing and stripping of the plantar fascia and muscle origins from the distal fragment may be necessary to allow adequate correction by open-
ing wedge osteotomy. A tricortical iliac crest graft is recommended. (C) Calcaneal closing wedge osteotomy for varus of the heel.
relative length of the overall foot by dividing the correction will ever exist. Additionally, a calcaneal osteotomy can be
between the two columns rather than taking all the correction combined with other procedures, and it does not hinder the
from a lateral wedge resection and possibly shortening the performance of a future triple arthrodesis, for example.
foot excessively. Midfoot supination can be improved by using The opening wedge technique theoretically increases the
a quadrilateral graft to obtain an opening wedge plantarward, height of the heel and may therefore require Achilles tendon
as well as medially. Because of the cartilaginous nature of the or other posterior release to avoid producing equinus (Fig.
midfoot bones, obtaining an opening wedge medially can be 19.62A and B). Practically speaking, wound closure on the
technically difficult before 6 to 8 years old.87,156 However, if medial aspect of the ankle can be compromised, especially
technically feasible, this approach does not require soft tissue in a recurrent situation in which the osteotomy is being
release to achieve correction of a bean-shaped foot.133 performed through a previous incision.188 For this reason, a
lateral closing wedge technique with some lateral displace-
Calcaneal Osteotomy. In a foot with fixed heel varus, with ment (see Fig. 19.62C) is associated with less wound-
or without other significant residual deformity, an opening healing morbidity, but because it decreases the height of
or closing wedge osteotomy or a lateral displacement oste- the heel to some degree, it also risks lateral impingement
otomy can be used. The essential prerequisite for an opening problems between the calcaneus and fibula. For effective
wedge osteotomy is sufficient ossification of the calcaneus lateral displacement—or posterior displacement138,166 if
to stabilize a bone graft. The advantage of the calcaneal oste- calcaneovarus or valgus is being addressed (see “Transfer for
otomy as proposed by Dwyer is that subtalar motion is pre- Insufficient Triceps Surae”)—the plantar fascia and muscle
served, although in a recurrent deformity after soft tissue origins must be stripped or divided to fully mobilize the dis-
release it is debatable whether significant subtalar motion tal osteotomy fragment.
The osteotomy should be made roughly parallel to the internal tibial torsion or hindfoot medial spin in a patient
subtalar joint and internally fixed, usually with threaded who has previously undergone subtalar release but exhib-
pins, which are later removed. If an opening wedge tech- its persistent medial rotation of the talus and calcaneus. In
nique is used, weight bearing must be delayed, or collapse such a patient another subtalar release would probably be
of the graft and loss of correction may occur. Tibial bone can ineffective because of the fixed bony position. Should the
be used, but a tricortical iliac crest graft, because of its can- internal foot progression angle be due to medial forefoot
cellous nature, is preferred because of faster incorporation. deviation with talar neck deformity or be due to midfoot
Debate rages about the efficacy of a calcaneal osteot- medial deviation, correction by foot procedures, such as lat-
omy, both in terms of effective correction of heel position eral column shortening56,123 or plantar fascia release,25,123 or
and in terms of its effect on the midfoot. Dwyer claimed both, directly addresses the pathoanatomy. Supramalleolar
that correction of heel varus alone could produce gradual osteotomy is not generally effective for multiple-plane cor-
correction of forefoot equinus and midfoot varus. Other rections of residual clubfoot because remodeling of the dis-
investigators38,58,188 have not confirmed this, and calca- tal end of the tibia by continued physical growth causes the
neal osteotomy as an isolated procedure for recurrent or deformity to recur. It should be reserved only for rotational
residual varus is rarely performed at our institution because correction.143
the dynamic gradual correction is minimal at best. Correc- Goldner recommends up to 35 degrees of external rota-
tion of heel position in an older child is more permanently tion correction at a level just proximal to the distal tibial
accomplished by subtalar fusion (as part of triple arthrod- physis (Fig. 19.63). The fibula does not usually have to be
esis, for example), and thus every effort should be made osteotomized unless greater correction is needed, but doing
to delay interim procedures, such as a calcaneal osteotomy, so may make rotation easier. The tibial osteotomy is fixed
until an age at which a definitive correction can be achieved. with two oblique pins (Video 19.9). Before wound closure
Although we use calcaneal osteotomy in conjunction with the vascular status of the foot must be ascertained by deflat-
midfoot and forefoot procedures (such as first metatarsal or ing the tourniquet, with adjustment of the amount of rotation
cuneiform osteotomy to correct supination/cavus and lateral should there be any sign of ischemia. In Goldner’s series, 2 of
column shortening to correct midfoot varus; see Fig. 19.58) 66 patients required a decrease in the amount of correction
in a child deemed too young for triple arthrodesis,133 such because of sluggish circulation, with no sequelae after refix-
a combination is rarely performed because of the “interim” ation with less correction. All patients had successful union
nature of the procedure. It is better to eliminate the interim and maintained their rotational correction at follow-up.
procedure and perform definitive correction at 10 years Supramalleolar osteotomy to correct an intoeing gait in an
old if possible. Thus a calcaneal osteotomy as an isolated otherwise plantigrade foot has rarely been performed at our
procedure has limited utility, and a calcaneal osteotomy in institution. Because of the late knee valgus seen on follow-
combination with other procedures for interim correction up, this procedure should probably be considered more fre-
of recurrent hindfoot and midfoot deformity is unattractive, quently. It is unknown, however, whether earlier correction
though sometime necessary, for the reasons just discussed. of an internal foot progression angle will change the degree
of knee valgus documented in follow-up studies.7,111,128
Supramalleolar Osteotomy. Persistence of a toe- in gait is
common in an otherwise plantigrade foot, regardless of the Triple Arthrodesis. After the age of 10 years, management
surgical technique performed. Postoperative intoeing more of residual deformity requires bony stabilization, not only to
than two standard deviations from normal has been docu- correct the remaining deformity, which will be resistant to
mented by Yngve and colleagues in 48% of patients204 and has soft tissue procedures, but also to maintain the correction.
been the indication for further surgery in 8% to 25% of postop- Triple arthrodesis has been the standard orthopaedic proce-
erative patients in other series.92,124 In patients with abnormal dure for producing and maintaining correction since it was
peroneal muscle histopathology, Loren and associates reported first described in the 1920s.88,164 A triple arthrodesis may be
an increased incidence of internal torsional deformity, pre- regarded as the ultimate salvage procedure in that the surgeon
sumably caused by the muscle imbalance.124 An internal foot is capitulating to fusion of movable joints, but older children
progression angle can result from several sources: true internal with symptomatic recurrent deformity will not generally have
tibial torsion; medial spin of the hindfoot in the ankle mor- foot joints that are functionally acceptable. Hence, their sac-
tise; and medial deviation of the forefoot, with or without rifice tends to be a moot point, especially if correction of the
true metatarsus adductus, in which the medially deviated deformity and a plantigrade, if stiff, foot are finally achieved.
talar neck directs the forefoot into an internal foot progression Triple arthrodesis can be used for either varus or overcor-
angle.13 In a younger child, a residual internal foot progression rected valgus feet (Video 19.10). A varus foot with heel varus
angle should be observed for spontaneous correction, but if and midfoot supination is inadequate for a weight-bearing
the toe-in gait persists for 2 years after clubfoot surgery, there platform129 because it produces pain from excessive lateral
is justification for correction to avoid the long-term secondary ray pressure and frequent instability with lateral ankle pain or
deformity at the knee—primarily valgus—seen in association giving way as a result of rotational stress on ligaments.182 For a
with an excessive internal foot progression angle.5,76,85 valgus foot, the deformity per se may be fairly well tolerated
Should an intoeing gait be severe and not resolve with 2 because of a broad plantar weight-bearing surface. Eventually,
years of observation, correction by supramalleolar external pain over the plantar medial surface—the talar head—and
rotation osteotomy can be effective,92 and because it avoids lateral impingement symptoms because of the loss of heel
additional foot dissection, it does not contribute to further height and valgus translation of the calcaneus become the
stiffness. The deformity should be secondary to persistent indications for surgical correction of a valgus foot.
A B C
D E
FIG. 19.63 (A) Persistent intoeing 2 years after clubfoot release bilaterally. (B) Anteromedial supramalleolar exposure of the distal end of the
tibia. (C) Two parallel pins have been placed, one proximal and one distal to the osteotomy site. (D) The osteotomy has been cut and the
distal fragment rotated by using the parallel pins to control movement of the osteotomy. The osteotomy is then fixed by oblique pinning,
and the parallel pins are removed. (E) Postoperative appearance. The feet are now aligned with the knees. (Courtesy J.L. Goldner, MD.)
Removal of appropriate wedges, based laterally, corrects splitting, required by the not infrequent swelling and slug-
a varus foot (Fig. 19.64). A classic lateral incision over the gish circulation after triple arthrodesis in a multiply oper-
sinus tarsi and curved dorsomedially toward the talar head ated foot.
provides adequate exposure to align the foot with the ankle The most crucial aspect of correction of varus is to avoid
mortise. Care must be taken to not align the foot with, undercorrection and leave the foot fixed in residual varus
for example, the knee because the foot will be placed in and supination. Thus slight correction to valgus and pro-
a relatively supinated position if external tibial deformity nation is favored over an undercorrected position.148,182
and knee valgus are present.148 Internal fixation is recom- Although radiographic pseudarthrosis has been reported
mended, especially of the talonavicular joint, which is the in as many as 23% of cases,3 a single pseudarthrosis may
most frequent joint to progress to pseudarthrosis.31,148,203 remain asymptomatic if the other joints are successfully
In addition, internal fixation can maintain the corrected fused. Meticulous attention to bony contact between joint
position in the presence of postoperative cast loosening or surfaces and careful preparation and cartilage removal are
A B
FIG. 19.64 Triple arthrodesis for clubfoot. The

wedges, based laterally, can be safely removed
from the standard sinus tarsi incision. The foot
must be aligned with the ankle mortise and not
with the knee axis. (A) Incision. (B) Lateral view
of wedges to be removed. (C) Posterior view of C D
wedges. (D) Dorsal view.
the best insurance against pseudarthrosis. Precision in the Major issues surrounding foot correction include the role
performance of triple arthrodesis will be rewarded with a of soft tissue “release” before or after correction of the defor-
stable, corrected foot and a functional patient. mity and the need for an osteotomy to allow bony correction
For a discussion of valgus deformity after clubfoot sur- with regeneration. Because of the lengthy treatment time often
gery, see “Valgus Overcorrection.” required for severe or neglected deformities, it is attractive to
attempt partial acute correction by soft tissue release, with the
Correction Using the Ilizarov Technique. Because stretch- intention of decreasing the total time necessary in external fixa-
ing plus elongation of contracted tissue is fundamental to the tion. Unfortunately, preliminary dissection can produce ischemic
management of clubfoot, it is not surprising that the meth- skin complications leading to necrosis when poorly vascularized
ods of Ilizarov have been applied to a neglected or recur- or scarred areas are impaled by transfixation wires (Fig. 19.66).
rent deformity, especially in the presence of severe scarring. Thus, in previously unoperated, neglected clubfeet and in
Several investigators in addition to Ilizarov himself have severely scarred or multiply operated tissue, correction by tissue
reported application of the technique to clubfoot by com- distraction only, with no preliminary surgery, has been recom-
bining multiple-plane corrections through the use of hinged mended.37,145,198 It is usually necessary to hold the foot in the
distraction between a tibial frame and a foot frame, with the corrected or overcorrected position for 2 to 4 months, either in
hindfoot and forefoot usually treated separately.e The Taylor a frame or in a cast, once the plantigrade position is reached, to
spatial external fixation frame can also be used.50,62 Skeletal avoid relapse. In feet with previous surgery and significant anky-
fixation is achieved via proximal and distal tibial rings; hind- losis, correction via osteotomies (crescentic or through multiple
foot fixation is achieved via crossed or nonparallel transverse joints) with no acute correction is preferred (see Fig. 19.65).
wires in the calcaneus or talus (or both), supplemented as Experience has shown that correction of deformity by soft
necessary by an axial calcaneal half-pin fixed to a semicircu- tissue lengthening may be transient, and the surgeon must be
lar ring controlling the heel; and forefoot fixation is achieved prepared to perform soft tissue release, tenotomies, or bony
transversely with wires through the metatarsals or cuneiforms stabilization after frame correction. Because surgery on a foot
via a semicircular ring over the dorsum (Fig. 19.65). Angular made stiff and atrophic by frame immobilization may be com-
correction with lengthening can then be achieved between the plicated by infection and poor wound healing, a waiting period
forefoot and hindfoot or between the hindfoot and tibia, or is recommended between frame removal and further surgery;
the entire foot can be moved as a unit. The ability to achieve functional bracing is used during this waiting period while tissue
lengthening and correction in a foot destined to be shorter health and muscle and joint function recover to some degree.
because of a deformity is another attraction of the Ilizarov Rehabilitation is a major problem after frame removal;
method. all reports universally document ankle and subtalar stiff-
ness (<20 degrees of motion with no dorsiflexion), even
when only tissue distraction is used. These results37,73,198
e References 20, 22, 26, 37, 52, 73, 145, 197. are undoubtedly due to the long (5–9 months) treatment
B C E
F G H I
J K L M
FIG. 19.65 Ilizarov correction of rigid varus foot deformity. (A–C) Clinical appearance of a 12-year-old boy with a multiply operated left
clubfoot. After triple arthrodesis complicated by vascular insufficiency and infection, he is left with a rigid, painful supination deformity of
both the hindfoot and forefoot. (D) Radiograph showing triple arthrodesis in supination. (E) Separate correction of the hindfoot and forefoot
position was done through two osteotomies, one via talonavicular and calcaneocuboid fusions and one via subtalar fusion to allow calca-
neal correction. (F and G) Angular correction of hindfoot varus by distracting medially between the distal tibial ring and the distal calcaneal
ring. Note the olive wire fixation of the main talar fragment to prevent ankle subluxation. (H and I) Correction of forefoot supination. The
metatarsals are fixed to a forefoot ring by two olive wires. The forefoot is rotated in relation to the distal tibial ring, which incorporates the
ankle via the fixation of the main talar fragment (see F). Correction occurs through the midfoot osteotomy. (J and K) Correction of forefoot
equinus after correction of supination. The forefoot ring is dorsiflexed in relation to the main talar fragment, which is fixed to the distal tibial
ring. (L and M) Clinical appearance of the forefoot ring before rotational correction.
N O P Q
FIG. 19.65, cont’d (N) Radiograph obtained at the completion of correction of supination. The frame is modified to begin
forefoot dorsiflexion. (O–Q) Final result 2 years later. The foot is now nearly plantigrade, with all toes in contact with the floor.
(The great toe underwent flexion contracture release after frame correction.) Compare the weight-bearing surfaces of the
involved foot with those of the normal foot. Total time in the frame was 8 months.
FIG. 19.66 Ischemic necrosis of the lateral toes and midfoot in a 6-year-old with arthrogryposis. He underwent complete posteromedial and
lateral soft tissue release before foot frame application. Acute correction was attempted but relaxed within hours because of ischemia, which
did not recover on removal of the foot portion of the frame.
period, the underlying ankylosis of the deformity itself, and The disadvantages of external fixation and distraction for
the stiffness induced by cartilage pressure as, for example, recurrent clubfoot also involve psychological adaptation to
recurrent equinus is corrected by posterior distraction. Con- the lengthy and admittedly uncomfortable process. In our
troversy exists concerning the use of ankle hinges to control experience, patients are uniformly unable to bear weight on
the talus, which may subluxate anteriorly if nonconstrained a foot frame, and osteopenia, soft tissue edema, and trophic
correction of equinus is attempted. Some authors report changes are universal while the foot is being corrected. Min-
correction without constrained ankle correction,73,145,198 imizing overall time in the frame, with early removal and
whereas others recommend hinges26 and also an anterior cast application once correction of the deformity is com-
motor rod to aid in dorsiflexion between the forefoot and pleted, is the best compromise for this dystrophic morbid-
distal tibial ring (see Fig. 19.65J and K). Distraction of ity. Although patients may not fully bear weight for months
the ankle joint during equinus correction has been alluded after treatment, rehabilitation must be vigorous to resolve
to without evidence that range of motion at follow-up is the treatment-induced morbidity. Because there are few
improved. other options for a late-recurring or neglected deformity
with poor skin coverage, the Ilizarov technique remains and anterior tibialis tendons are taut, and the foot is everted
extremely useful to correct such deformities without fur- into a valgus, externally rotated position. The navicular is
ther shortening the foot by more bone resection. However, palpable as it lies on the talar neck, where it abuts the ante-
the physical and psychological disturbances and the lengthy rior tibial surface at the front of the ankle joint. There may
treatment time must not be underestimated. be some flexibility of the foot, but passive correction of the
For References, see expertconsult.com. deformity is not possible.
Coleman and colleagues distinguished two types of ver-
Vertical Talus tical talus: the first with talonavicular dislocation and the
second with concomitant dislocation of the cuboid on the
Definition calcaneus.4 Lichtblau identified three groups.18 In group I
Vertical talus is a condition characterized by a fixed dor- (teratogenic), a rigid, often bilateral deformity was pres-
sal dislocation of the talonavicular joint in conjunction with ent at birth with tight extensors and heel cords. In group
rigid hindfoot equinus. These structural abnormalities pro- II (neurogenic), often associated with myelomeningocele or
duce a rocker bottom deformity of the foot that is notice- neurofibromatosis, the deformity was accompanied by mus-
able at birth.4,18,19,23,28 This condition has also been termed cle imbalance, and a variable degree of deformity and rigid-
congenital convex pes valgus17,24 but is most appropriately ity, but it was more correctable than suspected. In group
named teratologic dorsolateral dislocation of the talocalca- III (acquired), intrauterine malposition was the attributed
neonavicular joint.32 The first description was by Henken in cause as no other defects were noted. In such patients,
1914,12 and the characteristic features were well defined by the condition was unilateral, moderate in clinical severity;
Lamy and Weissman.17 the calcaneus was not necessarily fixed in equinus; and the
deformity was partially correctable.18
Etiology A less severe manifestation of the deformity has been
The exact etiology of vertical talus is unknown. Increasing called the oblique talus.19 In this variant there is a rocker
evidence implicates abnormalities of skeletal muscle as a bottom deformity of the foot and an equinus contracture
likely causative factor. Skeletal muscle biopsies of children of the hindfoot, but the navicular can be reduced when the
with vertical talus have demonstrated abnormal variation in forefoot is plantar flexed.
muscle fiber size, aberrancy of fiber type predominance, and Severe flatfoot or valgus deformities are sometimes con-
decreased size of type I muscle fibers when compared with fused with vertical talus because the talus is vertical on a
normal controls.22 It remains unclear, however, whether lateral radiograph. The clinical and radiographic difference
these abnormalities are a cause or a result of the joint defor- between the conditions is that in a severe flatfoot, the calca-
mities present. Other possible causes include congenital neus can be easily dorsiflexed and there is no fixed disloca-
vascular abnormalities; muscle imbalance, especially over- tion of the navicular.
pull of the anterior tibial tendon in paralytic disorders; and
intrauterine compression, particularly when coupled with Pathologic Anatomy
arthrogryposis.15 It has also been suggested that the defor- Several investigators have carefully described the patho-
mity represents an arrest in fetal development of the foot anatomy of vertical talus.2,7,11,37 The skeletal anatomy is
occurring between the 7th and 12th weeks of gestation.2,37 most characteristic (Fig. 19.68). The navicular articulates
Autosomal dominant transmission through three genera- with the dorsal aspect of the neck of the talus and is locked
tions of a Honduran family has been reported,30 as well as there. The proximal articular surface of the navicular is tilted
transmission from parent to child.17,25 plantarward. The head of the talus is flattened superiorly
and is ovoid in its length. The calcaneus is displaced pos-
Clinical Features and Associated Conditions terolaterally in relation to the talus, is in contact with the
It is important to note that while vertical talus may be pres- distal end of the fibula, and is tilted into equinus. MRI has
ent in isolation, associated congenital anomalies are found demonstrated marked lateral displacement of the anterior
in approximately 60% of patients.22 The condition has been calcaneus in relation to the talar head with lateral translation
found in 10% of patients with myelomeningocele and 11% of the calcaneus at the subtalar joint in addition to the ever-
of patients with arthrogryposis.1,27 No vertical tali were sion typically present.33 The angle between the axes of the
noted in 128 children with the amyoplasia subtype arthro- talus and calcaneus is markedly increased. The subtalar joint
gryposis, 2 were found in 25 children with distal arthrogry- is abnormal, with the anterior facet usually absent and the
posis, 4 in 13 with other syndromes such as Larsen, 7 in 34 middle facet hypoplastic. The articular facet of the calcaneus
with multisystem disease, and 5 in 25 children with unclas- for the cuboid is inclined dorsally and laterally, and there is
sifiable syndromes. Those with distal arthrogryposis were a variable degree of subluxation of the calcaneocuboid joint.
most easily treated.1 Vertical talus has also been identified These abnormalities result in elongation of the medial col-
in prune-belly syndrome, spinal muscular atrophy, neuro- umn and shortening of the lateral column of the foot.
fibromatosis, congenital dislocation of the hip, Rasmussen Ligamentous abnormalities mirror the bony deformi-
syndrome, and trisomy 13-15 and 18.10,14,34,35 The neur- ties (Figs. 19.69–19.71). The spring ligament is attenuated,
axis should be studied in patients without other apparent whereas the tibionavicular portion of the superficial deltoid
pathology to rule out occult neurologic dysfunction.7 is markedly contracted thereby sustaining the navicular in a
The classic appearance is a rocker bottom foot, which dislocated position. Other contracted ligaments include the
is a foot with a convex plantar surface, the apex of which bifurcated ligament between the calcaneus and the navicular
is at the talar head (Fig. 19.67). The calcaneus is fixed in and cuboid, the calcaneofibular ligament, and the interosseous
equinus, with a contracted Achilles tendon. The peroneal talocalcaneal ligaments. There are corresponding contractures
A B
C D
FIG. 19.67 Congenital vertical talus. (A) Pronation of the forefoot. (B) Valgus of the heel. (C) Absence of an arch, the rocker bottom deform-
ity. (D) Elevation of the lateral toes and tight peroneal tendons.
of the tibialis anterior, long toe extensors, peroneus brevis, and in a nearly vertical position, almost parallel to the tibia
triceps surae (Figs. 19.72 and 19.73). The posterior tibial and (Fig. 19.74). The calcaneus is also in an equinus posture
peroneal tendons may be displaced anteriorly so that they act with an increased talocalcaneal angle. In children younger
as dorsiflexors rather than plantar flexors. than 3 years old the navicular is unossified. Its position may
The vascular supply to the foot in vertical talus has been be inferred from the direction of the metatarsals and the
shown to be dominated by the dorsalis pedis and anterior position of the ossified cuneiforms. These structures align
tibial arteries. The posterior tibial artery has been noted with the neck of the talus, well dorsal to the talar head. The
to be deficient in a study of seven limbs in four patients. navicular is always dislocated dorsally on the talus and, when
This configuration places the vascular supply at risk when ossified, is seen to abut the anterior aspect of the tibia. A
extensive anterior dissection is performed and the forefoot line through the axis of the talus as seen on a lateral radio-
is plantar flexed.29 graph passes posterior to the cuboid rather than through it,
as in a normal foot (Figs. 19.75–19.77). A standing radio-
Radiographic Findings graph shows the same deformities. On a forced dorsiflexion
A foot with a vertical talus has a characteristic radiographic radiograph the talus and calcaneus remain plantar flexed.
appearance.23,36 On a lateral projection the talus appears In forced plantar flexion the navicular fails to reduce on
B C
FIG. 19.68 Bone and joint changes (pathoanatomy) in congenital vertical talus. (A) Medial aspect of the right foot showing dorsiflexion of
the forefoot at the midtarsal joint; vertical talus, producing a rocker bottom convexity; subluxation of the navicular on the neck of the talus,
which locks the talus vertically; and calcaneus in 20 to 25 degrees equinus. (B) Lateral aspect of the right foot. Dotted lines indicate the dis-
placed head of the talus. (C) Dorsal aspect showing an abducted forefoot beginning at the midtarsus. Dotted lines indicate the head of talus
subluxed below the navicular bone. (Redrawn from Tachdjian MO. Congenital convex pes valgus. Orthop Clin North Am. 1972;3:133.)
Plantar calcaneonavicular ligament Tibia
Dorsal talonavicular ligament Deltoid ligament
Cuneonavicular ligament
Posterior talocalcaneal ligament
A
Tibia
Long plantar ligament Navicular
Deltoid ligament
First cuneiform Calcaneus

Long plantar
Medial cuneonavicular ligament
ligament
Plantar calcaneonavicular ligament Head of talus
B
FIG. 19.69 Ligamentous pathologic changes in congenital vertical talus—medial view. (A) Normal foot. (B) Malformed foot with congenital
vertical talus (pes valgus).
the talus, either as viewed directly or as inferred from the Differential Diagnosis
position of the metatarsals and cuneiforms.9 When all ele- Calcaneovalgus is a flexible deformity, which distinguishes
ments exist (calcaneus in equinus, navicular dislocated with it immediately from a vertical talus. Furthermore, while the
the foot in a neutral position), but the navicular is reducible forefoot is dorsiflexed against the tibia, the hindfoot is in
on a plantar flexion radiograph, the condition is termed an dorsiflexion rather than in equinus and plantar aspect of the
oblique talus.23 foot is flat rather than convex.
The term oblique talus is given to an intermediate defor- Treatment

mity, neither a true vertical talus nor a flexible flatfoot. The A minimally invasive method of treatment involving serial
diagnostic finding is subluxation of the navicular on the talus casting and limited surgery has been recommended and
in a standing position, with reduction of the navicular in is increasingly being attempted as a first-line treatment in
maximum plantar flexion.16 infants with idiopathic and non-isolated congenital verti-
At walking age, a flatfoot with a heel cord contracture may cal talus deformities.6 The technique involves gradually
also be mistaken for a vertical talus. Though a flatfoot may have stretching the foot into plantarflexion and inversion through
a dorsally displaced navicular in the standing position, the talo- the midfoot while stabilizing the talar head. In this manner,
navicular joint is easily reduced with plantar flexion. In fact,
the navicular is never truly dislocated in a flexible flatfoot. The
valgus deformity in flatfoot is also flexible and will reduce on
inversion of the foot, which restores the arch contour. There is
no such flexibility or reducibility in a vertical talus deformity.
Posterior tibio-
Tibia fibular ligament
Fibula Anterior tibiofibular ligament
Anterior talofibular ligament Medial malleolus
Posterior tibio- Bifurcated ligament
fibular ligament
Dorsal tarsal ligament Posterior talotibial Lateral
Posterior talo- ligament malleolus
fibular ligament
Deltoid ligament
Posterior talofibular ligament
Calcaneofibular ligament Calcaneocuboid ligament Calcaneofibular ligament

Long plantar ligament
FIG. 19.70 Ligamentous pathologic changes in congenital vertical FIG. 19.71 Ligamentous pathologic changes in congenital vertical
talus—lateral view. talus—posterior view.
Extensor Tibia
tendons Gastrocnemius muscle
Anterior tibial muscle Soleus muscle
Flexor digitorum
Deltoid ligament longus muscle
Posterior tibial muscle
Flexor hallucis longus

muscle
Tendon of extensor
hallucis longus muscle Achilles tendon
First metatarsal
Calcaneus
Tendon of anterior tibial muscle
Cruciate ligament
Tendon of flexor hallucis longus
First cuneiform muscle
Tendon of flexor digitorum longus muscle
Navicular
Plantar calcaneonavicular ligament Tendon of posterior
Head of tibial muscle (note displacement
talus caused by vertical talus)
FIG. 19.72 Abnormalities of muscles and tendons in congenital vertical talus.
H
↑A G
C F F
D
B
A B
FIG. 19.73 Pathologic soft tissue changes in an infant with congenital vertical talus who died 8 hours after birth. (A) Lateral view. Note the
rocker bottom foot with dorsiflexion of the forefoot (A) and equinus deformity of the heel. The apex angulation of the lateral column is at
the calcaneonavicular joint. The calcaneus (B) is displaced laterally under the talus and lies in close proximity to the distal end of the fibula
(C). The contracted triceps surae (F) is holding the calcaneus in plantar flexion. The peroneus longus (D) and peroneus tertius (E) are short-
ened. (B) Medial view. The anterior tibial (G) and extensor hallucis longus (H) muscles are shortened. (The extensor digitorum longus is also
contracted, but it is not apparent in this photograph.) The triceps surae muscle (F) is shortened. These musculotendinous contractures are
secondary obstacles to anatomic alignment of the talocalcaneonavicular joint. (From Campos da Paz A Jr, De Souza V, De Souza D. Congeni-
tal convex pes valgus. Orthop Clin North Am. 1978;9:210.)
A B
C D
FIG. 19.74 A child with congenital vertical talus. (A) Lateral radiograph showing the increased talocalcaneal angle, equinus of the calcaneus,
and dorsal dislocation of the navicular. The bone ossified over the talus is the medial cuneiform; it indicates the position of the navicular,
which is not yet ossified in this child. (B) Plantar flexion lateral radiograph. The navicular is still dorsally displaced over the talar neck (again
indicated by the location of the cuneiform). (C) Dorsiflexion lateral radiograph. The hindfoot remains in neutral position and lacks true
dorsiflexion. (D) Lateral radiograph after open reduction of the dislocated navicular and soft tissue release. The pin secures the navicular in a
reduced position opposite the talus.
the midfoot is “reduced” to the vertically oriented talus and

the calcaneus is allowed to passively move in from a valgus
to a varus position as the midfoot deformity is corrected.
No attempts are made to improve the equinus deformity.
Serial long leg plaster casts are applied to allow for progres-
sive gradual correction. Radiographs after four to six casts
are used to monitor adequacy of correction and once the
talonavicular joint is felt to be reduced (described by Dobbs
as a talar axis first metatarsal base angle of <30 degrees),
the patient undergoes Kirschner wire stabilization of the
talonavicular joint with capsulotomy to confirm proper
reduction followed by a heel cord tenotomy to correct the
equinus.6 Fractional lengthenings of the extensor digito-
rum communis and peroneus brevis tendons are sometimes
required to achieve an adequate reduction of the talona-
vicular joint. Transfer of the tibialis anterior tendon to the
FIG. 19.75 Line drawing showing the alignment of normal struc- dorsal aspect of the talar neck has also been used with this
tures on a lateral radiograph. The long axis of the talus cuts the
technique at the time of surgery to allow talar dorsiflex-
lower half of the cuboid, whereas the long axis of the calcaneus
passes through the upper half of the cuboid.
ion and maintenance of the talonavicular reduction. Similar
to clubfeet managed via the Ponseti method, post-casting
braces are used to maintain midfoot alignment and ankle
dorsiflexion. Advocates of this technique report preserva-
tion of ankle range of motion, correction of abnormal radio-
graphic parameters, and successful avoidance of extensive
soft tissue release.6
Surgical correction is the mainstay of treatment for
many children with congenital vertical talus deformities.
The difficulty of surgical correction depends on the sever-
ity of the deformity, the associated diagnoses, and the age
of the patient. Milder cases require less extensive releases,
whereas rigid, arthrogrypotic deformities require circum-
ferential releases and will probably never achieve normal
mobility.
Single-stage release, two- stage release, anterior
approaches, soft tissue release with navicular excision, and
Grice- Green subtalar fusion after release have all been
reported to be effective.f We prefer a single-stage release
FIG. 19.76 Relationship of structures as seen on a lateral radio- performed at approximately 1 year of age, as described in
graph of a foot with congenital vertical talus. The long axis of the Plate 19.1 on page 787. A modified Cincinnati incision is
talus passes below and behind the cuboid bone and cuts through used, with extension across the dorsum of the foot as nec-
the anterior portion of the calcaneus, and the long axis of the essary to lengthen the toe extensors and peroneals. There
calcaneus passes plantar to the cuboid. are four components to the release. The first component is
reduction of the navicular on the talus by release of the ante-
rior tibialis tendon and the tibionavicular and talonavicular
ligaments and capsule. The reduction is stabilized by a pin
placed across the talonavicular joint and by reconstruction
of the spring ligament. The second component is lengthen-
ing of the toe extensors and peroneals to allow reduction of
the forefoot. The cuboid is reduced on the calcaneus with
release of the bifurcate ligament and the calcaneocuboid
joint capsule. The third component is release of the equi-
nus contracture, lengthening of the Achilles tendon, and
division of the ankle and subtalar joint capsules. The fourth
stage is transfer of the anterior tibialis tendon to the talus
if necessary to dynamically stabilize the correction. In older
children with resistant deformities, excision of the navicular
may be necessary to achieve the first step of correction.25
It must be noted that this is a very extensive exposure
and release. In milder deformities some components may
FIG. 19.77 Relationship of structures as seen on a lateral radio- not be required. For example, if the extensor tendons and
graph of a foot with congenital vertical talus. The long axis of the
talus passes very close to the anterior aspect of the calcaneus. f References 4, 8, 9, 17, 21, 23, 26, 27, 37, 38.
peroneals are only mildly contracted, they should not be

Table 19.1 Reported Incidence of Tarsal Coalition.
lengthened unless their length does not allow the foot to
Study Material Incidence (%)
rest in neutral at the end of the procedure. When the entire
release is necessary, it is imperative that the surgeon pre- Pfitzner35 Autopsy 0.38 (2 of 524)
serve as many superficial veins as possible so that venous Harris and Beath12 Army recruits 0.03 (1 of 3619)a
drainage of the forefoot is not compromised. Sometimes
percutaneous tenotomy of the extensors can be performed Vaughan and Army personnel 1.0 (21 of 2000)
with a less extensive skin incision. Segal44
A postoperative splint or a bivalved cast is used to main- Shands and Children’s clinic 0.9 (11 of 1232)
tain correction, and the foot should be elevated. Any cast or Wentz40
dressing that constricts the foot must be released because aOf 3619, 72 (2%) had peroneal spastic flatfoot.
swelling is often a problem after the surgery. A cast change
under anesthesia may be required in a week or two to con-
vert to a solid cast. The cast should be maintained for 6 to Tarsal Coalition
12 weeks, depending on the severity of the deformity.
Children between 3 and 4 years old may best be man- A tarsal coalition is an abnormal connection between two
aged with a concomitant Grice extraarticular arthrodesis at or more bones of the foot that may produce pain and limi-
the time of the release.4 Older children may also require tation of foot motion. The most common coalitions are
excision of the navicular to shorten the medial column and talocalcaneal and talonavicular, but many different combi-
allow reduction of the forefoot. nations of fusions between tarsal bones have been reported.
The condition has also been called peroneal spastic flatfoot.
Results and Complications The reported incidence of tarsal coalition has varied from
Good or excellent results have been reported in 76% to 0.03% to 1.0% (Table 19.1).11,35,40,44
85% of children who had a one-stage release and reduc-
Etiology
tion. However, residual midfoot sag, forefoot abduction,
decreased motion, and recurrent deformity have been While the etiology of tarsal coalition is unknown, the most
noted.31 Studies suggest that surgery should be done likely cause is failure of normal segmentation of the fetal
before the child is 27 months old.31 Correction at an early tarsal (Fig. 19.78).13 In a study comprising 142 feet from
age may avoid the need for tendon lengthening and has 7-to 20-week fetuses, 16 feet had talocalcaneal bridges.18
been shown to have good functional results.37 Compared These bridges were not found in older fetuses. Although
with a posterior approach, anterior approaches require less a coalition may be present at birth, symptoms typically
operative time and have been shown to have higher clini- appear later as the child matures (Fig. 19.79). The cause
cal scores and fewer complications.21 Good clinical results of pain from a coalition is also conjectural. The coalition
have been obtained with Grice fusions and lateral column may produce abnormal hindfoot and midfoot motion that
lengthening,20 as well as navicular excision,3 and excellent induces painful peroneal muscle. Partial and cartilaginous
or good results in 53% of feet treated with Grice proce- coalitions may be painful because of stress across the incom-
dures as part of a reoperation. Those with severe defor- plete fusion.
mity and less extensive surgery had worse results. Some of A number of reported cases of familial occurrence
the Grice procedures resulted in overcorrection. The most of coalitions have been reported. Boyd described a fam-
common reason for surgical failure was inadequate reduc- ily with bilateral talonavicular bars in three generations,3
tion of the navicular.23 and there are several other reports of familial occurrence
Dobbs reported excellent ankle range of motion, normal- of this coalition.2,38 Wray and Herndon described calca-
ization of all radiographic parameters, and a low recurrence neonavicular coalition in three generations of a family andg
of talonavicular subluxation following serial casting and Wray and Herndon proposed that this phenomenon rep-
minimal surgery to include talonavicular pinning, Achilles resented autosomal dominant inheritance with reduced
lengthening, and fractional lengthening of other tendons if penetrance.49 One study found that 39% of first-degree
needed.5 relatives had some type of coalition,22 evidence of almost
Complications after corrective surgery for vertical talus complete penetrance of autosomal dominant inheritance
are not infrequent and can be severe. Studies have shown of the disorder.
that most of the blood supply to the foot may come from
Clinical Features and Differential Diagnosis
the anterior tibial and dorsalis pedis arteries.27 Hootnick
and associates reported ischemic necrosis resulting in ampu- Tarsal coalitions usually become symptomatic in adoles-
tation of a corrected foot and warned against overstretching cence, with patients typically presenting for evaluation
or otherwise compromising the dorsal arterial supply to the between the ages of 12 and 16 years. Some coalitions have
foot.13 been documented in children as young as 6 years,45 but
Correction of a neglected deformity in an older child is such cases are rare. Pain is usually the initial complaint.
difficult. Full correction of severe deformities is not pos- The pain is often over the tarsal sinus, but it may also be
sible, and later reconstruction by triple arthrodesis is appro- localized beneath the medial malleolus, along the arch
priate for the symptomatic foot. The deformity is not easily of the foot, or occasionally on the dorsum of the foot.
corrected with a triple arthrodesis, and a supplemental bone The pain is exacerbated by vigorous sports activities,
graft is necessary to correct the valgus deformity.
For References, see expertconsult.com. g References 1, 2, 7, 14, 37, 38.
FIG. 19.78 Complete medial talocalcaneal bridge in the foot of a A

72.3-mm fetus (coronal section). (Courtesy Barbara Anne Harris
Monie. From Harris RI. Retrospect—peroneal spastic flat foot. J Bone
Joint Surg Am. 1965;47:1658.)
particularly running on uneven surfaces. A history of fre- B

quent ankle sprains is not uncommon because restricted
FIG. 19.79 Radiographic findings in a child with mild complaints of
subtalar motion limits the foot’s ability to accommodate foot pain. (A) Anteroposterior radiograph showing a medial bony
to uneven terrain while transferring forces to the tibiotalar connection between the talus and navicular. (B) Oblique radio-
joint. Patients may also notice external rotation of the foot graph showing the talonavicular coalition. Surgical treatment was
and stiffness of the hindfoot. Progressive flatfoot is also an not required.
occasional complaint.
Fifty percent to 60% of tarsal coalitions are bilat-
eral. Patients with unilateral complaints may therefore
have asymptomatic coalitions in the contralateral foot, patients with tarsal coalitions.19 A useful test is to have
which may remain asymptomatic or become painful later the patient attempt to walk on the lateral border of the
in life. This lack of correlation between symptoms and foot, an impossible task if there is limited inversion of
radiographic findings has led to considerable speculation the foot.
about the pain-producing mechanism when a coalition is A tarsal coalition is easily distinguished from a flexible
present. flatfoot simply by the range of motion of the hindfoot. By
The predominant physical finding is decreased range definition, a flexible flatfoot has a full or excessive range of
of motion of the subtalar joint in a patient with a flatfoot inversion and eversion, although the occasional patient with
(Fig. 19.80). Passive inversion and eversion of the cal- a tight heel cord may have some mildly restricted motion.
caneus are limited or absent. Gentle effort to move the Nonetheless, the hindfoot should invert during a toe rise
subtalar joint may result in some motion, but the motion maneuver in a child with a flexible flatfoot, which does not
may be limited by a grab or spasm of the peroneals when occur when a coalition is present.
the patient feels pain with the movement. When the A difficult clinical problem is a child or adolescent with
patient walks, there may be fixed external rotation of the classic symptoms and physical findings of a tarsal coalition
foot with a larger than normal foot progression angle. No despite normal appearing radiographs. Surgical exploration
hindfoot inversion occurs during a toe rise because of the of the feet in many of these cases has yielded variable find-
lack of normal subtalar motion (Box 19.2). Lack of tibial ings. Some feet have fibrous coalitions, whereas others have
external rotation during a toe rise has also been noted in unexplained inflammatory changes in the subtalar joint. The
The subtalar joint is a complex consisting of three parts:

the anterior and middle facets in the anterior compartment
and the posterior facet in the posterior compartment. The
interosseous talocalcaneal ligament separates the two com-
partments. All three parts of the subtalar joint, as well as
the calcaneonavicular area, should be studied to rule out the
presence of a coalition.
Plain radiographs should include AP, lateral, oblique,
and Harris views (Figs. 19.83 and 19.84). The standing
oblique view (Fig. 19.85), obtained at a 45-degree angle in
a lateral-to-medial direction, is the best view for identifying
a calcaneonavicular coalition (see Fig. 19.83). This condi-
tion appears either as a solid bony connection between the
anterior projection of the calcaneus and the navicular or as
an irregular radiolucent line at the junction of the projection
of the calcaneus and navicular. The diagnosis can usually be
corroborated with a lateral radiograph, which will show an
elongated anterior projection of the calcaneus, the so-called
anteater’s nose (Fig. 19.86).30 Other coalitions, such as talo-
navicular, cubonavicular,48 naviculocuneiform,8,26,39 calca-
neocuboid (see Fig. 19.79), cuboid metatarsal, and multiple
coalitions, can be recognized on plain radiographs.
There is a significant incidence of a second coalition
in a foot in which one coalition has been identified (see
Fig. 19.83). Thus any patient in whom a calcaneonavicular
FIG. 19.80 Lateral and medial views showing clinical findings in
coalition is identified on plain radiography should undergo
peroneal “spastic” flatfoot. Note the severe pes planovalgus with
abduction of the forefoot. The peroneal tendons are taut, and there
CT of the subtalar complex to rule out any additional coali-
is marked restriction of subtalar motion. tions. In any coalition, there may be an anterior beak on
the talus, which is believed to be a traction spur caused
by abnormal motion at the ankle as a result of the lack of
Box 19.2 Clinical Findings Associated With subtalar motion (Fig. 19.87).47 It has also been proposed
Peroneal Spastic Flatfoot that the spur or beak is caused by impingement of the
• estricted subtalar motion
R navicular against the head of the talus, which results from
• Hindfoot valgus deformity abnormal talonavicular motion because of a lack of subtalar
• Abduction of the forefoot mobility.32
• Tightness of the peroneal tendons A talocalcaneal coalition may appear on the Harris
view as a bony bridge across the medial subtalar joint.
The Harris view is a posterior oblique projection in which
clinician should remember that the subtalar joint is often
the beam is directed through the posterior facet of the
involved in children with pauciarticular juvenile arthritis and
talocalcaneal joint.4,12,32 Narrowing of the joint and
the joint may be the initial site of the disease. Thus other
obliquity of the joint surface of the medial facet of the
joints should be carefully examined to rule out systemic
subtalar joint may also indicate the presence of a coali-
arthritis.
tion. When a talocalcaneal coalition is present, the lateral
Occasionally, other foot deformities, such as cav-
radiograph will frequently demonstrate an uninterrupted
ovarus deformity42 and talipes equinovarus,41 are noted in
“C”-shaped arc formed by the medial outline of the talar
patients with coalitions. Patients with fibular hemimelia
dome and the posteroinferior aspect of the sustentacu-
usually have asymptomatic tarsal coalitions. Coalitions
lum tali. This finding is termed a C-sign and has been
that are associated with a limb deficiency are present at
reported to be present in 41% of feet with a talocalcaneal
birth and are compensated for by the development of a
coalition.27
“ball-and-socket” ankle, which allows inversion and ever-
CT of the hindfoot is the best study for assessing a
sion to take place through the tibiotalar joint. These defor-
bony talocalcaneal coalition. A narrowed medial facet joint
mities are almost always asymptomatic and do not require
suggests a fibrous coalition. CT also allows the extent of
treatment.21,29 Nievergelt-Pearlman syndrome is a rare,
the coalition to be determined.15,36,43,45,46 If the coalition
heritable condition in which there are massive tarsal and
extends into the posterior facet, the prognosis for regaining
carpal coalitions (Fig. 19.81).33 Massive synostosis of the
motion after resection may be poor.47
tarsal bones may also be seen in patients with Apert syn-
MRI is even more accurate than CT in demonstrating
drome (Fig. 19.82).
fibrous tarsal coalitions and therefore should be consid-
ered when clinical suspicion of a coalition is high but CT
is nondiagnostic.10 It should be noted, however, that MRI
The presence of tarsal coalitions may be suspected from is not necessary to diagnose most coalitions.46 A techne-
plain radiographs of the foot, but a definitive diagnosis is tium bone scan has also been shown to help in the diag-
generally made with CT. nosis of a fibrous coalition when the CT appearance is
B C
D
FIG. 19.81 A 10-year-old girl with Nievergelt-Pearlman syndrome. (A) Lateral radiograph of the left foot showing massive coalition of the
talus to the calcaneus. Note also the talonavicular and calcaneocuboid–fourth metatarsal coalition. (B) Lateral radiograph of the right foot
showing coalitions between the talus-calcaneus-cuboid and metatarsals. (C) Radiograph of the hand showing fusion of the distal carpal row.
There is also fusion of the first metacarpophalangeal joints of all four fingers. (D) Lateral radiograph of the foot of the mother, who was also
treated for Nievergelt-Pearlman syndrome. Both mother and daughter underwent corrective osteotomies through the hindfoot bony mass
to improve the weight-bearing surface of the foot.
equivocal.6,24 Increased uptake in the area of the subta- associated with a tarsal coalition. The most common non-
lar joint indicates that the coalition is responsible for the operative approach is the use of a firm orthosis, flattened
patient’s symptoms. on the bottom to reduce inversion and eversion stress on
When a bony coalition is present at birth, such as in the foot. To achieve this reduction in motion, we prefer to
some cases of fibular hemimelia, the ankle will adapt use the UCBL orthosis. The addition of high-top shoes may
to allow inversion and eversion motions to occur at the also be helpful. In children who do not experience relief of
ankle joint. The talus will become dome shaped and the symptoms from an orthosis, a 4-to 6-week period of immo-
distal end of the tibia will be spherically shaped, like an bilization in a short-leg walking cast may significantly allevi-
acetabulum. This condition is termed a “ball-and-socket” ate symptoms, and the relief may be long lasting. Subtalar
ankle.21 steroid injections are occasionally used at our institution for
talocalcaneal coalitions that have failed other forms of con-
Treatment servative treatment.
Conservative Treatment Surgical Treatment
All authors agree that an initial trial of conservative treat- Patients who continue to have symptoms that limit their
ment is necessary and may be successful in relieving the pain activities despite conservative therapy are appropriate
A C
FIG. 19.82 Massive tarsal coali-

tion in Apert syndrome. (A and
B) Radiographs of the feet. (C–E)
Characteristic clinical appearance
D E
of the feet.
A B C
FIG. 19.83 Tarsal coalition: imaging findings in a 14-year-old boy with foot pain. Inversion and eversion were severely limited, and there
was peroneal spasm on attempted range of motion. (A) Oblique radiograph demonstrating a calcaneonavicular coalition. (B) Harris view
showing irregular surfaces and narrowing of the medial facet, suggestive of a talocalcaneal coalition. (C) A computed tomography scan
showing a large bar across the medial facet of the subtalar joint confirms the subtalar coalition.
FIG. 19.84 Tarsal coalition (ar-

rows): penetrated axial view of both
feet. Left, The left middle facet joint
is normal; note that the radiolu-
cent articular cartilage space lies
horizontally. Right, Fibrocartilaginous
coalition of the middle facet joint. Its
radiolucent line is tilted medially and
downward, with irregular margins
that lack cortication.
FIG. 19.85 Calcaneonavicular coalition. (A)

Oblique view of the foot showing a carti-
laginous bar. Note the flattened ends of the
two bones on either side of the cartilagi-
nous bridge. (B) Postoperative radiograph
obtained after the bar was excised. After
surgery, the peroneal spasm disappeared
and full range of motion of the subtalar joint A B
was achieved.
candidates for surgical excision of the coalition. A contra- Calcaneonavicular Coalition. A calcaneonavicular coalition
indication to surgery is the presence of massive coalitions, is excised through a dorsolateral tarsal sinus incision (Video
such as those involving the medial facet and more than half 19.11).9 Care must be taken to excise the entire coalition.
the posterior facet. Beaking of the talus is not evidence of The most plantar extent of the bar is the most difficult to
degenerative disease of the ankle joint and is not a con- remove. After the coalition is resected, some form of inter-
traindication to surgical resection.47 At times, the surgeon position graft must be used to fill the space between the
will be surprised to find that a rigid foot becomes flexible calcaneus and navicular to prevent symptomatic reossifica-
when the patient is anesthetized. These patients often have tion. Typical options include local autogenous fat graft or
a fibrous coalition with peroneal spasm limiting motion. the origin of the extensor digitorum brevis. While some
The presence of foot motion under anesthesia, however, authors report better filling of the resected bony gap using
does not necessarily obviate the need for resection of the fat graft, we have had considerable success using the ori-
coalition. gin of the extensor digitorum brevis following application
FIG. 19.86 “Anteater’s nose” associated with a calcaneonavicular

bar (arrow), a prominent dorsal process of the calcaneus.
of bone wax into the bony interstices at the areas of resec-

tion.28 The muscle is secured within the area of resection FIG. 19.87 Talar beaking (arrow), a prominence on the dorsum of
using a suture passed through the plantar surface of the foot the talus, is often associated with tarsal coalitions. It is probably a
and tied over a button. We prefer to immobilize the foot in traction spur from abnormal tarsal mobility.
a short-leg walking cast for 3 weeks, followed by range-of-
motion exercises designed to regain subtalar motion. should further expose the subtalar joint complex and inspect
it to be certain that the entire coalition has been removed.
Medial Talocalcaneal Coalition. Resection of a talocalcaneal Fusion of the hindfoot may be necessary to alleviate
coalition is more complex than excision of a calcaneonavicular symptoms in patients with extensive coalitions and those in
bar. The coalition is approached medially through a short, lon- whom excision of a coalition does not provide relief. In these
gitudinal incision centered over the sustentaculum tali (Fig. situations, we prefer to perform a subtalar fusion. Peterson
19.88). The flexor digitorum and the posterior tibial tendon has reported using a dowel technique to fuse the talocal-
are identified and released from their sheaths. The coalition caneal, talonavicular, calcaneocuboid, or all three joints.34
usually lies in the interval between the tendons but if needed, Others recommend a triple arthrodesis when excision of the
the flexor halluces tendon can be exposed and reflected plan- coalition does not provide relief of symptoms.4
tarward with the flexor digitorum for more exposure. Because Unusual coalitions of the calcaneocuboid, cubonavicular,
it is difficult to distinguish the bar by direct dissection, it is naviculocuneiform, and other joints are generally treated
helpful to identify the subtalar joint posteriorly and anteriorly symptomatically. If further treatment is necessary, arthrod-
so that the bar lies between two recognizable joint surfaces. esis of the subtalar joint may be indicated, but there are few
If necessary dissection can be carried out between the reports of treatment of these entities.8,26,39,48
Achilles tendon and the neurovascular bundle to identify
the posterior facet of the subtalar joint. Exposure of the Results and Complications
posterior subtalar joint is similar to that in the approach for Many authors have reported almost uniformly successful
correction of a clubfoot. The joint is followed medially until long-term results after resecting calcaneonavicular and talo-
the coalition is encountered. Anteriorly, the talonavicular is calcaneal coalitions, with only a few failures, some of which
identified. The anterior subtalar facet is located just behind may have been caused by incomplete resection.9,20,22,25,47
the talonavicular joint. Just posterior to the anterior subta- Kumar and associates identified three types of coalition:
lar facet, the surgeon will encounter the anterior margin of type I, osseous bridging; type II, cartilaginous coalition; and
the coalition. The coalition is identified and then resected type III, fibrous coalition. The type of coalition, however,
until the nonfused subtalar joint surfaces are seen. High- did not influence the outcome. By employing self-reported
speed burrs, rongeurs, and a curet are used to excise the outcomes measures, Mahan and associates found that over
bar. Alternatively, the superior and inferior boundaries of 70% of patients had excellent function and were not limited
the coalition can be marked with Kirschner wires, verified by pain during desired activities following coalition excision.
with an intraoperative Harris heel view and osteotomes Outcomes did not vary with the type of coalition.23
then passed along the wires to excise the coalition en bloc Other authors have reported residual pain and stiffness
(see Fig. 19.88). Bone wax is interposed on the exposed after resection and have performed arthrodeses in these
bone surfaces to prevent refusion. An autogenous fat-free patients. Wilde and co-workers found that if the coalition
graft may be used as an interposition.5,31 A split portion of involved 50% or less of the area of the posterior facet of the
the flexor hallucis tendon has also been used as an interposi- calcaneus, the outcome after resection was good.47 When
tion graft between the margins of the coalition. fusion of the posterior facet was greater than 50%, the post-
Once the coalition has been removed, the subtalar joint operative results were not good. These feet had heel val-
is taken through a range of motion to assess the complete- gus greater than 16 degrees, and most had narrowing of the
ness of the resection. If motion is still limited, the surgeon posterior talocalcaneal joint and impingement of the lateral
A B
C D
FIG. 19.88 Medial approach to the subtalar joint for resection of a talocalcaneal coalition. (A) The skin incision overlies the palpable susten-
taculum tali and the interval between the posterior tibial tendon and flexor digitorum longus is identified. (B) The posterior tibial tendon
is elevated and retracted dorsally and the flexor digitorum is reflected plantarward to expose the coalition. (C) Kirschner wires are passed
along the superior and inferior margin of the coalition converging beyond the most lateral extent of the coalition to guide resection. (D) Fol-
lowing resection, the normal posterior facet is visible (arrow).
process of the talus on the calcaneus. Comfort and Johnson from South Africa in 1770.6 The unfortunate term “lobster-
reported a 77% success rate if coalitions involved a third or claw” deformity was first used by Cruveilhier in 1829.4
less of the total subtalar joint surface.3
Gait analysis following resection of tarsal coalitions has Etiology
demonstrated that while most patients demonstrate sig- The disorder is very rare, estimated to occur in 1 in every
nificantly increased passive subtalar motion and dramatic 90,000 births. Inheritance is autosomal dominant with vari-
improvement in clinical symptoms, severe restriction in sub- able penetrance.1,5,9,11,15 Cleft foot is probably caused by
talar inversion-eversion persists during walking.17 Following a functional defect in the apical ectodermal ridge, which
coalition resection, medial midfoot plantar pressure has been induces limb bud formation in the embryo.1,9 Further work
shown to normalize to some degree during walking but remains has suggested that the locus of the defect may be at chro-
significantly higher than in normal feet during running.16 mosomal region 7q21.2–q21.3.3
In our experience, large coalitions and, at times, average-
size coalitions in large patients may remain symptomatic Clinical Features
after resection. Most of these cases have subsequently been Most cases are bilateral, but occasionally a single cleft foot
treated by either subtalar fusion or triple arthrodesis. We will occur.7,8 The hands are often cleft as well, and the cleft
have also encountered a small number of patients with foot may also be associated with a triphalangeal thumb.9,10
the clinical features of a peroneal spastic flatfoot in whom The degree of defect varies considerably among patients,
no coalition was found during surgical exploration. These but the defect itself is usually conical with the base being
patients have persistent symptoms postoperatively, and to distal. In more severe cases, as progressively more rays are
date we have not identified the cause of the problem. deleted, the deletions move from the tibial side toward the
For References, see expertconsult.com. fibular side, with the fifth ray being the last to be affected.
The first metatarsal may be of normal size, or it may be
broad and connected toward the center of the defect.
Cleft Foot
The different degrees of deformity have been nicely
Cleft foot is a congenital anomaly characterized by a deficit in classified by Blauth and Borisch based on their own patient
the central rays of the foot. The first report of the disorder was experience and from the literature.2 Types I and II are feet
A B C D
FIG. 19.89 Technique for closing a cleft foot.16 The technique is possible only if at least two metatarsals are present. (A) On the fifth ray,
a rectangular flap is raised starting from the plantar surface of the foot and extending to the dorsum. Opposite this flap on the first ray, a
rectangular flap is raised starting on the dorsum and extending to the plantar surface. (B) The flaps are raised until the skin of the entire cleft
is removed. At the distal tip of the toe with the greatest length, a flap is raised for suturing to the adjacent toe to make a wide toe web. (C)
If the toes spring apart, a closing wedge osteotomy is done at the base of each metatarsal to centralize the bones. An attempt is made to
create an intermetacarpal ligament. (D) K-wires are inserted until the bones heal, usually in 6 weeks. (Redrawn from Wood VE, Peppers TA,
Shook J. Cleft-foot closure: a simplified technique and review of the literature. J Pediatr Orthop. 1997;17:502.)
with minor deficiencies, both with five metatarsals. In type of a contralateral toe to correct the defect have been
I the metatarsals are normal, whereas in type II they are par- reported.13,14
tially hypoplastic. As the degree of deformity increases, the For References, see expertconsult.com.
number of metatarsals decreases: four metatarsals in type
III, three in type IV, two in type V, and one in type VI. The
authors also reported polydactylous and monodactylous Neurogenic Abnormalities
cleft feet with distal tibiofibular diastasis.
Cavus Foot
Treatment Pes cavus is defined as an abnormal elevation of the lon-
Treatment of the disorder is somewhat controversial. Some gitudinal arch of the foot. The deformity is complex
authors propose that the feet be left untreated if they are and consists of forefoot equinus and hindfoot varus or
plantigrade and capable of shoe wear, whereas others advo- calcaneus.
cate closure of the defect before walking age. We have
found that most widely split feet function well without sur- Etiology
gical closure and patients are generally able to wear shoes The etiology of pes cavus is neurologic in most patients.27,55
that are smaller than usual but are not modified. Occasion- Two thirds of patients with pes cavus have been found to
ally, custom-molded orthoses are necessary to improve shoe have an underlying neurologic diagnosis11 such as cere-
wear or to relieve excessive pressure over prominent areas bral palsy,7 poliomyelitis, Friedreich ataxia, or myelome-
on the sole of the foot. We recommend surgical closure if ningocele. Spinal cord pathology such as tethered cord,
shoe wear cannot reasonably be expected because of the lipomeningocele, and diastematomyelia commonly result
degree of deformity present. in cavovarus deformities (Fig. 19.90).33,76 Patients with
Based on a series of 42 operations in 15 feet, Wood and Charcot-Marie-Tooth disease and other peripheral neurop-
associates16 recommended a closure technique (Fig. 19.89) athies initially may be seen for treatment of cavus.41 Pes
if at least two metatarsals are present. First, rectangular cavus has also been described in patients with tumors or
flaps are raised until the entire skin of the cleft is open. injuries of the sciatic nerve.4,6
Metatarsal osteotomies are performed, if necessary. The The common thread among all these neurologic condi-
intermetatarsal ligament is reconstructed with local liga- tions is the presence of muscle imbalance.56 Cavus feet are
mentous tissue, joint capsule, or tendon from the cleft or produced by weakness and contracture of the intrinsic foot
from autografted plantaris or fascia lata. The closure is sta- musculature, with preservation of strength in other mus-
bilized with K-wires. The authors recommended that the cles. A classic condition associated with cavus foot defor-
procedure be performed at approximately 6 months and mity is Charcot-Marie-Tooth disease.75 In this disease, the
before 1 year of age. posterior tibialis and peroneus longus remain strong and
An alternative technique has been reported by Sumiya serve to invert the hindfoot and depress the first metatar-
and Onizuka.12 In their procedure, the defect is closed sal head. The tibialis anterior and peroneus brevis are weak
and a third toe is created with double pedicle flaps from and therefore cannot dorsiflex the ankle, elevate the first
the cleft area. Subsequent procedures divide the third metatarsal, or evert the foot. The result of this pattern of
and fourth toes to create five toes by using free skin grafts muscle imbalance is hindfoot varus with a pronated, dorsi-
from the skin defects. The toes are reconstructed for cos- flexed forefoot.29,46 The intrinsic muscles of the sole of the
metic reasons. Subsequent grafting procedures are usually foot are weak and become contracted, resulting in elevation
necessary for managing retraction of the toes. Sumiya and of the longitudinal arch.53 Clawing of the toes occurs as the
Onizuka recommended that surgery be performed before first metatarsal head is depressed, which leads to extension
1 year of age. Use of a silicon graft and transplantation of the MTP joint. The toe extensors are recruited to help
dorsiflex the ankle in the presence of a weak tibialis ante- Posttraumatic causes of pes cavus can also occur follow-
rior, thus contributing to extension of the MTP joints. As ing certain types of lower extremity trauma. Equinocavus
MTP extension progresses, the long toe flexors are stretched deformities may develop in patients who have compartment
tightly, which results in flexion of the proximal interphalan- syndrome of the leg or foot after severe trauma.35 In addi-
geal (PIP) and distal interphalangeal (DIP) joints. tion, cavus has been seen in children with sciatic nerve palsies
Another cause of pes cavus is residual deformity from from intramuscular injections in the area of the nerve.6 Cavus
a clubfoot. Although cavus is nearly universally present in feet have been found to develop in children who sustain lac-
infants undergoing surgical release, recurrent clubfoot fre- erations of either the peroneus brevis or peroneus longus.13,19
quently has cavus as a component of the deformity. Finally, a group of patients exist in whom a complete
neurologic evaluation fails to disclose the cause of the cavus
deformities. A small subset of these children are seen with
cavus as infants, in which case the deformities are termed
congenital cavus deformities.3,70
Clinical Features
Cavus deformities of the feet can be divided into those lim-
ited to cavus without hindfoot deformity, those associated
with hindfoot varus (cavovarus), and those that have hindfoot
calcaneus (calcaneocavus). Simple pes cavus is characterized
by plantar flexion of the forefoot that is balanced across the
medial and lateral aspects of the foot, with even distribution
of weight on the first and fifth metatarsal heads. The heel is
A in neutral position or in a few degrees of valgus (Fig. 19.91).
Cavovarus is much more common than calcaneocavus. Cav-
ovarus results from elevation of the longitudinal arch with
plantar flexion of the first metatarsal and, to a lesser degree,
5
the second metatarsal. The first metatarsal is pronated. The
depressed first metatarsal head acts as one limb of a tripod.
When the metatarsal head strikes the floor, inversion of the
heel takes place and leads to hindfoot varus (Figs. 19.92 and
19.93). Calcaneocavus usually occurs in flaccid paralysis,
6 such as myelomeningocele or poliomyelitis, and is caused by
paralysis of the gastrocsoleus. The hindfoot is in a fixed cal-
caneus position with plantarflexion of the forefoot.
Patients may seek treatment of cavovarus because of fre-
quent ankle sprains. The deformity of the foot creates an
7 unstable base for weight bearing, and the ankle twists during
activities. The ankle instability in patients who have a neuro-
logic cause of their cavovarus deformity is compounded by the
muscular weakness in the calf. Other patients have complaints
of pain and callosities on the soles of the feet. The varus defor-
mity of the hindfoot leads to calluses along the lateral border
8 of the foot, especially in the area of the base of the fifth meta-
B tarsal (Fig. 19.94). Plantar flexion and equinus of the meta-
tarsal heads in the presence of hyperextended MTP joints
FIG. 19.90 Pes cavus (A) in a 13-year-old boy with thoracic syrin- can lead to abnormal pressure under the metatarsal heads and
gomyelia (B).
FIG. 19.91 Cavus deformity of the foot. (A)

Pes cavus. There is a fixed equinus deformity of
the forefoot on the hindfoot. (B) The hindfoot
is in neutral. A B
FIG. 19.92 (A and B) Pes cavovarus. Note the

plantar flexion of the medial column of the
A B
forefoot and inversion of the heel.
A B
FIG. 19.93 (A) Pes cavovarus in a 13-year-old boy with a tethered cord. The first metatarsal is depressed, and there is clawing of the great
toe of the left foot. (B) The heel has a fixed varus deformity.
the abductor digiti quinti, the interossei, the posterior tibi-

alis, and the plantar aspects of the capsules of the joints
of the midfoot. In a unilateral deformity, the involved foot
appears shorter than the contralateral side because the mid-
foot is drawn up as the forefoot plantar flexes (Fig. 19.95).
Equinus of the forefoot should be evaluated and the
prominence of the metatarsal heads noted. Some patients
have prominence of only the first metatarsal head on the
plantar aspect of the foot, whereas others have plantar
flexion of all the metatarsals leading to prominence of all
the metatarsal heads. The hindfoot should be inspected
for varus or valgus, and the presence of equinus or calca-
neus determined. True equinus of the hindfoot is very rare
in patients with pes cavus. Although patients may walk on
FIG. 19.94 Plantar surface of a 13-year-old boy with unilateral pes their toes, the hindfoot is typically maximally dorsiflexed to
cavovarus. The fifth metatarsal base is very prominent and a callus
compensate for midfoot equinus (Fig. 19.96).
has developed.
Coleman and Chesnut described a “block test” to clinically
evaluate the flexibility of the varus component in a cavovarus
metatarsalgia. Finally, patients with clawing of the toes may foot.16 The patient stands on a wooden block or a book. The
have calluses or blisters over the dorsum of the flexed PIP heel and lateral border of the foot are placed on the block, and
joints of the toes because of rubbing with shoe wear. the heads of the first through third metatarsals are allowed to
Clinical examination should first focus on documenting drop off the block medially. This allows plantar flexion of the
the components and flexibility of the foot deformity.32 In first ray relative to the rest of the foot. If the heel varus is flex-
younger children with a flexible deformity, elevation of the ible and secondary to plantar flexion of the first metatarsal,
longitudinal arch in the sitting position may flatten some- the calcaneus will evert to neutral or valgus with this maneuver
what when the child stands. A tight band along the sole of (Fig. 19.97). If the varus is fixed, the heel remains in varus
the foot can be felt as the forefoot is dorsiflexed. The tight despite allowing the first metatarsal to plantarflex. This is clini-
structures can include the plantar fascia, the abductor hal- cally important in determining the need for bony hindfoot sur-
lucis, the flexor hallucis brevis, the flexor digitorum brevis, gery in reconstruction of the foot. Other methods of assessing
A B
FIG. 19.95 (A and B) Ten-year-old boy with a cavus right foot. The foot appears smaller than the contralateral foot because of elevation of
the arch and forefoot equinus.
A B
FIG. 19.96 (A) Clinical photograph of a cavovarus foot. (B) Even though the patient walks on his toes, the calcaneus is maximally dorsi-
flexed. The apparent equinus is a result of the midfoot and forefoot plantar flexion.
A B C D
FIG. 19.97 (A) Pes cavovarus in adolescent boy with cerebral palsy. (B) Hindfoot varus is present and there is a callus beneath his fifth meta-
tarsal base. (C) The hindfoot varus is passively correctable to neutral. (D) The Coleman block test shows partial correction of the varus.
STANDING such as Charcot-Marie-Tooth disease. If parents report foot

deformities, their feet should be examined as well.
Standing AP and lateral radiographs can help clarify the defor-
mity present. A standing lateral view of the foot to include
the ankle joint is inspected for the position of the calcaneus.
The angle of the inferior border of the calcaneus with the
tibia should be measured. If the angle exceeds 30 degrees,
the ankle is dorsiflexed, and the tendency for patients to walk
on their toes is specifically not caused by ankle equinus (Fig.
19.98). Most patients with cavus secondary to Charcot-Marie-
Tooth disease have a dorsiflexed calcaneus on lateral radio-
graphs even though they walk on their toes.1 Some patients
do have ankle equinus, such as those who have residual club-
FIG. 19.98 Radiograph of the foot of a 16-year-old girl with a chro- foot deformity, and this can be seen on a lateral radiograph.
mosomal abnormality. The patient walks on her toes because of Meary angle is the angle between the longitudinal axis of
the cavus deformity. The calcaneus, however, is not in equinus. The the talus and the first metatarsal shaft on a standing lateral
first metatarsal is plantar flexed. Meary angle, which is the angle radiograph.42 The normal Meary angle is 0 degrees because the
between the axis of the talus and the shaft of the first metatarsal,
axes of the first metatarsal and talus should be parallel. Plantar
measures 45 degrees (normal is 0 degrees). Hibbs angle, which is
flexion of the first ray is seen as an increase in Meary angle
the angle between the axis of the calcaneus and the first metatar-
sal, measures 110 degrees (normal is >150 degrees). (see Fig. 19.98). Hibbs angle is defined as the angle between a
line drawn along the longitudinal axis of the calcaneus and one
drawn down the shaft of the first metatarsal. This angle should
hindfoot flexibility include manual examination of the hind- be greater than 150 degrees in a normal foot (Fig. 19.99) with
foot with the patient lying prone and looking at the position of an angle less than this indicative of pes cavus.28
the hindfoot with the patient kneeling.52 Forefoot equinus is apparent on lateral weight-bearing
A thorough neurologic examination is crucial in the radiographs in patients with pes cavovarus. The apex of
evaluation of a patient with pes cavus. Sensory distur- the deformity is often at the level of the cuneiforms or the
bances, especially disturbances in light touch sensation, cuneiform-metatarsal joints. It is important to identify the
vibration, and proprioception, are commonly present in precise location of the apex of the cavus deformity when
a stocking-glove distribution in patients with peripheral planning surgical correction.
neuropathies such as Charcot-Marie-Tooth disease. Deep The subtalar joint should also be inspected on the stand-
tendon reflexes are diminished in patients with periph- ing lateral radiograph. Usually there is some overlap of the
eral neuropathy and Friedreich ataxia. In such conditions, joint in a normal foot. In cavovarus the subtalar joint is seen
the ankle jerk reflex is more diminished than the patellar en face, so one can see through it (see Fig. 19.98). The cal-
reflex. Ataxia and dysarthria are also seen in Friedreich caneus will also appear shortened because of malrotation of
ataxia. Clonus is present in children with cerebral palsy the bone. The lateral talocalcaneal angle is decreased, with
and myelopathy as a result of spinal cord pathology. The the two bones appearing relatively parallel on a standing lat-
motor examination is very important in pes cavus. Muscles eral view of a cavovarus foot.
that are weak should be identified, and those that remain
strong may be useful in tendon transfer to rebalance forces Further Diagnostic Evaluation
across the foot. When the cause of the varus deformity is not readily appar-
The legs should be inspected for evidence of atrophy. ent, a pediatric neurologist should be consulted. MRI of the
Patients with asymmetric foot deformities often have rela- brain and spinal cord is performed to rule out cerebral or
tive hemiatrophy of the calf musculature on the side of the spinal cord abnormalities. Electrodiagnostic studies may be
cavus foot. Leg length discrepancy is also frequently present, performed. Nerve conduction velocities are significantly
with an ipsilateral short leg relative to the contralateral side. slowed in patients with type I Charcot-Marie-Tooth disease.
The spine should be examined in all patients with cavus When the deformity is due to denervation, electromyogra-
deformities. Surgeons are urged to examine the bare feet of phy will show a neuropathic pattern with fibrillation.
all children being evaluated for scoliosis. The presence of With recent discoveries in the field of molecular genet-
pes cavus in such a patient may be the first clue to an under- ics, DNA studies have replaced electrodiagnostics and nerve
lying spinal cord pathology. Signs of dysraphism should be biopsies in the evaluation for peripheral neuropathies, such
sought on physical examination as well. A hairy patch on as Charcot- Tooth disease and Friedreich ataxia.8,36
Marie-
the back, an overlying hemangioma, or a deep dimple in the Specific mutations can be identified in most of these patients
sacral region may alert the surgeon to the presence of a teth- and lead to a definitive diagnosis. Please see Chapter 34 for
ered cord or lipomeningocele. further information on molecular genetic evaluation.
Finally, the examiner should question the parents
regarding any foot deformity that they themselves possess. Treatment
Charcot-Marie-Tooth disease is transmitted as an autoso-
mal dominant trait, but the phenotype varies among family Conservative Treatment
members. A moderately elevated arch in a parent supports There is little role for conservative treatment in feet with
the diagnosis of a hereditary motor and sensory neuropathy cavus deformities.51 Stretching the contracted plantar
FIG. 19.99 Methods of measuring

the degree of pes cavus on a standing
lateral radiograph of the foot. (A) In a
normal foot, the longitudinal axis of
the talus is parallel to the longitudinal
axis of the first metatarsal. (B) Meary
measures the angle formed between
lines drawn through the centers of the
longitudinal axes of the talus and the
first metatarsal. (C) Hibbs measures the
angle formed between two lines drawn
through the centers of the longitudi-
nal axes of the calcaneus and the first
metatarsal. B C
structures has no proven benefit in these children. Attempts The decision to surgically correct a hindfoot deformity in
to modulate muscle imbalance and halt deformity progres- a cavovarus foot should be made before surgery. The Cole-
sion via botulinum toxin injections into the peroneus lon- man block test, described earlier, establishes whether the
gus and tibialis posterior have proved to be unsuccessful in hindfoot varus is fixed or is simply compensatory for the
a randomized trial.12 Shoe inserts designed to elevate and plantar flexed first ray. When a fixed deformity is present,
offload the metatarsal heads may have some utility in reliev- soft tissue surgery with or without metatarsal or cuneiform
ing symptoms of metatarsalgia. Ankle-foot orthoses may be osteotomies will be insufficient to fully correct the foot.
prescribed to improve a drop foot gait seen in conjunction Conversely, when the Coleman block test indicates flexibility
with pes cavus in children with peripheral neuropathies. of the hindfoot, surgical correction of the forefoot equinus
by plantar release, usually combined with a first metatarsal
Surgical Treatment or medial cuneiform osteotomy, will allow the hindfoot to
Indications for surgery are progressive deformity, calluses assume a neutral to valgus position, thereby obviating the
beneath the metatarsal heads or base of the fifth metatarsal, need for hindfoot surgery.
or ankle instability.46 These indications are frequently pres- The preoperative physical examination is also critical
ent during the patient’s initial evaluation. Surgical decision when selecting tendon transfers in a cavovarus foot. In
making in pes cavus is determined by the following 10 fac- patients with progressive peripheral neuropathies, such
tors described by Tachdjian64: (1) the apex of the deformity, as Charcot-Marie-Tooth disease, weakness or paralysis of
(2) the type of pes cavus (i.e., cavovarus versus calcaneoca- certain muscles rules out their use as potential transfer
vus), (3) the position of the hindfoot, (4) the presence of candidates. Similarly, in such patients there is often a clear
a claw-toe deformity, (5) the presence of skin changes on lack of ability to dorsiflex the ankle, and in these children,
the sole of the foot, (6) abnormal shoe wear, (7) the rigidity anterior transfer of the posterior tibialis tendon to the dor-
of the deformity, (8) the strength of the muscles, (9) the sum of the foot may be indicated to restore swing phase
stability of the neurologic disease, and (10) the age of the dorsiflexion.
patient and skeletal maturity of the foot.
Surgical treatment of pes cavus can be divided into soft Soft Tissue Surgery
tissue surgery, osteotomies, and arthrodesis procedures. Plantar Release. Plantar release is always performed dur-
Soft tissue surgery is always part of the surgical reconstruc- ing surgery to correct a cavus foot. With mild flexible
tion of a cavus foot. Because the deformity is driven by deformities in young children, a simple plantar fasciot-
muscular imbalance, contractures must be released and the omy may be adequate to allow the forefoot to dorsiflex
forces exerted by the tendons rebalanced. In young patients and the longitudinal arch to flatten. Although percutane-
with flexible deformities, soft tissue surgery is adequate to ous techniques have been embraced by some, most still
correct the deformity. In older patients, flexibility is lost as prefer an open approach to the plantar fascia.66 Most
adaptive bony changes occur, and osteotomies will be neces- often an aggressive plantar release is necessary. In this
sary to restore a plantigrade foot. approach the plantar fascia is transected and the abductor
hallucis is divided from its origin. Care must be taken to allowed excellent exposure of the plantar structures.
expose the neurovascular bundle medially and to trace Lateral incisions have also been described, but we do
the tibial nerve to its division into medial and lateral plan- not recommend this approach because the neurovascu-
tar nerves. The nerves may be inadvertently injured dur- lar structures are not easily seen and thus are prone to
ing the release if they are not protected (see Plate 19.2 injury.
on page 793). When considering a plantar release in patients with
Steindler described his plantar release for the a radiographically proven equinus component of their
treatment of pes cavus in 1920. Through a longitudi- deformity, it is important to defer lengthening of the
nal medial incision, the plantar fascia is first divided. Achilles tendon until a later date.51 When stretching the
The flexor digitorum brevis, abductor digiti quinti, arch after plantar release, the Achilles tendon provides
and abductor hallucis brevis are then extraperiosteally “something to push against.” If a concomitant Achilles
released from their origins on the undersurface of the tendon lengthening procedure were performed, the ten-
calcaneus and stripped distally.62 Short-leg casts are sub- don would be susceptible to overlengthening, and the
sequently applied to stretch the forefoot out of equinus stretch of the plantar release would be limited (Fig.
and lengthen the arch. The casts are changed at inter- 19.101).41 Luckily, most patients with cavus feet do
vals as the foot is progressively corrected. 58 Additional not have equinus at the ankle, but if such is the case,
release of the calcaneonavicular spring ligament, the staging the Achilles tendon lengthening procedure is
knot of Henry, and the calcaneonavicular component recommended.
of the bifurcate ligament has also been described (Fig.
19.100).51 Medial release of the subtalar and talonavicu- Peroneus Longus–to–Peroneus Brevis Transfer. One
lar joints in cavovarus feet with inflexible heel varus was tendon transfer that has been commonly used as part of
successful in 85% of patients.51 surgical reconstruction of a cavus foot is a peroneus longus–
Sherman and Westin reported satisfactory results in to–peroneus brevis transfer. The action of the peroneus
83% of 191 feet after plantar release for correction of longus is to depress the first metatarsal head. In patients
pes cavus associated with clubfeet or poliomyelitis.58 with cavovarus, the peroneus longus overpowers the ante-
They advocated serial stretching casts after the release. rior tibialis and leads to excessive plantar flexion of the
The worst results occurred in patients with calcaneocavus first ray.67 Removing the deforming force and transferring
from polio with paralysis of the gastrocsoleus. In these the tendon to the peroneus brevis tendon can be helpful
patients, serial casting was ineffective because exces- in maintaining correction in some children.5,25 Because the
sive dorsiflexion of the hindfoot resulted in little resis- peroneus brevis is responsible for hindfoot eversion via its
tance against which a corrective midfoot force could be insertion at the base of the fifth metatarsal, augmentation
applied.58 of this typically weak muscle by a peroneus longus trans-
We have used a medial incision when performing fer also provides for dynamic hindfoot varus correction by
plantar releases and prefer it because it permits excel- counteracting overpull of the tibialis posterior.
lent exposure of the neurovascular bundle. Thometz The tendons are exposed laterally beneath the lateral
and Gould used a plantar incision centered over the sole malleolus. The peroneus longus is sutured to the peroneus
of the foot66 because the scar was less problematic and brevis, and the longus tendon is transected distally.
B FIG. 19.100 (A) Lateral radio-

graph of a 4-year-old boy with a
severe cavus deformity and ankle
equinus. (B) Radiograph obtained
immediately after surgery, which
consisted of complete plantar
release (including midfoot capsul-
otomies), posterior release, Achilles
tendon lengthening, and first
metatarsal osteotomy. (C) Stand-
ing radiograph obtained 2 months
after surgery showing marked
A C
improvement in foot position.
Gastrocnemius muscle
Overlengthened
Achilles tendon
Achilles
tendon
Plantar fascia
No spread in
A B plantar fascia
FIG. 19.101 (A) Equinus coexisting with cavus. The plantar fasciotomy should be performed first. (B) If the Achilles tendon is lengthened
simultaneously, the divided plantar fascia cannot be stretched and the Achilles tendon will be overlengthened, thereby resulting in calcaneo-
cavus.
A B
FIG. 19.102 (A and B) Clawing of the toes of the right foot results from weakness of the anterior tibialis muscle. As the patient tries to dor-
siflex the ankle, the toe extensors fire. Over time the metatarsophalangeal joints become dorsally subluxated and the proximal interphalan-
geal joints of the toes become flexed.
Anterior Transfer of the Posterior Tibialis Tendon. Patients transfer is performed in conjunction with other procedures
with cavovarus feet as a result of peripheral neuropathy or as part of a comprehensive cavus deformity correction.
myopathies such as Duchenne muscular dystrophy may ben- The surgical technique is described in detail in Plate 35.1
efit from anterior transfer of the posterior tibialis tendon (see (see Chapter 35). In brief, the tendon is detached from its
Chapter 35).26,44 Candidates for this transfer have weak or insertion, retracted proximal to the medial malleolus, and
paralyzed anterior tibialis muscles and therefore cannot dorsi- brought anterior to the ankle by being passed through a gener-
flex the ankle during gait. The strong posterior tibialis serves ous window in the interosseous membrane. The tendon is then
to invert the foot and promotes hindfoot varus. By transfer- inserted through a bony tunnel in the midline on the dorsum
ring the posterior tibialis tendon through the interosseous of the midfoot, and its suture is tied over a button on the sole
membrane to the dorsum of the foot, the surgeon may be able of the foot. In adolescents and young adults, a bio-interference
to convert the deforming force leading to varus and inversion screw provides secure fixation of the transferred tendon after
to an active dorsiflexor of the ankle. This transfer is not help- proper tensioning and obviates the need for a plantar button.
ful in patients with cavovarus and cerebral palsy because it
may lead to a reverse deformity of calcaneovalgus over time. Transfer of the Toe Extensors to the Metatarsal Heads.
An isolated posterior tibialis tendon transfer is not effec- Patients with pes cavus often have claw toes secondary to
tive in correcting a cavus foot deformity, but it may be use- recruitment of the toe extensors as ankle dorsiflexors and
ful in augmenting dorsiflexion of the ankle and improving plantar flexion of the metatarsal heads. The MTP joints of
varus of the hindfoot in flexible deformities. The tendon the toes become hyperextended, whereas the PIP and DIP
joints become flexed (Fig. 19.102). The deformity may be in patients with poor sensation as a result of neurologic
flexible or rigid. Blisters and calluses may develop on the disease. The osteotomy is usually fixed with K-wires or
dorsum of the interphalangeal (IP) joints of the toes from a Steinmann pin, which can be removed 6 weeks after
rubbing against the shoes. When severe, the toes are sus- surgery.
pended dorsally and do not make contact with the floor, and Some patients have a more global equinus of the forefoot,
the metatarsal heads are prominent on the plantar aspect of with the medial and lateral aspects of the forefoot equally plan-
the foot and develop callosities. tar flexed. In such patients, multiple metatarsal osteotomies
Chuinard and Baskin recommended transfer of the exten- have been performed to elevate the forefoot and correct the
sor hallucis longus and extensor digitorum longus proximally cavus (Fig. 19.103).25,63,69 Excellent or good results have been
into the corresponding metatarsal necks.14 The IP joint of reported in 84% of feet treated with osteotomies of all five
the great toe and the PIP joints of the lesser toes are then metatarsals.25,63,65,70 Reported complications included persis-
fused to prevent a flexion deformity from developing.17 This tent metatarsalgia, delayed healing, residual varus, cross-union,
procedure, commonly referred to as a Jones transfer,34 was nonunion, and delayed union, particularly with osteotomies
described by Hibbs in 1919 (see Plate 19.3 on page 798).28 performed at the base of the fifth metatarsal.66,72 A rocker bot-
The transferred tendons assist in ankle dorsiflexion and, bet- tom deformity has been described, as a result of prominence of
ter yet, may allow dorsiflexion of the metatarsal heads with the proximal metatarsals in the sole of the foot.55
improvement in the forefoot equinus component of the cavus Instead of metatarsal osteotomies, Mosca prefers a
deformity.48,68 The Jones transfer is indicated only when the plantar-based opening wedge osteotomy of the medial cune-
cavus deformity is being concurrently corrected or when the iform because the osteotomy is closer to the radiographic
cavus is flexible. It is ineffective in cases of rigid cavus. apex of the deformity. Less transfer metatarsalgia was noted
The surgical procedure entails exposure of the distal inser- at follow- up when this procedure was performed.23,46
tion of the long toe extensors. After transection, the tendons Mubarak has reported nearly universal good to excellent
are tagged with suture, and each metatarsal neck is exposed. A cavus correction when a double osteotomy of the first ray
trephine or drill is used to create a bony tunnel for passage of (cuneiform plantar opening wedge combined with a dorsal
the extensor tendon. The tendon is then passed on its suture closing wedge metatarsal osteotomy) was combined with
through the tunnel in the metatarsal neck and sutured to itself cuboid and calcaneus osteotomies.47
under tension. If there is an extension contracture of the MTP
joint, the dorsal capsule should be released. The IP joint of Calcaneal Osteotomy. A calcaneal osteotomy is indicated in
the hallux or the PIP joint of the lesser toes is exposed, and children with inflexible hindfoot varus on the Coleman block
all articular cartilage is resected from the joint. A Steinmann test. The osteotomy is made posterior to the posterior facet
pin is used to fix the joint, and the foot is placed in a cast for of the subtalar joint and extended obliquely and distally to
6 weeks to allow fusion. At 6 weeks, the IP and PIP joints are the plantar surface of the calcaneus. Correction is achieved
usually sufficiently healed to permit the pins to be removed. either by sliding the inferior fragment laterally or by creat-
The procedure, though not particularly difficult, can be ing a laterally based closing wedge, as described by Dwyer
rather lengthy, particularly when done bilaterally. For this (see Plate 19.4 on page 796 and Video 19.12).20–22,61 A con-
reason, we usually stage these tendon transfers to follow comitant plantar release must be done to correct the forefoot
surgical correction of the cavus deformity—the plantar equinus and contracture of the plantar fascia as well as to
release and concomitant osteotomies. Most patients are allow for full mobilization of the calcaneal tuberosity. The
satisfied with the results, although abnormal elevation of calcaneal osteotomy is fixed with a staple, screw, or threaded
the first ray has been noted in those who also had peroneus Steinmann pin (Fig. 19.104).
longus–to–peroneus brevis transfer, thus caution is recom- Satisfactory results have been reported in more than
mended in using concomitant tendon transfers.10 half of patients after a Dwyer osteotomy. Although incom-
Another tendon transfer recommended for use in claw- plete correction or recurrence of the deformity have been
toe deformity is the Girdlestone-Taylor procedure, which reported, overcorrection into valgus rarely is a problem. The
entails transfer of the long toe flexors to the extensor worst results have been noted in patients with neurologic
mechanism.65 This procedure has less predictable results conditions.18,21 Dekel and Weissman noted that a calcaneal
than the Jones transfer and for that reason is not usually osteotomy was of benefit in patients younger than 12 years
selected.66 with inflexible varus of the hindfoot.18
Mitchell described another calcaneal osteotomy for use
Osteotomies in the surgical correction of calcaneocavus deformities.45
Metatarsal Osteotomies. In patients who have flexible The osteotomy is performed through a lateral approach,
hindfoot varus on the Coleman block test, plantar flexion similar to the Dwyer osteotomy, but instead of the oste-
of the medial part of the forefoot may be correctable by a otomies being translated laterally, the distal fragment is
first metatarsal osteotomy.2,41 The osteotomy is performed slid superiorly and posteriorly. This adds to the length of
proximally, so care should be taken to avoid damaging the the calcaneus and corrects the excessive vertical calcaneal
physis of the first metatarsal. A dorsal closing wedge oste- pitch (Fig. 19.105). Samilson described a similar procedure
otomy is performed in conjunction with a plantar release, in which the shape of the osteotomy is crescentic rather
and the forefoot is dorsiflexed. than linear to allow easier displacement.54,55 Regardless of
The advantage of a metatarsal osteotomy is that it the shape of the osteotomy, a plantar release must be per-
allows correction of the plantar flexed medial forefoot by formed to permit translation of the osteotomy and correc-
bone realignment rather than by stretching casts, which tion of the arch of the foot.9 Frequently, tendon transfers
may promote breakdown beneath the first metatarsal head into the calcaneus are also performed to augment the weak
FIG. 19.103 Anteroposterior (A)

and lateral (B) radiographs of a
9-year-old boy with cavovarus
and a history of previous clubfoot.
(C) Lateral radiograph 3 months
after plantar fascia release and
dorsal closing wedge midfoot os-
teotomy. A small Achilles tendon
lengthening was performed 6 A C
weeks after the osteotomy.
A
B
C D
FIG. 19.104 (A and B) Preoperative radiographs of a 12-year-old girl with rigid pes cavovarus secondary to Charcot-Marie-Tooth disease.
(C and D) Surgical correction consisted of plantar fascia release, posterior tibial tendon transfer, first metatarsal osteotomy, and calcaneal
osteotomy.
Line of osteotomy
Peroneal
tendons
retracted
Calcaneofibular
ligament divided
and retracted
Threaded Steinmann
pin transfixing
osteotomized segments
B C
Posterior segment of
calcaneus displaced
backward and upward
FIG. 19.105 (A) In patients with calcaneocavus deformity, an oblique osteotomy of the calcaneus can be performed through a lateral
oblique incision. The line of osteotomy from the superior part of the calcaneus inclines plantarward and distally. (B) The posterior fragment
is displaced superiorly in a maneuver that requires plantar release. (C) Fixation with a threaded Steinmann pin is used to maintain the dis-
placement. A short-leg cast is then applied.
or paralyzed gastrocsoleus. This procedure was popular in Cole believed that preservation of hindfoot motion was
patients with poliomyelitis, but it remains an option today important and that this osteotomy allowed cosmetic improve-
in treating calcaneocavus secondary to other neurologic ment of the foot and improvement in painful symptoms.15
diseases. Jahss proposed a tarsometatarsal dorsal wedge resection
osteotomy for the correction of cavus deformity.31,32 The
Midfoot Osteotomies. Several different osteotomies of the apex of the resected wedge is slightly more distal than that
midfoot have been proposed for surgical reconstruction of described by Cole, and the osteotomy described by Jahss
a cavus foot. These osteotomies all involve removing a dor- does remove a small amount of plantar bone in the area
sally based V-shaped wedge of bone from the midfoot at or of the tarsometatarsal joints to allow easier closing of the
just proximal to the apex of the cavus deformity. Plantar osteotomy. More bone is resected from the tarsometatarsal
soft tissue release is generally performed either before or in joints of the second and third rays than from the first or
addition to an osteotomy of the midfoot. the lateral rays. The amount of forefoot equinus that can
Cole described a dorsal closing wedge osteotomy of the be corrected with this osteotomy should not exceed 20 to
midfoot in 1940.15 The proximal cut is made through the 25 degrees. Jahss thought that greater correction led to the
navicular and cuboid bones, and the distal cut is made at an development of a rocker deformity in the sole of the foot
appropriate level to allow adequate dorsal bony resection to and persistent symptoms. He therefore recommended triple
correct the cavus deformity (see Plate 19.5 on page 798). arthrodesis for feet with severe deformities. Additionally, he
warned that if a callus is present on the sole of the foot pre- in neighboring mobile joints and to possible pressure ulcer-
operatively, the osteotomy must be performed proximal to ation if the foot is not perfectly positioned.43,77
the callus for successful redistribution of pressure across the The technique recommended for triple arthrodesis has
foot. This holds true for calluses in the area of the cuboid, been debated. In all the techniques, correction of the defor-
which will not improve after the Jahss osteotomy. mity is achieved by resecting appropriate bone wedges. The
Japas described yet another midfoot osteotomy to be more severe the deformity, the larger the wedges that must
used in pes cavus (see Plate 19.6 on page 800).33a In this be removed. This leads to noticeable shortening of the foot.
case the osteotomy does not include resection of a wedge. Similarly, removal of the joint surfaces of the hindfoot tar-
A V-shaped osteotomy is made dorsally, with the apex of sals leads to growth inhibition of these bones and further
the V at the navicular and the limbs extending distally to shortening. For this reason, triple arthrodesis is reserved for
just proximal to the cuboid–fifth metatarsal joint laterally patients 10 to 12 years and older.24
and proximal to the medial cuneiform–first metatarsal joint Siffert and associates advocated a technique for triple
medially. The forefoot is dorsiflexed through the osteotomy arthrodesis called the “beak” triple arthrodesis.59,60 In this
by depressing the base of the osteotomy and prying the dis- procedure a dorsal wedge resection is carried out through the
tal part of the foot dorsally and fixing it with Steinmann talonavicular and calcaneocuboid joints, but a small shelf of
pins. The advantage of this osteotomy is that the foot is not dorsal talar head is left intact (Fig. 19.108). The navicular
shortened further by bony resection, yet the joints are all (with attached forefoot) is then placed beneath this protru-
left mobile in the midfoot and hindfoot. The limitation of sion of the talar head, thereby resulting in less overall short-
the osteotomy is that it cannot correct severe cavus because ening of the foot. The vascular supply to the talus is better
a wedge is not resected. Furthermore, rigid hindfoot varus preserved with this approach, but a dorsal prominence from
cannot be corrected. Because the amount of correction the anterior beak of the talus may be obvious and bothersome.
achievable is limited and the osteotomy is technically chal- The Lambrinudi or Hoke triple arthrodesis corrects cavus
lenging, we currently do not use it in our practice. deformity by taking a larger wedge from the talonavicular
Wilcox and Weiner modified the Japas osteotomy.74 A and calcaneocuboid joints dorsally than from the plantar
dome osteotomy with bone resection is made through the surface of the joint.26,29,37 Hindfoot varus is corrected by
base of the fifth metatarsal, the cuboid, and the three cunei- resecting a laterally based wedge from the subtalar joint.
forms. Joint fusions are not performed. The shape of the Fixation with screws or staples is used to maintain the posi-
osteotomy allows greater ability to correct the deformity tion of the foot postoperatively, and a non–weight-bearing
because the apex is gently curved and more mobile. At long- cast is worn.
term follow-up of 139 feet, 76% of patients had satisfactory Although a solid fusion should maintain correction, it has
results.71 Because satisfactory results were only obtained in been found that if muscle imbalance persists, loss of cor-
67% of children younger than 8 years old, the authors rec- rection can occur over time in a cavus foot that is driven
ommended that other methods of correction be considered by a neurologic disease. Tendon transfers may be necessary
in this age group. to balance forces across the foot.39 These transfers can be
Wicart and Seringe performed plantar- based open- staged to follow the arthrodesis, but the decision to include
ing wedge osteotomies of the cuneiforms combined with a tendon transfer in the surgical reconstruction must be
plantar release and a calcaneal osteotomy, with satisfactory made before the triple arthrodesis because it is impossible
results in 64% of 36 feet. Triple arthrodesis was ultimately to test the motor power of many of the muscles to the foot
necessary in 33%.73 We have no experience with this proce- after solid hindfoot fusion.31
dure at present.73 Studies of teens who underwent triple arthrodesis
Finally, as in most complex deformities, correction of tend to show deterioration of function with the passage of
severe pes cavovarus or calcaneocavus has been achieved by time.30 This is particularly true with Charcot-Marie-Tooth
osteotomy and gradual distraction and correction with exter- disease, where long-term studies (21 years after surgery)
nal fixation such as the Ilizarov device (Fig. 19.106)38,49,50 found that almost half the patients have poor results.77
The application of complex foot fixation frames will not Symptoms found on follow-up studies result from failure
be described in detail here. (See the earlier discussion of to achieve or maintain a plantigrade foot in the presence of
the Ilizarov technique for further information.) It should progressive neuropathy. Pseudarthroses of the talonavicular
be emphasized, however, that the bone correction attained joint may occur,43,57 but are not usually painful.40,57 Revi-
is insufficient for long-term satisfactory outcomes in cavus sion surgery to treat pseudarthrosis or suboptimal position
deformity, even after Ilizarov reconstruction, and that soft of fusion is complicated, but possible. Patients with para-
tissue balancing procedures or arthrodesis must be per- lytic deformities tend to have better results after triple
formed to decrease the likelihood of recurrence.38,50 arthrodesis than do those with peripheral neuropathy or
spina bifida.
Triple Arthrodesis. When the amount of deformity pres- We recommend triple arthrodesis in patients in whom
ent in a foot with pes cavus cannot be corrected fully by previous attempts at surgical correction of cavus have
soft tissue release and osteotomy, a triple arthrodesis may failed and in patients with severe, rigid deformities not
be necessary to obtain a plantigrade foot (Fig. 19.107).2,32 amenable to less aggressive procedures. We prefer calca-
This procedure should be the last resort for correction of neal osteotomy for hindfoot varus when the cavus is cor-
pes cavus, particularly when the cause of the deformity is rectable by plantar release. A midfoot osteotomy is used
neuropathic and sensation to the foot is disturbed.55 The when the cavus is rigid, but the hindfoot is not severely
lack of protective sensation in such cases (e.g., in myelo- deformed. When inflexible hindfoot varus is present with
meningocele) leads to destruction and Charcot arthropathy a very stiff cavus deformity, triple arthrodesis offers the
A B
D
FIG. 19.106 (A) Preoperative lateral radiograph of a 15-year-old with a cavus foot secondary to melorheostosis. (B) Due to the severity of
the deformity, gradual correction of the cavus and equinus were performed using a ring external fixator following a posterior release, plantar
fascia release and midfoot osteotomy. (C) Clinical appearance of the foot during the late stages of correction. (D) Lateral radiograph of the
foot prior to removal of the fixator.
A B
FIG. 19.107 (A) Preoperative radiographic appearance of a 17-year-old male patient with a cavus foot secondary to Charcot-Marie-Tooth
disease. The deformity recurred after plantar fascia release and first metatarsal osteotomy, posterior tibialis tenotomy, and the Jones proce-
dure. (B) Triple arthrodesis resulted in a plantigrade foot.
A B C
FIG. 19.108 Technique of “beak” triple arthrodesis for correction of severe pes cavus deformity. Medial and lateral incisions are used for
exposure of the subtalar, talonavicular, and calcaneocuboid joints. With the exception of the head of the talus, all joint surfaces are denuded
of hyaline cartilage, as for an ordinary triple arthrodesis. A dorsally based wedge is removed from the calcaneocuboid joint and navicular
bone. The plantar half or third of the talar head-neck is resected to form a beak. Care is taken to not disturb the soft tissues in the superior
aspect of the talus and anterior part of the ankle joint. (A) Lines of the osteotomy. (B) Area of bone to be resected (pink areas). (C) Final
result demonstrating correction of the cavus deformity. Note that the forefoot is displaced plantarward and locked under the talar beak.
(Redrawn from Siffert RS, Forster RL, Nachamie B. “Beak” triple arthrodesis for correction of severe cavus deformity. Clin Orthop Relat Res.
1966;45:102.)
only possible solution despite long-term studies show-

ing deterioration in results. Unfortunately, in these chil-
dren less aggressive surgery via osteotomy cannot fully
correct the deformity, and all studies of osteotomies
include a percentage of patients who ultimately require
triple arthrodesis after the initial procedure. Great care
must be taken in obtaining the most plantigrade position
possible, because residual deformity will accelerate the
occurrence of symptoms after triple arthrodesis.
Toe Deformities
Hallux Valgus
Children with hallux valgus deformities, commonly
known as bunions, are frequently seen in a busy pedi-
atric orthopaedic practice. However, just as in the adult
population, there is no consensus on how treatment
should proceed in these patients. The deformity itself
consists of lateral deviation of the great toe and medial
angulation of the first metatarsal, with the apex of the
deformity at the first MTP joint. Hallux valgus is usually
FIG. 19.109 Hallux valgus with metatarsus primus varus in an bilateral (Fig. 19.109).
adolescent girl.
Up to 88% of adolescent patients with hallux valgus are

female. Usually there is a strong family history. Pedigree
charts have demonstrated a family history of hallux valgus
in up to 90% of patients with bunions.118 Most patients
seem to inherit the deformity from their mothers.h Multi-
2
generational family histories positive for bunions in female
ancestors suggest a probable sex-linked dominant trait with Plantar insertion
variable penetrance, whereas bunions in males may be due for abductor hallucis
to an autosomal dominant trait or more complex pattern of muscle
inheritance. Flexor hallucis brevis
Adductor muscle (sesamoids
Anatomy laterally displaced)
hallucis muscle,
A complete understanding of the anatomy of the medial side oblique head Oblique orientation
of the forefoot is necessary before discussing the treatment
of juvenile or adolescent hallux valgus. The first metatarsal 1
articulates proximally with the medial cuneiform and, to a
much lesser extent, with the second metatarsal. Although Flexor hallucis
the metatarsocuneiform joint is usually transverse in direc- longus tendon
tion, in some children with hallux valgus, the joint is cres-
centic and sloped medially (Fig. 19.110), which directs the
shaft of the first metatarsal medially.
There is also a common association with metatarsus pri-
mus varus, defined as an intermetatarsal angle between the
first and second rays of 10 degrees or more on a weight-
bearing radiograph. Although it is widely accepted that
many patients with hallux valgus have concomitant meta-
tarsus primus varus, it remains unclear which condition is FIG. 19.110 Pertinent anatomy in hallux valgus. The adductor
primary and which is compensatory.4,11,39,56,78 hallucis is a deforming force pulling the great toe laterally. The in-
Soft tissues around the joint (the medial and lateral collat- sertion of the abductor hallucis is more plantar than normal, which
eral ligaments, the adductor hallucis, and the abductor hallu- leads to muscle imbalance. The sesamoids are held within the flexor
hallucis brevis and are displaced laterally. The flexor hallucis longus
cis) confer the majority of joint stability. The abductor inserts
then migrates laterally across the first metatarsophalangeal joint. θ1,
onto the plantar aspect of the proximal phalanx. The adduc- Intermetatarsal angle; θ2, hallux valgus angle. Note the obliquity of
tor hallucis inserts onto the lateral aspect of the proximal pha- the first metatarsocuneiform joint.
lanx and also anchors the lateral aspect of the plantar plate
and the sesamoids. The plantar surface of the first metatarsal
head has two grooves in which rest the tendons of the flexor is still not normal and expectations may be unrealistically
hallucis brevis enveloping the sesamoids. The flexor hallucis high.
brevis inserts into the base of the proximal phalanx, whereas The clinician should examine the whole patient to look
the flexor hallucis longus inserts into the distal phalanx. for an underlying cause of the hallux valgus. Cerebral
With the development of hallux valgus, the adductor ten- palsy and its spasticity lead to hallux valgus as a result
don becomes a deforming force and the abductor is rendered of increased tone in the adductor hallucis and equinoval-
relatively powerless because of its plantar location. This imbal- gus deformity. Patients with connective tissue diseases,
ance leads to internal rotation of the great toe. The sesamoids such as Ehlers-Danlos syndrome and Marfan syndrome,
translate laterally, leaving their grooves. The extensor hallucis are prone to the development of hallux valgus because
longus and flexor hallucis longus tendons bowstring across the of generalized ligamentous laxity. There is controversy
lateral side of the first MTP joint (see Fig. 19.110).136 whether the presence of flexible flatfoot leads to hal-
lux valgus. Several authors have implicated pes planus
Clinical Features as a risk factor for hallux valgus and for recurrence of
Patients with hallux valgus generally seek care for pain or deformity after surgical correction.62,72,124 Others, how-
cosmetic concerns. The pain is located over the prominent ever, find that the incidence of hallux valgus in patients
head of the first metatarsal or over the medial aspect of the with pes planus does not differ from that of the general
first MTP joint. Rarely, a patient may complain of pain over population.24,79
the plantar sesamoids. Redness, swelling, and an inflamed
bursa may be noted over the MTP joint prominence. Stiff- Radiographic Examination
ness is not usually present. Standing AP and lateral radiographs of the feet are neces-
Shoe wear tends to exacerbate the symptoms. Patients sary to critically assess the hallux valgus deformity. The
will complain about the appearance of their feet. Caution hallux valgus angle is measured by using the technique of
should be exercised before operating on patients without Hardy and Clapham.55 A line is drawn along the shaft of
pain because the cosmetic appearance of the corrected foot the proximal phalanx and another along the shaft of the
first metatarsal; their intersection is the hallux valgus angle
(Fig. 19.111). The normal hallux valgus angle is 16 degrees
h References 15, 24, 46, 52, 91, 124. or less.136
FIG. 19.111 (A) Clinical appearance of

the right foot of an 11-year-old with
idiopathic hallux valgus. (B) Radiograph
shows an intermetatarsal angle of 15 de-
grees. The hallux valgus angle measures
42 degrees. It is the angle formed by a
line drawn along the axis of the proximal
phalanx and a second line drawn along
A B
the shaft of the first metatarsal.
The intermetatarsal angle between the first and second measures between 25 and 40 degrees. In severe deformity,
metatarsals is measured to assess the foot for the presence the hallux valgus angle measures more than 40 degrees.93
of metatarsus primus varus. The normal intermetatarsal
angle is 9 degrees or less. When the intermetatarsal angle Treatment
is increased, the slope of the first metatarsal–medial cunei- Pediatric patients with hallux valgus are strongly encouraged
form joint should be inspected. The metatarsocuneiform to avoid surgical treatment if possible.81 First, shoes should
articulation is normally transverse. An oblique orientation of be sufficiently wide in the toe box to not rub or place lateral
this joint predisposes to metatarsus primus varus and then pressure on the great toe. The use of high-heeled shoes with
to hallux valgus (see Fig. 19.111).53 narrow toe boxes should be specifically discouraged because
The distal metatarsal articular angle (DMAA) is measured such shoes force the toe up onto the narrow dorsal surface
by drawing a line across the articular surface of the meta- of the first metatarsal head and then push it into a valgus
tarsal head at the MTP joint and another line along the first position. Toe spacers and other splints have been tried,52,53
metatarsal shaft. The intersection is the DMAA. The normal but are largely considered ineffective.26,78 Patients with hal-
DMAA is less than 10 degrees.120 It is common in juvenile lux valgus and pes planus may benefit from using an arch
and adolescent patients to find an elevated DMAA indicative support.98 Conservative treatment may be helpful in reliev-
of varus angulation of the distal first metatarsal articulation ing pain but is not expected to correct the deformity.136
(Fig. 19.112). The first MTP joint in these patients is congru- In skeletally immature patients, it is wisest to delay sur-
ous, which becomes clinically important if surgery is contem- gery until the first metatarsal physis has closed. The risk of
plated.23 Likewise, the presence of an incongruous first MTP recurrence is higher in younger patients after surgical correc-
joint should be determined radiographically. tion.11,124,128 Coughlin found that the risk of overcorrection
The length of the first metatarsal relative to the second into hallux varus was highest in patients who had open physes.23
metatarsal should be assessed, measuring the lengths with Before skeletal maturity, there is a theoretical risk of damage to
a reference line drawn from the proximal medial navicular the proximal first metatarsal physis during osteotomy, although
to the proximal lateral cuboid. The first metatarsal may be problems resulting from physeal arrest have not been reported.
relatively long, of similar length, or relatively short in com- Surgical treatment can be divided into six options: distal
parison with the second metatarsal. soft tissue realignment (McBride procedure), distal metatar-
Finally, the physes of the proximal phalanx and the first sal osteotomy (Mitchell and chevron osteotomies), metatar-
metatarsal should be viewed to see whether they remain sal shaft osteotomies (Scarf and Ludloff osteotomies), basilar
open. The first metatarsal physis is located proximally, first metatarsal osteotomy, double metatarsal osteotomies,
unlike the physes of the second through fifth metatarsals. and metatarsal-cuneiform fusion. Selection of the appropriate
This may influence surgical treatment as well. surgical treatment is based upon radiographic measurements
made on the AP radiograph revealing (1) congruency of the
Classification MTP joint, (2) presence or absence of metatarsus primus varus,
Hallux valgus may be classified as mild, moderate, or severe. and (3) severity of the bunion. First, if the MTP joint is incon-
In mild deformities the hallux valgus angle is less than 25 gruous, distal soft tissue realignment must be included in the
degrees. With moderate hallux valgus, the hallux valgus angle surgical procedure to restore more normal joint alignment and
B D
FIG. 19.112 Scarf osteotomy. (A) Standing anteroposterior film of a 15-year-old with Langer-Giedion syndrome and severe hallux valgus.
Note the high distal metatarsal articular angle. (B) Intraoperative dorsal view demonstrates the laterally directed articular surface of the first
metatarsal. (C) Intraoperative lateral view again shows the laterally directed articular surface of the first metatarsal as well as the distal and
longitudinal limbs of the scarf osteotomy. (D) Following lateral translation and internal rotation of the plantar segment of the osteotomy, the
distal metatarsal articular angle and intermetatarsal angle have been corrected. An Akin osteotomy was performed to gain further correction
of the hallux valgus angle.
decrease the risk for arthritis. If the joint is congruous, there the physis of the first metatarsal should not be violated in a
may be no need to open the joint capsule, and correction can skeletally immature patient. Finally, internal fixation is gener-
be achieved by nonarticular osteotomies. Second, if metatarsus ally advised to maintain alignment while osteotomies heal.
primus varus is present, it is crucial to restore a normal inter-
metatarsal angle between the first and second rays to decrease Distal Soft Tissue Realignment (McBride Procedure)
the risk for recurrence. Third, certain procedures are indicated Soft tissue realignment should not be performed in isolation,
for mild hallux valgus and contraindicated in severe cases. but it is often part of the surgical reconstruction of hallux val-
A few caveats must be kept in mind when operating on gus. The subluxed MTP joint is realigned by advancing the
bunions in adolescents. First, the metatarsal head does not usu- medial capsule via a V-Y plasty with the base of the V made
ally have a large protuberant medial eminence. It is not gener- distally. When the lateral soft tissues are addressed, the adduc-
ally necessary to shave off the medial aspect of the metatarsal tor tendon is released or transferred to the lateral aspect of the
head, and when shaving is done, care should be taken to not distal first metatarsal. Removing the lateral sesamoid has fallen
remove too much bone because this can lead to postoperative out of favor.94,95 When performing soft tissue realignment, the
complications such as stiffness and hallux varus.119 Second, surgeon should not treat the medial and lateral aspects of the
first metatarsal head concurrently because the vascular supply MTP joint stiffness have been noted.6,15 Metatarsal shorten-
to the metatarsal head could be injured with resultant AVN. ing has led to the development of second and third metatar-
When soft tissue realignment is performed without sal stress fractures after distal osteotomy.30
osteotomy, recurrence is frequent (50% to 75%).23,58,123 Other studies have reported up to 93% good and excellent
Hallux varus is also known to develop after the McBride results after the Mitchell osteotomy with internal fixation,
procedure.94,122 Soft tissue realignment in isolation has been plantar flexion of the metatarsal head, and efforts to preserve
abandoned in the treatment of juvenile hallux valgus. metatarsal length.45,91,96,144 Postoperative recurrence has been
linked with inadequate correction of the intermetatarsal angle.45
Distal Metatarsal Osteotomy It appears that if care is taken to preserve length, to plantar flex
In most children with hallux valgus, soft tissue realignment the metatarsal head, and to internally fix the fragments, good
is performed in conjunction with osteotomy of the first results can be obtained with the modified Mitchell osteotomy.
metatarsal. Distal osteotomies consist of the Mitchell oste-
otomy and the chevron osteotomy. In the Mitchell osteot- Chevron Osteotomy. A second distal metatarsal osteotomy
omy, the distal aspect of the first metatarsal is osteotomized that has been popular for the treatment of hallux valgus is
transversely, and a second osteotomy that originates on the the chevron osteotomy.6 A V-shaped osteotomy is performed
medial cortex but does not penetrate the lateral cortex is with the apex of the V placed distally. The two limbs are
made a few millimeters distal to the first cut (Fig. 19.113). directed proximally to the dorsal and plantar surfaces of the
This incomplete osteotomy should be located 2 cm proxi- distal first metatarsal. The distal fragment is then translated
mal to the articular surface of the first metatarsal.24 The
distal fragment is then translated laterally with the step cut
hooked over the lateral edge of the proximal fragment. Cur- Medial view
rent opinion favors internal fixation of the osteotomy over
suture fixation through drill holes.13,102 The metatarsal head
should not be dorsiflexed because this will offload the first
metatarsal and cause transfer metatarsalgia.
Mitchell Osteotomy. The Mitchell osteotomy is adequate for

the treatment of mild to moderate hallux valgus. It is contra- Dorsal view
indicated in the presence of a short first metatarsal because it
produces further shortening through its step cut. It is effective
when used in conjunction with medial reefing of the capsule.
Recurrence has been reported in up to 65% of cases.6,15
Loss of fixation was a frequent problem and the use of inter-
nal fixation with Kirschner wires has been recommended. FIG. 19.114 Distal chevron osteotomy of the first metatarsal. A V-
Plantar calluses beneath the second metatarsal as a result of shaped osteotomy based distally is performed. The distal fragment
transfer lesions after shortening of the first metatarsal and is then translated laterally and held with pins or screws.
30°–35°
2 cm
FIG. 19.113 Mitchell’s first metatarsal oste-

otomy. (A) Typical hallux valgus deformity.
Osteotomy is done 2 cm from the meta-
tarsophalangeal joint. (B) Two osteotomies
are made distally in the first metatarsal, the
A B C
more distal of which is incomplete laterally.
The osteotomy is then displaced laterally and
secured with screws or pins. (C) The medial
eminence is cautiously resected, and a V-Y-
capsulorrhaphy is performed at the medial 12°–15°
metatarsophalangeal joint.
A B C D
FIG. 19.115 (A) Severe hallux valgus in a 16-year-old girl. (B) Radiograph showing an increased intermetatarsal angle, lateral translation of
the sesamoids, and an increased hallux valgus angle. The first metatarsocuneiform joint is normal. (C) A crescentic proximal first metatarsal
osteotomy with pin fixation and distal soft tissue realignment was performed. Resection of the medial eminence was slightly excessive. (D)
Follow-up radiograph showing healing with good alignment.
laterally (Fig. 19.114). The osteotomy is usually stable once As in all bunion surgeries, the major complication after
translated but fixation is frequently used in the form of a proximal metatarsal osteotomy is recurrence. Scranton
screw, bioabsorbable peg, or temporary Kirschner wire. Good and Zuckerman found fewer recurrences when closing
results have been published for this osteotomy in up to 85% wedge osteotomies were performed than when open-
of patients, with poor results attributed to technical errors, ing wedge osteotomies were performed.124 The opening
such as loss of position and overzealous resection of the medial wedge increases the length of the first metatarsal and
eminence—producing a gouged metatarsal.57,144 A recurrence increases tissue tension across the capsule of the MTP
rate of 20% has been reported, but metatarsal shortening was joint. Closing wedge osteotomies shorten the metatar-
not a problem.146 sal and may therefore predispose to transfer metatarsal-
AVN can result from distal first metatarsal osteotomies gia, although some surgeons have found this not to be a
and has been described after both the Mitchell and the problem.126 Success has been achieved with a proximal
chevron osteotomies.45,70,115 Circulatory changes can result opening wedge osteotomy with bone grafting using either
from disruption of the nutrient vessels that feed the meta- the resected exostosis or iliac crest.3,88 Because most ado-
tarsal on the lateral side of the metatarsal neck. Combining lescents do not have large exostoses, it is questionable
a distal metatarsal osteotomy with lateral capsular release whether it is best to choose a procedure in which an iliac
places the first dorsal metatarsal artery at risk. Minimal crest graft must be taken if alternatives exist. Metatarsal
periosteal stripping on the lateral side of the metatarsal length is usually preserved with a crescentic osteotomy of
should be allowed during the exposure for a distal osteot- the base of the first metatarsal. By basing the concavity of
omy. When AVN does occur, it is commonly asymptomatic. the crescent proximally and using a crescentic saw blade
to make the cut, Mann and colleagues reported satisfac-
Proximal First Metatarsal Osteotomy tory results in 95% of patients.95 Loss of correction of
Proximal metatarsal osteotomy is used frequently in the the intermetatarsal angle after proximal crescentic first
surgical correction of hallux valgus in adolescents. It metatarsal osteotomy is rare.37
allows good correction of metatarsus primus varus and can
be combined with distal soft tissue realignment without Double Metatarsal Osteotomy
undue risk for AVN. The osteotomy may be an opening Peterson and Newman described a double first metatar-
wedge based medially, a closing wedge with the base lat- sal osteotomy for the treatment of adolescent bunions.116
eral, or most commonly, a crescentic osteotomy without In patients with a congruous, but laterally directed MTP
bone resection. The choice of an opening or closing wedge joint, they recommended a closing, medially based oste-
osteotomy is determined by the preoperative length of the otomy of the distal metatarsal to direct the joint surface
first metatarsal relative to the second metatarsal. When a more medially and a proximal, opening wedge osteotomy
proximal osteotomy is performed, the physis of the first to decrease the intermetatarsal angle. The authors used
metatarsal should be left undisturbed in younger patients. the distal wedge as a bone graft in the proximal osteot-
Fixation with a Steinmann pin, Kirschner wire, or screw is omy. Fixation was achieved with a longitudinal intramed-
advised (Fig. 19.115). ullary pin or alternatively with a plate and screws.5 The
length of the first metatarsal is preserved, and because

the entire procedure is extracapsular, stiffness of the first
MTP joint was not a problem. They recommended this
procedure only for severe hallux valgus deformities in
skeletally mature patients but achieved very good results,
with 1 case of hallux varus occurring in 15 procedures.116
One study reported that MTP joint stiffness may have
led to dissatisfaction in some patients.67 A recent study
comparing distal, proximal, and double first metatarsal
osteotomies for juvenile bunions demonstrated that the
double osteotomies provided the most powerful correc-
tion of all radiographic deformity parameters simultane-
ously though they carried the highest incidence of DMAA
overcorrection.38
Diaphyseal Osteotomies A
The clear advantage of the double osteotomy is the proce-
dure’s ability to maintain joint congruity by correcting an
elevated DMAA while reducing both the hallux valgus and
intermetatarsal angles (see Fig. 19.112). The same goal
can be achieved more efficiently with a single osteotomy
of the metatarsal diaphysis known as a scarf osteotomy.
Though initially described in 192699 the scarf osteotomy
has gained great popularity among adult foot and ankle
surgeons over the last 20 years for the powerful correction
that can be achieved when done properly.7,143 The scarf B
osteotomy is a single zed-shaped osteotomy of the meta-
tarsal created by making a long transverse cut with a dorsal
limb distally and a plantar limb proximally (Fig. 19.116).
The osteotomy allows for translation of the articular sur-
face laterally (to address primus varus and hallux valgus) as
well as rotation of the articular surface medially to address
an elevated DMAA. Fixation is usually achieved with two Removal of
2.0 or 2.7 cortical screws. While the procedure is tech- protruding
nically demanding, significant improvement in the hallux bone
valgus angle, intermetatarsal angle, and the DMAA with
high levels of patient satisfaction have been reported fol-
lowing scarf osteotomies for symptomatic adolescent bun-
ion deformities.42
Metatarsal-Cuneiform Fusion C
Another way to realign the first metatarsal and narrow FIG. 19.116 (A) Scarf osteotomy of the first metatarsal. (B) An
the intermetatarsal distance between the first and sec- increased intermetatarsal angle, hallux valgus angle, and distal
ond rays is to fuse the base of the first metatarsal to the metatarsal articular angle are present prior to correction. (C) Cor-
medial cuneiform, a procedure popularized by Lapidus.85 rection of these deformities is achieved following lateral translation
This procedure is proposed as treatment of hallux val- and medial rotation of the distal osteotomy segment.
gus in the presence of a hypermobile first ray in older
patients who are skeletally mature. Signs of a hypermo-
bile first ray include the presence of a dorsal bunion, a Other Procedures
callus beneath the second metatarsal head, and a rounded The Akin procedure consists of a medial closing wedge
or sloped metatarsocuneiform joint on radiographs.106 proximal phalangeal osteotomy.2 Although it may align the
Often this group of patients will have generalized liga- toe in cases of hallux interphalangeus, it corrects neither
mentous laxity and flatfeet. Modifications of the origi- hallux valgus at the MTP joint nor increased intermetatarsal
nal procedure include the use of internal fixation and angle. While this procedure is not recommended in isolation
the abandonment of resecting bony wedges, which led for cases of adolescent hallux valgus,47 we frequently use it
to relative shortening of the first ray. The first metatar- in conjunction with a scarf osteotomy to provide additional
sal should also be slightly plantar flexed to share in the correction of the hallux valgus angle.
weight-bearing forces with the lesser metatarsals. Distal A novel treatment option unique to the growing foot is
soft tissue realignment of the first MTP joint is usually the use of growth modulation surgery to prevent progres-
performed concomitantly. Good results after the modi- sion of juvenile hallux valgus and potentially effect gradual
fied Lapidus procedure have been achieved in 77% to correction of the deformity. Lateral hemiepiphysiodesis of
91% of patients.20,49,105 the first metatarsal has been shown in one small series to
A B
C
FIG. 19.117 (A) Clinical appearance of the foot of a 16-year-old girl with cerebral palsy. (B) Radiographs of the toe of the right foot show
hallux valgus with an overlapping second toe and medial shift of the sesamoids. (C) Radiograph after first metatarsophalangeal fusion. (D)
Clinical appearance of the feet after surgery.
successfully halt hallux valgus progression in all cases and elevated. We prefer crescentic osteotomy to opening or clos-
achieve significant correction of the intermetatarsal angle ing wedge techniques because it preserves metatarsal length.
and hallux valgus angle in just over 50% of patients.32 These We have performed metatarsocuneiform fusion in selected
results were reported in a juvenile patient population, patients with hypermobility, with satisfactory outcomes.
and the procedure may therefore be most appropriate for
younger children with greater growth potential.
Hallux Valgus Interphalangeus
Finally, fusion of the first MTP joint may be performed
in patients with hallux valgus. Patients who are candidates Hallux valgus interphalangeus is a rare deformity in which
for MTP fusion are those who have underlying neurologic the great toe deviates laterally with the apex of the deformity
conditions, such as cerebral palsy, and those with inflamma- located at the IP joint (Fig. 19.120). It is not associated with
tory arthritis and joint degeneration, such as teenagers with metatarsus primus varus. Symptoms include difficult shoe wear
rheumatoid arthritis (Figs. 19.117 and 19.118).31,43,48,60,66 and pain located over the medial prominence of the great toe.
MTP fusion is not selected as treatment of idiopathic hallux Treatment is by osteotomy of the proximal phalanx.47,126
valgus. MTP fusion is described in further detail in the foot A closing wedge based medially is preferred. Internal fixa-
section of Chapter 31. tion or fixation is performed with threaded Steinmann pins.
Recommended Treatment
Hallux Varus
As many children have congruent but maldirected preopera-
tive MTP joints, our procedure of choice for most patients Hallux varus is described as a medial deviation of the great
with adolescent bunions is a scarf osteotomy with the addition toe at the MTP joint. In children the condition can be either
of an Akin osteotomy for very severe deformities (Fig. 19.119). congenital or acquired, but acquired hallux varus is rare in
A basilar first metatarsal osteotomy with distal soft tissue children; in adults it is usually acquired as a complication of
realignment is often used when the DMAA is not significantly hallux valgus surgery.119
Congenital hallux varus can be divided into three (Fig. 19.121).64 Third, hallux varus is uncommonly part
types. First, hallux varus may occur in isolation with a of an underlying skeletal dysplasia, such as diastrophic
normal first metatarsal. In this form a taut fibrous band dwarfism (see Chapter 36).
runs from the medial side of the great toe to the base of Symptoms from hallux varus are both cosmetic and
the first metatarsal, which leads to medial deviation of related to the ability to wear shoes. Shoe wear is nearly
the hallux. Second, hallux varus may coexist with other impossible with this deviation of the great toe. Addition-
malformations of the foot, such as a longitudinal bracket ally, the deformity is believed to worsen with age.71 For this
epiphysis of the first metatarsal or preaxial polydactyly reason, surgical correction is proposed in infancy.
A B A B
FIG. 19.118 (A) Symptomatic bunion deformity in an adolescent FIG. 19.119 (A) Standing anteroposterior radiograph of a
boy with juvenile polyarticular arthritis. (B) First metatarsophalan- 16-year-old female with a symptomatic bunion deformity. Note the
geal fusion with pin fixation led to relief of symptoms. Concomitant lateral deviation of the distal metatarsal articular surface. (B) Scarf
hindfoot and ankle valgus was also treated. and Akin osteotomies provided correction of all components of the
deformity including the elevated distal metatarsal articular angle.
A B
FIG. 19.120 Bilateral hallux valgus interphalangeus. (A) Clinical appearance. Note the lateral deviation of the distal phalanx of the great toe.
(B) Anteroposterior radiograph of both feet showing lateral subluxation of the interphalangeal joint of the hallux.
A B C
D E F
FIG. 19.121 (A and B) Preoperative clinical and radiographic appearance of a 1-year-old girl’s foot with complex preaxial polydactyly and
hallux varus. (C and D) Appearance at 14 years old. Hallux varus has recurred through the interphalangeal joint. (E) A lateral closing wedge
proximal phalangeal osteotomy was performed. (F) Clinical appearance of the foot after surgery.
Surgery for congenital hallux varus consists of release Hallux Rigidus

of the tight tissues on the medial side of the toe, including
Hallux rigidus is defined as a condition in which there is
the abductor hallucis and the medial capsule of the MTP
restriction of motion at the first MTP joint.127 This condi-
joint. The great toe is usually syndactylized to the second
tion is far more common in older adults, but it can rarely
toe to maintain correction.75 The lateral MTP joint may
occur in adolescents.27 Girls are affected more often than
be reefed, and extensor hallucis brevis rerouting has been
boys, and the disease is frequently bilateral. There may be a
described.41,97 When present, accessory ossicles or bones
positive family history. Several theories regarding the etiol-
should be excised. Temporary fixation of the MTP joint
ogy of hallux rigidus have been proposed, including repeti-
with a Kirschner wire should be done to maintain position
tive trauma, a hypermobile long first ray, osteochondritis
while the tissues heal. Mills and Menelaus reported satis-
dissecans, and plantar contracture.131
factory results at 12.7 years in 12 of 17 feet that had under-
Initial symptoms mainly consist of pain during gait. Dis-
gone surgical correction of congenital hallux varus with the
comfort in the MTP joint is greatest during heel rise because
Farmer and McElvenny procedures described earlier.100
the great toe normally dorsiflexes at this time. Physical
Arthrodesis of the first MTP joint is reserved for those in
examination reveals painful limitation in dorsiflexion of the
whom primary reconstruction fails and painful arthritis
first MTP joint. Dorsiflexion is lost before plantar flexion is.
develops.100
There is often a palpable osteophyte on the dorsum of the
Acquired hallux varus generally occurs in adults. Causes
joint, and swelling may be present. The base of the meta-
include overcorrection from bunion surgeries such as the
tarsal appears more plantar than normal, and the metatarsal
McBride procedure, trauma, and systemic arthritis. Many
head is elevated. Observation of gait shows that patients
authors have reported surgical correction of this deformity
walk on the lateral border of the feet to avoid rolling over
after hallux valgus surgery.36,68,107,129,138
the great toe.
A B
FIG. 19.122 Radiographic (A) and clinical (B) example of postaxial polydactyly with duplication of all phalanges of the small toe, the fifth
metatarsal, and the cuboid.
Radiographs show narrowing of the joint. Lateral plain patients, but bilateral cases need not be symmetric.117 Most
films can demonstrate dorsal osteophytes at the base of the series report a slight male preponderance.16
proximal phalanx and metatarsal head. The exostoses may Many gene mutations have been implicated in causing
become quite large and obscure visualization of the joint polydactyly.8 The homeobox (or Hox) genes have been
itself. Osteochondritic lesions of the metatarsal head can be identified as loci.50 On a molecular level, disruptions in the
seen in young patients.135 apical ectodermal ridge of the limb bud as a result of abnor-
Treatment is initially directed toward symptomatic malities in Bmp4 have been found to result in both preaxial
relief, and nonsteroidal medications are prescribed.127 The and postaxial polydactyly.125
patient should be restricted from participating in sports. The fifth toe is most frequently duplicated, a condi-
Shoe modifications that have been recommended include tion termed postaxial polydactyly (Fig. 19.122). Postaxial
a high toe box to relieve rubbing of the dorsum of the joint, polydactyly accounts for 80% of cases of polydactyly in the
a rigid shank within the sole of the shoe to limit motion of foot.117,141 Preaxial polydactyly is duplication of the great
the MTP joint at heel rise, a stiff insert that extends past toe (Fig. 19.123). The central toes are infrequently dupli-
the MTP joint medially to limit MTP motion, and a rocker cated. Polydactyly is generally an isolated malformation,
bottom shoe to assist in push-off. but there are certain syndromes in which polydactyly is a
Surgical treatment of early hallux rigidus is cheilectomy, feature, among them being Ellis–Van Creveld syndrome, tri-
with resection of the prominent osteophytes, débridement somy 13, tibial hemimelia, and Down syndrome.17,18 Post-
of the joint, and synovectomy.93 If cheilectomy is unsuc- axial duplications are associated with other malformations
cessful, a dorsal closing wedge osteotomy of the proximal in only 11.8% of cases, and preaxial polydactyly is seen as
phalanx may be helpful. In advanced cases, arthrodesis of part of a syndrome in 20% of patients.18,29,77 Polydactyly
the MTP joint is recommended in young, active patients of the hand occurs in 34% of children with polydactyly of
who remain limited in function after other forms of treat- the foot.117
ment have failed.90,127 Polydactyly of the foot can be further divided into two
groups, type A being a well-formed articulated digit and
type B a rudimentary digit (Fig. 19.124).117 Venn-Watson
Polydactyly
classified the metatarsal abnormalities in polydactyly in
Polydactyly is the most common congenital toe deformity, 1976. The metatarsal may be normal with a duplicated dis-
with an incidence of 1.7 per 1000 live births.44 Polydactyly tal phalanx of the toe. It may be a block metatarsal, which is
is seen more frequently in black infants, with an incidence a widened and often shortened metatarsal. The metatarsal
of 13.9 per 1000 live births in blacks and 1.3 per 1000 in can be Y shaped and give rise to two separate articulations
whites.145 A positive family history is present in 30% of with the toes or be T shaped with a less distinct division
patients.117 Polydactyly is bilateral in approximately 50% of between the articular surfaces. The metatarsal head may be
A B
FIG. 19.123 Radiographic (A) and clinical (B) example of preaxial polydactyly with duplication of the great toe.
the foot that will require excision. Generally speaking, the

outer toes are usually amputated in preaxial and postaxial
polydactyly, unless those toes are clearly better developed
than the inner duplicated toes. When the inner toes are
removed, capsular and intermetatarsal ligament repair is
very important.
In postaxial polydactyly, amputation of the most lat-
eral small toe is generally performed via a racquet incision.
Excision of the lateral aspect of a Y-or T-shaped metatarsal
should also be performed through a dorsolateral extension
of the racquet incision. In cases of a widened metatarsal
head without a separate articulation, the lateral prominence
should be shaved down to reduce the bump over the fifth
metatarsal head. Growth arrest of the distal metatarsal phy-
sis has not been a problem.117
Usually the most medial great toe is excised in preax-
ial polydactyly, except when the more lateral great toe is
clearly underdeveloped. In these cases, the medial toe may
be preserved and the lateral great toe amputated. Regard-
less of which toe is removed, careful soft tissue balancing
of the adductor and abductor hallucis insertions should be
performed because hallux varus is a frequent complication
FIG. 19.124 Rudimentary sixth toe in an 18-month-old boy. of preaxial polydactyly surgery.117,141 When preaxial poly-
dactyly is seen with a block first metatarsal, transfer lesions
to the lesser metatarsals can develop as a result of shorten-
widened and may articulate with both proximal phalanges of ing of the first metatarsal relative to the rest of the foot.
the duplicated toes. Finally, the ray may be duplicated alto- Central polydactyly is generally treated by amputation of
gether, with a duplicated metatarsal articulating with the the duplicated central digit and repair of the intermetatarsal
duplicated toe.142 Newer classification systems have been ligament. With growth, the foot may widen.118
proposed specifically for preaxial polydactyly to improve
preoperative evaluation and treatment.14
Syndactyly
Treatment is surgical excision of the duplicated toes in
children approximately 1 year old.109 Surgery improves Congenital webbing of the toes is a common malfor-
cosmesis and facilitates normal shoe fitting. Preoperative mation. The syndactyly may extend all the way to the
radiographs should be obtained to define the anatomy of the tips of the toes (Fig. 19.125), but more commonly it
metatarsal and identify any additional duplications within is incomplete, with only proximal webbing. The most
A B
FIG. 19.125 (A and B) Syndactyly of the first, second, and third toes in a 1-year-old child.
resect the most peripheral toe with preservation of skin

flaps. The skin from the amputated toe can then be used
to cover the remaining toe.2 Patients with syndactyly of the
fourth and fifth toes often have coexisting postaxial poly-
dactyly. Stevens recommends resection of the duplicated
sixth toe without separation of the fourth and fifth toes
because spread between the fourth and fifth toes is likely to
develop over time.131
Complex syndactyly of the toes is seen in patients with
Apert syndrome.22,33 Treatment is difficult because of the
significant deformities, but once again, separation of the
syndactylies is not advised.
Macrodactyly
Macrodactyly is the term given to enlargement of one or
more toes as a result of hyperplasia of both the soft tissue
and bony elements of the digit.1,19,34,59 While some patients
have a positive family history,101 the condition may be idio-
FIG. 19.126 Subtle syndactyly of the second and third toes extend- pathic. In such cases, concomitant involvement of the hands
ing just to the proximal interphalangeal joint on the right. can be seen.73,74,83 Macrodactyly may also be a manifesta-
tion of a generalized syndrome. Proteus syndrome, tuberous
common site is between the second and third toes (Fig. sclerosis, neurofibromatosis, and Klippel-Trénaunay-Weber
19.126), followed by syndactyly of the fourth and fifth syndrome can all have macrodactyly of the toe as an accom-
toes.20 The toenails may be confluent in more severe panying feature.97,112,132,140 The hamartomatous tissue in
cases. the enlarged toe may be lymphatic, vascular, fibrofatty, or
Syndactyly does not lead to functional problems. The nerve related. Differentiation of tissue type can usually be
webbing is simply a cosmetic issue and does not require made with MRI.12,28,35 Recent genetic research has revealed
treatment. Families usually readily agree to nontreatment that affected tissues in some forms of segmental overgrowth
once they are counseled regarding the need for skin grafts have a mutation of PIK3CA gene that is felt to drive tissue
and the inevitable visible scars after release. proliferation. In that regard, some instances of macrodactyly
Syndactyly may be present in combination with poly- are associated with CLOVES syndrome (Congenital Lipo-
dactyly (Fig. 19.127).18,111 In these cases it is advisable to matous Overgrowth, Vascular Malformations, Epidermal
Nevus and Skeleta/Spinal Anomalies) or similar conditions In the second form, the toe or toes are markedly enlarged
on the PIK3CA- Related Overgrowth Spectrum, though relative to the rest of the foot (Fig. 19.128), a condition
confirmation requires identification of a pathologic PKI3CA termed localized gigantism. The phalanges are enlarged,
allele within the involved tissue.76 which leads to deformity and inability to fit into shoes
Two forms of macrodactyly exist. In the first, the toes because of the protruding digit. The metatarsal is involved
are enlarged in proportion to a hypertrophied foot. Shoe in more than 50% of patients.19
wear problems are limited to the possible need to buy two Radiographs reveal the increased length and width of
different-sized shoes. Treatment is not usually necessary. the involved bones. The amount of soft tissue involvement
can be indirectly measured via the metatarsal spread angle,
which is assessed on a weight-bearing AP radiograph of the
foot. The angle formed by the axes of the first and fifth
metatarsals can be compared with the normal foot or be
measured serially over time.19
Surgical treatment can be helpful, with the goal of obtain-
ing a foot that is painless, cosmetically acceptable, and shoe-
able. Reconstruction can be achieved by epiphysiodesis with or
without soft tissue debulking, distal amputation (resection of
phalanges),82 metatarsal or phalangeal diaphyseal shortening,
or ray resection.51 When epiphysiodesis is performed, the toe
remains very big until the ipsilateral toes and the contralateral
foot undergo sufficient growth that the toe does not appear
protuberant.137 Another disadvantage of epiphysiodesis is
that the excessive length may be corrected but the abnormal
width of the toe and foot remains. When one toe is markedly
enlarged, ray resection is recommended because the cosmetic
result is usually acceptable to the parents, multiple surgeries
are not needed, and the foot can be fit into a shoe immedi-
ately after surgery. This procedure has been shown to provide
a measurable reduction in foot size and excellent functional
results, even if with multiple metatarsal involvement.80 The
FIG. 19.127 Preaxial polysyndactyly. exception is when the first ray is involved. Because the first
B
FIG. 19.128 (A–C) Macrodactyly of the second toe in a 2-year-old boy. Second ray resection restored the ability to wear shoes.
ray is functionally important during gait, it should rarely be In patients with Klippel- Trénaunay-
Weber syndrome,
resected. Surgical debulking of the great toe can be performed macrodactyly can be very difficult to treat satisfactorily.
but seldom leads to long-term satisfaction. As a result, macro- In this condition, localized gigantism or hemihypertrophy,
dactyly of the great toe remains a perplexing surgical problem. hemangiomas, and abnormal venous varicosities are found
Though debulking of the hypertrophied toe might seem (Fig. 19.129).97 The pathologic circulation to the toe leaves
initially appealing, studies of the complications after this the child susceptible to wound dehiscence and infection
procedure usually sway the orthopaedic surgeon from after surgery. Tissue enlargement may recur after resection,
performing an isolated debulking. Complications include and in some cases there has been proximal migration of
regrowth of the hypertrophic tissue, stiffness of the MTP hemihypertrophy. While these cases are extremely difficult
and IP joints, delayed wound healing, and excessive bleed- to treat, the identification of the PIK3CA mutation has led
ing from the surgical wounds. to advances in the medical management of this difficult con-
dition. Rapamycin has been shown to effectively inhibit cell
growth resulting from activation of the PIK pathways.113
Varus Fifth Toe

This deformity, also known as congenital digitus minimus
varus, is present at birth and may be genetic in etiology. The
fifth toe is dorsiflexed, adducted, and overlaps the fourth
toe. The fifth toe supinates such that the toenail lies later-
ally (Fig. 19.130). Pain over the dorsum of the fifth toe as a
result of local irritation from wearing shoes tends to develop
over time. The deformity is generally bilateral.
Conservative measures such as buddy taping are not effi-
cacious, and surgical treatment is therefore required in a
symptomatic patient.103,114 Soft tissue reconstruction con-
sists of release of the contracted extensor tendon, dorsal
capsulotomy of the MTP joint, and excision of the abnormal
skin crease between the fourth and fifth toes.61 Temporary
fixation with a smooth K-wire is usually helpful. A dorsal
incision should be avoided because it may contract postoper-
atively and lead to recurrence. The Butler procedure includes
release of the dorsal MTP joint capsule and tenotomy of the
extensor digitorum longus tendon via a circumferential inci-
sion about the base of the toe with dorsal and plantar longi-
tudinal extensions (Figs. 19.131 and 19.132).10,21,136 When
this procedure is performed, care must be taken to identify
and protect the neurovascular bundles. This incision may
FIG. 19.129 Macrodactyly of the first and second toes in a child place the circulation to the toe at risk, particularly in older
with Klippel-Trénaunay-Weber syndrome. children, and is no longer commonly used.
A B
FIG. 19.130 Varus fifth toe. The deform-

ity was treated by excision of the proximal
phalanx of the little toe, extensor tenotomy,
dorsal capsulotomy of the fifth metatar-
sophalangeal joint, and surgical syndactyly
of the fourth and fifth toes. (A) Preopera-
tive photograph. (B and C) Postoperative
photographs. (D) Interpretive diagram. (From
Kelikan H. Hallux Valgus, Allied Deformities of
the Forefoot and Metatarsalgia. Philadelphia: C D
Saunders; 1965:328.)
A B C
D E F
FIG. 19.131 Butler’s operation for an overriding fifth toe. (A and B) A dorsal racquet inci-
sion is made, with a second handle added on the plantar aspect. The plantar handle is
inclined laterally and is a little longer than the dorsal handle. (C) The contracted extensor
tendon to the fifth toe is exposed by elevating the skin flaps. The neurovascular bundles
should be identified and carefully preserved. (D) Sectioning of the extensor tendon and
the dorsomedial part of the capsule of the metatarsophalangeal (MTP) joint. (E) In severe
deformity, the articular surfaces of the MTP joint may be incongruous because of plantar
capsular adhesions. (F) Appearance of the toe before skin closure. It lies freely in normal
alignment without tension. (G) Closure of the wound. Skin sutures securely hold the toe in
correct position. (From Cockin J. Butler’s operation for an overriding fifth toe. J Bone Joint
G
Surg Br. 1968;50:78.)
The McFarland operation consists of extensor tenotomy, Curly Toe

dorsal and medial capsulotomy of the MTP joint, proximal
phalangectomy, and syndactylization of the fourth and fifth This common deformity is characterized by flexion and medial
toes. Tachdjian preferred this procedure,134 but we do not deviation of the PIP joint of the toe. The toe rotates laterally at
have experience with it at our hospital. the DIP joint and underlies the adjacent normal toe. The cause
When there is recurrence after soft tissue release, proxi- of curly toe deformity is congenital tightness of the flexor digi-
mal phalangectomy may be indicated. Amputation of the torum longus and brevis tendons.136 Curly toes are usually pres-
fifth toe is not recommended. ent bilaterally and most commonly affect the third or fourth
FIG. 19.132 (A) Clinical photograph of a

3-year-old with an overriding fifth toe. (B)
Clinical appearance of the toes immediately A B
after the Butler procedure.
A B
FIG. 19.133 (A and B) Curly third, fourth, and fifth toes.
toes (Fig. 19.133). There is often a positive family history con- Extensor tenotomy of the toe that lies dorsally over the
sistent with an autosomal dominant mode of transmission. curly toe should not be performed.
The natural history of curly toe is resolution in 24% of
cases and persistence in the remaining 76%.133 Taping may
Hammer Toe
improve toe position transiently, but the deformity gener-
ally returns once taping is stopped.139 Though a recent pro- The hammer toe deformity consists of flexion of the PIP
spective study of 84 curly toes demonstrated a 94% rate of joint, with or without flexion of the DIP joint. It is simi-
improvement or resolution with taping during the newborn lar to a curly toe except that a hammer toe is not malro-
period, follow-up was relatively short and we have not yet tated. The MTP joint is usually hyperextended. When the
adopted this technique into our practice.130 Symptoms result MTP joint is passively plantar flexed, the PIP joint may be
from abnormal pressure on the adjacent metatarsal heads and extended.131 The most common toe affected is the second
pain in the underlying toe itself, which may develop corns. toe, and the second metatarsal may be longer than nor-
Surgery is recommended for children who have persis- mal.25,136 Although a hammer toe is generally asymptomatic
tent deformity at 6 years old. Flexor-to-extensor tendon in young patients, painful calluses may develop over the PIP
transfer led to satisfactory results in 37 of 43 children with joint with time.
curly toes.9 Simple open flexor tenotomy led to relief of Conservative treatment consisting of stretching and tap-
symptoms and did not result in a hyperextended position ing usually fails. The preferred surgical treatment is flexor
of the toe in 95% of 62 patients treated (Fig. 19.134).121 In tenotomy. Satisfactory results were achieved after flexor
a study comparing the results of flexor-to-extensor transfer tenotomy in 95% of cases.121 The Girdlestone procedure, in
versus flexor tenotomy, similar results were obtained with which the flexor tendon is transferred to the toe extensor,
either procedure.54 Tenotomy of the long and short toe flex- has similar success but is a more extensive procedure, and
ors without tendon transfer is currently recommended by the transfer is probably unnecessary.110 Complete or par-
most authors for the treatment of curly toes.121,131,139 If a tial resection of the proximal phalanx or arthrodesis of the
longitudinal skin incision is made, it should not cross the PIP joint may be necessary in older adolescents with fixed
flexor creases because this may predispose to recurrence. deformities (see Plate 19.7 on page 804).65,108,131
A B
FIG. 19.134 (A) Clinical photograph of a toddler with an asymptomatic curly third toe. (B) Clinical appearance immediately after flexor
tenotomy, third toe.
FIG. 19.135 Mallet toe. (A) Severe.

A B (B) Mild.
In many cases, polydactyly, syndactyly, or tarsal coalition

Mallet Toe
is present.104 It has been postulated that the cause of a lon-
A mallet toe is a deformity consisting of flexion of the DIP gitudinal epiphyseal bracket may be failure of proper fetal
joint as a result of congenital shortening of the flexor digito- formation of the primary ossification centers from the api-
rum longus (Fig. 19.135). As in hammer toe, the second toe is cal ectodermal ridge.87,131 This condition may also be pres-
most commonly involved, and the second ray may be long.136 ent in children with Apert syndrome.
Surgical treatment most commonly consists of tenotomy Treatment is surgical (Video 19.13). Osteotomy alone
of the flexor digitorum longus. Resection of the head of leads to persistent abnormal growth of the aberrant epiphysis.
the middle phalanx may be indicated in older teens with Resection of the abnormal longitudinal section of the epiph-
fixed deformities. Arthrodesis of the DIP joint has also been ysis plus interposition with polymethylmethacrylate or fat
advocated in older patients.131 has been described. The transverse extensions of the epiphy-
sis are preserved both proximally and distally. Mubarak and
colleagues demonstrated improved longitudinal growth in
Longitudinal Epiphyseal Bracket
the first metatarsal after such a procedure.104 They recom-
A longitudinal epiphyseal bracket, also known as a delta pha- mended performing this surgery on a 6-month-old for best
lanx, is a congenital condition in which the epiphysis extends results. At this age, the bracket will not be demonstrable on
along the base of the phalanx, up along the side of the diaphysis, plain radiographs, but it can be seen on MRI.104 In older chil-
and across the distal surface of the phalanx in a U configura- dren with significant varus deformity, consideration should
tion. The deformity was first described and named delta pha- be given to concomitant metatarsal osteotomy for deformity
lanx by Jones in 1964.69 This condition may involve the first correction at the time of bracket excision.
metatarsal or metacarpal as well because they also have proxi-
mally located epiphyses.104 Growth of the abnormal epiphysis
Hair Tourniquet Syndrome
leads to a shortened, wide, and usually triangular or trapezoidal
phalanx. The condition may be present in the hands, feet, or Hair tourniquet syndrome is a common but seldom reported
both63 and may be familial (Fig. 19.136).109 When present in phenomenon that results from circumferential strangulation of
the great toes, a hallux varus deformity develops. a digit, most frequently by a length of human hair. Children
A B
FIG. 19.136 (A) Bracket epiphysis in a girl 2 years, 9 months old that involves the proximal phalanx of the great toe. (B) A radiograph of her
father’s foot shows a similar deformity.
Subungual Exostosis
Subungual exostosis is a benign bone growth located on the
dorsomedial surface of the distal phalanx of the toe, just
beneath the toenail. The great toe is most commonly affected
(Fig. 19.137).84 Patients are typically first seen in the second
decade of life,86 with girls being affected more often than
boys. A posttraumatic etiology has been proposed.40,84 One
series found that 41% of patients with subungual exostoses
recalled a history of trauma to the great toe.142
Symptoms consist of pain and toenail irritation. On
physical examination, the lesion feels firm and is palpable
beneath the toenail. The nail may be tented by the mass.
Pressing on the toenail produces pain. Lateral radiographs
will reveal the mass, and histology reveals mature trabecular
FIG. 19.137 Subungual exostosis of the distal phalanx of the great bone capped by fibrocartilage.131
toe.
Management involves simple excision. Recurrence is
unusual (11%),84,90 and has been linked to incomplete
younger than 2 years old are most commonly affected and removal of the lesion.
present with progressive swelling, redness, and vascular con-
gestion distal to the area of constriction.2,44,89,92 A deep circu-
Glomus Tumor
lar groove in the area of the offending hair is found and when
caught early enough, the hair itself is visible. As swelling pro- A glomus tumor resembles a hemangioma and is present in
gresses, the offending hair may be too deep to visualize. If the the distal phalanx. It is very rarely seen in children. The
tourniquet is not removed in a timely fashion, ischemia, tissue classic triad of symptoms of a glomus tumor is pain, pin-
necrosis, and loss of the digit distal to the area of constriction point tenderness, and cold hypersensitivity. This is usually
occur. a solitary condition, although rarely, patients with multiple
Prompt diagnosis and treatment are critical. Treatment glomus tumors are encountered, which can result in a sig-
consists of immediate removal of the hair. In cases where nificant delay in diagnosis.2 Radiographically, a lytic lesion
a hair tourniquet is suspected but not visible, two dor- that is round and well circumscribed is seen. Histologic
sal peritendinous incisions have been used to extract the examination reveals characteristic intraluminal glomus cells.
hair.44 Toes may take some time to regain normal perfusion Treatment consists of excision of the lesion.2,131
after hair removal and parents should be counseled about
the possibility of partial loss of the toe even after prompt References
intervention. For References, see expertconsult.com.
Plate 19.1 Open Reduction of Dorsolateral Dislocation of the Talocalcaneonavicular Joint

(Congenital Vertical Talus)
Operative Technique (B) Z-plasty lengthening is performed in the anteropos-

terior plane. With a knife, the Achilles tendon is divided
(A) A longitudinal incision is made lateral to the tendo
longitudinally into lateral and medial halves for a distance
calcaneus, beginning at the heel and extending proximally
of 5 to 7 cm. The distal end of the lateral half is detached
for a distance of 7 to 10 cm. The subcutaneous tissue and
from the calcaneus to prevent recurrence of valgus defor-
tendon sheath are divided in line with the skin incision,
mity of the heel; the medial half is divided proximally.
and the wound flaps are retracted to expose the Achilles
When the equinus deformity is not marked, sliding length-
tendon.
ening of the heel cord is performed.
Proximal stem of
incision is medial
Achilles tendon
Skin incision
Line of incision in
Achilles tendon for
Z-plasty lengthening
B
Distal stem of
incision is lateral
Continued on following page

(Congenital Vertical Talus)—cont’d
(C and D) A posterior capsulotomy of the ankle and tendon posteriorly and proceeds dorsally over the navicular
subtalar joint is performed if necessary. The calcaneofibu- just past the extensor tendons.
lar ligament is sectioned. The thickened capsule of the cal- (F and G) The posterior tibial tendon is identified, dis-
caneocuboid joint and the bifurcate ligament are divided sected, and divided at its insertion to the tuberosity of the
through a separate lateral incision. The Cincinnati trans- navicular. The end of the tendon is marked with 0 Mersilene
verse incision is an alternative surgical approach; it is pre- suture for later reattachment. The articular surface of the head
ferred by these authors. of the talus points steeply downward and medially to the sole
(E) The incision is a modified Cincinnati incision that of the foot and is covered by the capsule and ligament. The
passes beneath the medial malleolus just past the Achilles navicular will be found against the dorsal aspect of the neck
Flexor hallucis longus muscle
Divided Achilles tendon

(proximal stump)
Division of posterior
tibiofibular and
talofibular ligaments
Peroneus longus tendon

Calcaneofibular ligament
is sectioned
Division of capsule of
calcaneocuboid joint
and bifurcate ligament
Divided Achilles tendon

C (distal stump)
Incision
Lengthened Achilles tendon
to correct equinus deformity
of hindfoot
Medial malleolus
E Base of first metatarsal
Head of talus
of the talus, where it locks the talus in a vertical position. The distally over the tibionavicular ligament (the anterior portion
pathologic anatomy of the ligaments and capsule is noted, and of the deltoid ligament) and over the dorsal and medial por-
the incisions are planned so that a secure capsuloplasty can be tions of the talonavicular ligament. A cuff of capsule is kept
performed and the talus maintained in its normal anatomic attached to the navicular for plication on completion of sur-
position. Circulation to the talus is another important con- gery. The longitudinal limb of the incision is made over the
sideration; it should be disturbed as little as possible by exer- head and neck of the talus inferiorly.
cising great care and gentleness during dissection. Avascular The articular surface of the head of the talus is identi-
necrosis of the talus is always a potential serious complication fied, and a large threaded Kirschner wire is inserted in its
of open reduction. The plantar calcaneonavicular ligament center. With a skid and the leverage of the Kirschner wire,
is identified and divided distally from its attachment to the the head and neck of the talus are lifted dorsally and the
sustentaculum tali, and 00 Mersilene suture is inserted in its forefoot is manipulated into plantar flexion and inversion
end for later reattachment. The talonavicular articulation is to bring the articular surfaces of the navicular and head of
exposed by a T incision. The transverse limb of the T is made the talus into normal anatomic position.
Anterior tibial tendon
Medial malleolus
Posterior tibial tendon

Flexor digitorum longus tendon
Navicular bone
Vessels
(outlined)
Laciniate ligament
Retraction of fascia
Incision and skin by sutures
Sustentaculum tali

Divided capsule divided and retracted
by whip suture
Bone skid under

head of talus
Talonavicular, deltoid, and
F tibionavicular ligaments cut
Insertion of Kirschner distally and reflected
pin in center of head
of talus
Kirschner wire
rotating talus
dorsally
Bone skid lifting

head of talus
Sustentaculum tali
Abductor hallucis muscle

Plantar calcaneonavicular ligament
G divided distally

(H) The Kirschner wire is drilled retrograde into the navic- and medial aspects by bringing the distal segment over the
ular, cuneiform, and first metatarsal bones to maintain the proximal segments.
reduction. Radiographs of the foot are obtained at this time The plantar calcaneonavicular ligament is sutured under
to verify the reduction. tension to the base of the first metatarsal. To tighten the
In severe cases, the calcaneocuboid and talocalcaneal posterior tibial tendon under the head of the talus, it is
interosseous ligaments may prevent reduction of the lat- advanced distally and sutured to the inferior surface of the
erally subluxated Chopart and subtalar joints. They are first cuneiform.
divided when necessary to allow reduction. In addition, The anterior tibial tendon may be transferred to provide
the extensor hallucis, extensor digitorum longus, and occa- additional dynamic force for maintaining the navicular in
sionally the peroneals may be contracted. They should be correct relation to the talus. The tendon is detached from
Z-lengthened to allow reduction of the foot into plantar its insertion to the medial cuneiform and first metatarsal
flexion. These releases require extension of the incision bone, and dissected free proximally and medially for a dis-
over the dorsum of the foot. tance of 5 cm. It is then redirected to pass along the medial
(I and J) A careful capsuloplasty is very important for aspect of the neck of the talus and beneath the head of the
maintaining the reduction and normal anatomic relation- talus, where it is fixed to the inferior aspects of the talus and
ship of the talus and navicular. The redundant inferior part navicular with 00 Mersilene sutures. Normally, the lower
of the capsule should be tightened by plication and overlap- end of the anterior tibial tendon may be split near its inser-
ping of its free edges. First, the plantar-proximal segment tion. Often the authors leave the attachment to the first
of the T of the capsule is pulled dorsally and distally and metatarsal intact and divide only the insertion to the medial
sutured to the dorsal corner of the inner surface of the dis- cuneiform. The tendon is split (if not normally bifurcated),
tal capsule. Next, the dorsoproximal segment of the T is and the portion to the medial cuneiform bone is transferred
brought plantarward and distally over the plantar-proximal to the head of the talus and the navicular. Sometimes, after
segment of the capsule and sutured to the plantar corner adequate capsuloplasty, the reduction of the talonavicular
on the inner surface of the distal capsule. Interrupted joint is so stable that anterior tibial transfer is not necessary
sutures are then used to tighten the capsule on its plantar to restore support to the head of the talus.
Kirschner wire is drilled

in retrograde fashion into
talus, navicular, medial
cuneiform, and first
metatarsal
Heel is 10° varus

and 15° calcaneus
H
Longitudinal arch is molded by plantar flexing
heads of metatarsals and calcaneus as
drilling of Kirschner wire proceeds
Tight closure of
capsule
Calcaneonavicular ligament
and posterior tibial tendon
advanced distally and sutured
to inferior surface of medial
cuneiform/first metatarsal
Dorsoproximal
segment
Plantar-proximal Abductor
segment hallucis
muscle
Flexor digitorum
longus tendon
Distal segment
I J

(K) The wounds are then closed in routine fashion. The of inversion, and the forefoot in plantar flexion and inver-
Kirschner wire across the talonavicular joint is cut subcu- sion. The longitudinal arch and the heel in the cast are well
taneously. To maintain the normal anatomic relationship molded.
of the os calcis to the talus, a Kirschner wire is inserted
transversely in the os calcis and incorporated into the cast.
Postoperative Care
An alternative method is to pass the wire from the sole of
the foot upward through the calcaneus into the talus. The The Kirschner wires are removed after 6 weeks. The foot
authors prefer the former because it controls the heel in is placed in a walking cast for another 4 to 6 weeks to
the cast and prevents recurrence of both equinus defor- maintain correction. Further splinting is necessary only
mity and eversion of the hindfoot. An above-knee cast is in children with neurologic abnormalities or those with
applied with the knee in 45 degrees of flexion, the ankle arthrogryposis.
in 10 to 15 degrees of dorsiflexion, the heel in 10 degrees
K-wire cut
subcutaneously Normal axis
Medial cuneiform
Navicular
Talus
Calcaneus—10° varus
Plate 19.2 Plantar Fasciotomy
(A) A 1-to 2-cm incision is made over the medial aspect (C) The fascia is isolated on its dorsal and plantar sur-
of the plantar fascia, which is easily palpable in the sole of faces, thus protecting the plantar divisions of the tibial
the foot. nerve. The fascia is then divided with scissors across the
(B) The plantar fascia can be seen within the wound. sole of the foot.
Tibial
nerve
Lateral Medial
plantar plantar nerve
nerve
Plantar fascia
B C
Plate 19.3 Transfer of the Long Toe Extensors to the Heads of the Metatarsals (Jones Transfer)
(A) A longitudinal incision is made on the dorsomedial With small Chandler elevator retractors, the soft tissues
aspect of the first metatarsal from the base of the proximal are retracted. The periosteum is not stripped. Through a
phalanx to the proximal fourth of the metatarsal shaft. The stab wound in the periosteum, a hole is drilled in the center
incision should be placed medial to the extensor hallucis of the first metatarsal head and enlarged to receive the ten-
longus tendon, toward the second metatarsal. The subcuta- don. The extensor hallucis longus tendon is passed through
neous tissue is divided and the wound flaps retracted with the hole in the first metatarsal in a medial-to-lateral direc-
0 silk sutures. The digital nerves and vessels should not be tion and sutured to itself with the forefoot in maximal
injured. dorsiflexion.
(B) The extensor hallucis longus and brevis tendons are (E) The extensor hallucis brevis tendon is then sutured
identified and sectioned at the base of the proximal pha- to the stump of the long toe extensor while holding the toe
lanx. An alternative technique is to leave the insertion of in neutral extension or in 10 degrees of dorsiflexion.
the extensor hallucis brevis tendon intact; the stump of the A similar technique is used to transfer the long extensor
extensor hallucis longus tendon is sutured to the intact bre- tendons of the lesser toes. Longitudinal incisions are made
vis tendon. between the second and third metatarsals and between the
(C) Silk whip sutures (00) are inserted into the ends of fourth and fifth metatarsals. The extensor brevis tendon
the long and short toe extensors. The long toe extensor is of the little toe is either absent or not of adequate size to
dissected free and its sheath is thoroughly excised with a transfer to the stump of the longus.
sharp scalpel as far proximally as possible. The tourniquet is released, and complete hemostasis is
(D) The epiphyseal plate of the first metatarsal is proxi- obtained. The wounds are closed with interrupted sutures.
mal, whereas that of the lateral four metatarsals is distal in
location. The extensor hallucis longus tendon is transferred
Postoperative Care
to the head of the first metatarsal. The long toe extensors
of the lesser toes are transferred to the distal third of the A cast with a sturdy, well-padded toe plate is applied and
metatarsal shafts, with care taken to not disturb the growth worn for 4 to 6 weeks. The plantar aspect of the metatar-
plate. When the patient is older than 10 to 12 years, the sals should be well padded to prevent ulceration. Special
tendons are transferred to the heads of the metatarsals muscle training for the transferred tendons is not required
because by then growth of the foot is almost complete. because this is an in-phase transfer.
Site of division
Incision Extensor hallucis

Extensor hallucis
brevis tendon
longus tendon
A B
Tendon sheath excision
D E
Extensor hallucis longus tendon passed through Extensor hallucis brevis tendon
hole in metatarsal head and sutured to itself sutured to stump of longus tendon
Plate 19.4 Dwyer Lateral Wedge Resection of the Calcaneus for Pes Cavus (see Video 19.12)
The forefoot equinus deformity is corrected first, either by a wedge of the os calcis with its base directed laterally
plantar soft tissue release or by dorsal wedge tarsal resec- is excised. The site of osteotomy is immediately inferior
tion, depending on the age of the patient and the severity and posterior to the peroneus longus tendon. The medial
of the deformity. Closing lateral wedge resection of the os cortex should be left intact. The width of the base of the
calcis is designed to correct a varus deformity of a hindfoot wedge depends on the severity of the varus deformity of
in which the heel is of adequate height and size. the heel.
(D) Next, a Steinmann pin is inserted transversely
across the posterior segment of the calcaneus. The forefoot
Operative Technique
is dorsiflexed to put tension on the Achilles tendon, and
(A) A 5-cm long oblique incision is made on the lateral with the Steinmann pin serving as a lever, the bone gap
aspect of the calcaneus parallel to but 1.5 cm posterior and is closed. The heel should be in 5 degrees of valgus. The
inferior to the peroneus longus tendon. The subcutaneous wound is closed and an above-knee cast is applied, the pin
tissue is divided and the wound flaps are retracted. being incorporated in the cast. The knee is in 45 degrees
(B and C) The peroneal tendons are identified and of flexion.
retracted dorsally and distally. The calcaneofibular
ligament is sectioned, and the periosteum is incised.
Postoperative Care
The lateral surface of the calcaneus is subperiosteally
exposed; with Chandler elevator retractors, the supe- The cast, pin, and sutures are removed in 4 weeks. A
rior and inferior aspects of the calcaneus are partially below-knee walking cast is then applied for an additional
exposed. With a pair of osteotomes of adequate width, 2 weeks, by which time the osteotomy should be healed.
Incision
Bone wedge to be removed
Peroneal tendons
retracted
Lines of osteotomy
Calcaneus
Fibulocalcaneal
ligament divided
B Osteotomes
Wedge of bone
removed
C D Steinmann pin in calcaneus
Plate 19.5 Dorsal Wedge Resection for Pes Cavus
The dorsal aspect of the tarsal bones may be exposed by with the peroneus brevis tendon. The long toe extensors
several means. Cole and Japas make a single dorsal longitu- are retracted medially.
dinal incision approximately 6 to 8 cm long in the midline (C) Next, through the medial wound, the capsule and
of the foot and centered over the midtarsal arch (navicu- periosteum of the navicular and first cuneiform bones are
locuneiform junction). Subcutaneous tissue is divided, and incised and elevated. The soft tissues are retracted dorsally
the long toe extensors are identified and separated. The and plantarward with Chandler elevator retractors. The
plane between the long extensor tendons of the second capsule of the talonavicular joint should not be disturbed.
and third toes is developed, and the extensor digitorum If in doubt, the surgeon should obtain radiographs to iden-
brevis muscle is identified, elevated, and retracted laterally tify the tarsal bones with certainty.
with the peroneus brevis tendon. The anterior tibial tendon (D and E) With osteotomes, a wedge of bone is excised,
and the long extensor tendons of the second and big toes including the naviculocuneiform articulation. The base of
are retracted medially. The periosteum is incised, longitu- the wedge is dorsal, its width depends on the severity of
dinally elevated, and retracted medially and laterally.15,33a the forefoot equinus deformity to be corrected. The wedge
Meary makes two longitudinal incisions, each approxi- osteotomy of the cuboid is completed through the dorso-
mately 5 to 6 cm in length, on the dorsum of the foot. lateral incision.
The medial incision is parallel to the longitudinal axis of (F) The forefoot is then manipulated into dorsiflexion.
the second metatarsal and is centered over the intermedi- If the plantar fascia is contracted, a plantar fasciotomy is
ate cuneiform bone. The extensor hallucis longus tendon, performed. In severe cases the short plantar muscles are
dorsalis pedis vessels, and anterior tibial tendon are iden- also sectioned. The first cuneiform bone should be dor-
tified, dissected free, and retracted medially. The lateral sally displaced over the navicular bone. Two Steinmann
incision is approximately 3 cm long and is centered over pins are inserted to transfix the tarsal osteotomy. The
the cuboid bone. The peroneus brevis is identified and medial pin is inserted into the shaft of the first metatar-
retracted laterally. sal and directed posteriorly through the first cuneiform,
We use two longitudinal incisions, one dorsolateral and across the osteotomy site, and into the navicular and head
the other medial. of the talus. The lateral pin is started posteriorly along
the longitudinal axis of the calcaneus and directed across
the calcaneocuboid joint and into the cuboid and base of
Operative Technique the fifth metatarsal. (Meary uses staples to maintain the
(A and B) Two longitudinal skin incisions are made. The position of the osteotomy.) Radiographs are obtained to
medial incision, approximately 5 cm long, is made over the verify the position of the pins and maintenance of correc-
medial aspect of the navicular and first cuneiform bones in tion of the forefoot equinus deformity. The tourniquet is
the interval between the anterior tibial and posterior tibial released, and complete hemostasis is obtained. The inci-
tendons. The subcutaneous tissue is divided. The anterior sions are closed. The pins are cut subcutaneously, and a
tibial tendon is retracted dorsally; the posterior tibial ten- below-knee cast is applied.
don is partially detached from the tuberosity of the navic-
Postoperative Care
ular and retracted plantarward to expose the medial and
dorsal aspects of the navicular and first cuneiform bones. The foot and leg are immobilized for 6 weeks, at which
The dorsolateral incision, approximately 4 cm long, is cen- time the cast, pins, and sutures are removed. A new
tered over the cuboid bone. The extensor brevis muscle below-knee walking cast is applied and worn for another
is identified, elevated, and retracted distally and laterally 2 to 4 weeks.
Anterior
Posterior
tibial tendon
tibial
tendon
Medial
skin incision
Wedge of bone First cuneiform

to be resected Navicular
Dorsolateral
skin incision
Anterior
tibial tendon
Posterior tibial
tendon
B C
Capsule and periosteum

incised, elevated, and retracted
Navicular
Anterior
tibial
tendon
Removal
of wedge
Posterior
tibial
tendon
D
First cuneiform
Note dorsal displacement

of first cuneiform
over navicular
Manipulation to
correct forefoot equinus
Wedge of
bone excised
E F
Plate 19.6 Japas V-Osteotomy of the Tarsus
Operative Technique are identified, dissected free, and retracted medially. The
osteotomy site is exposed extraperiosteally.
(A) The dorsal aspect of the tarsal bones is exposed
The talonavicular joint is identified next. Caution! Do
through a longitudinal incision 6 to 8 cm long in the mid-
not injure the midtarsal joint and compromise its function.
line of the foot (i.e., between the second and third rays)
If bony landmarks are distorted, radiographs are obtained
and centered over the midtarsal area at the naviculocunei-
for proper orientation. Inadvertent partial ostectomy of the
form junction.
head of the talus will result in aseptic necrosis and traumatic
(B and C) The subcutaneous tissue is divided. The
arthritis. The V line of the osteotomy is marked. Its apex
superficial nerves are isolated and protected. The long
is in the midline of the foot at the height of the arch of the
toe extensor tendons are identified and separated, and
cavus deformity, its medial limb extends to the middle of the
the plane between those of the second and third toes is
medial cuneiform and exits proximal to the cuneiform–first
developed. The extensor digitorum brevis muscle is iden-
metatarsal joint, and its lateral limb extends to the middle of
tified, elevated extraperiosteally, and retracted laterally
the cuboid and emerges proximal to the cuboid–fifth meta-
with the peroneal tendons. The extensor hallucis longus
tarsal joint. Often the V is shallow, shaped more like a dome.
tendon, dorsalis pedis vessels, and anterior tibial tendon
Incision
Incision
Line of V-osteotomy
Cuneiform-
metatarsal joint Note: medial limb of V
extends to midpoint of
medial cuneiform
Extensor hallucis longus

muscle, anterior tibial
tendon, dorsalis pedis
vessels retracted
medially
Extensor
digitorum
brevis and Plantar aponeurosis,
peroneal tendons long plantar ligament,
retracted laterally flexor digitorum brevis muscle,
and quadratus plantae muscle
B C are sectioned
Plate 19.6 Japas V-Osteotomy of the Tarsus—cont’d
Leverage exerted by a curved

periosteal elevator inserted
into osteotomy to facilitate
sliding surface
Forefoot elevated by
depressing base of distal
fragment plantarward
E Distal traction applied on forefoot
(D and E) The osteotomy is begun with an oscillating fragment is depressed plantarward. This maneuver corrects
bone saw and completed with an osteotome. Splintering of the cavus deformity and lengthens the concave plantar sur-
the ends of the medial and lateral limbs should be avoided. face of the foot. The foot is not shortened as it would be by
Next, a curved periosteal elevator is inserted into the oste- resection of a bone wedge, and any abduction or adduction
otomy site, manual traction is applied on the forefoot, and deformity can be corrected if necessary.
with the elevator used as a lever, the base of the distal
Note: pin is directed posteriorly

and laterally to terminate in
lateral part of calcaneus
Steinmann pin inserted through

distal part of first metatarsal
F
(F) Once the desired alignment is achieved, a single correction. The tourniquet is then removed, hemostasis
Steinmann pin is inserted through the distal part of the is achieved, and the wound is closed with interrupted
first metatarsal and directed posteriorly and laterally to sutures. The pin is cut subcutaneously, and a below-knee
terminate in the lateral part of the calcaneus or the cuboid. cast is applied.
Radiographs are obtained to verify the completeness of
Plate 19.7 Correction of Hammer Toe by Resection and Arthrodesis of the Proximal Interphalangeal Joint
Operative Technique (E and F) The proximal and middle phalanges are held
together by internal fixation with a Kirschner wire that is
(A1 and A2) A 3-to 4-cm longitudinal incision is made
inserted retrogradely. The Kirschner wire should not cross
over the dorsal aspect of the proximal interphalangeal
the metatarsophalangeal joint. The cancellous bony surfaces
(PIP) joint parallel to and at the lateral border of the
of the middle and proximal phalanges should be apposed, and
extensor digitorum longus tendon. The subcutaneous tis-
the rotational alignment should be correct. The capsule is
sue is divided and the skin flaps are retracted.
resutured tightly by reefing. The wound is closed in a routine
(B) The long extensor tendon is split and retracted to
manner. The end of the Kirschner wire is bent 90 degrees
expose the capsule of the PIP joint. The digital vessels and
and cut, with 0.5 cm of wire left protruding through the skin.
nerves are protected from injury. A transverse incision
is made in the capsule, and the joint surfaces are widely
Postoperative Care
exposed.
(C and D) With a rongeur, wedges of bone based dor- A below-knee walking cast is applied with a band of cast-
sally are resected from the head of the proximal phalanx ing material protecting the toe. The wire and cast are
and the base of the middle phalanx. Enough bone should removed in 6 weeks, when radiographs show fusion of the
be removed to allow correction of the deformity. interphalangeal joint.
Extensor digitorum longus tendon
A2
Incision
A1
Line of incision
of capsule
Capsule divided and reflected
Wedges of bone
to be removed
B C
Extensor digitorum longus

tendon is split
Internal fixation with

Kirschner wire
Anterior view showing

Bones aligned interphalangeal fusion
E F
Capsule repaired of second toe
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Disorders of The Foot

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Disorders of The Foot

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CHAPTER 19

Disorders of the Foot Anthony I. Riccio

and the intermediate cuneiform at 3 years. The navicular ossifies

bringing into question the traumatic etiology of these ossicles.17

Os vesalianum, ? Os fibulare, 10%

FIG. 19.8 Os trigonum in a 12-­year-­old child. Note also the ac-

FIG. 19.9 Fracture of a fused os trigonum.

sports. The pain is alleviated by wearing less constraining

anatomic repair of the tendon is the procedure of choice for

center. At maturity, the navicular is supplied by five or six

FIG. 19.17 Lateral radiograph obtained 1 year later showing recon-

the disorder. Reports indicate that symptoms resolve faster

Box 19.1 Characteristic Features of Metatarsus

and creating a skewfoot deformity. Napiontek and others

It should again be emphasized that no permanent change

Arthroereisis. Arthroereisis of the subtalar joint, using a

FIG. 19.32 Lateral radiograph of a subtalar arthroereisis screw,

Tibialis posterior muscle

Head of talus First cuneiform

FIG. 19.36 Medial displacement osteoto-

Superior talus Anterior talus Medial talus

A Normal Clubfoot B Normal Clubfoot C Normal Clubfoot

Assessment of Clubfoot by Severity

Sagittal plane evaluation of equinus Frontal plane evaluation of varus

Reducibility Points Other parameters Points

90° to 45° 4 Posterior crease 1

Classification grade Type Frequency (%) Score

Equinus: 2 points Varus deviations, reducibility to 00: 2 points

Derotation of calcaneopedal block: reducibility to –100: 1 points Adduction of forefoot,

tive approach to the treatment of clubfeet.152 Similar to Kite,

has confirmed that children with recurrent deformity were

a program because of excessive scarring and recurrent fibro-

calcaneonavicular impingement preventing midfoot abduc-

B FIG. 19.52 (A) Posterolateral corner. The peroneal tendons are

FIG. 19.55 Replacement of the lengthened flexor hallucis longus

FIG. 19.54 Incomplete correction of the midfoot despite calcaneo-

FIG. 19.59 Dorsal bunion correction. (A) The

Skin incision centered over

Evans Cuboid decancellation

Incision Graft being placed in

FIG. 19.64 Triple arthrodesis for clubfoot. The

Plantar calcaneonavicular ligament Tibia

Dorsal talonavicular ligament Deltoid ligament

First cuneiform Calcaneus

The term oblique talus is given to an intermediate defor- Treatment

Posterior talofibular ligament

Calcaneofibular ligament Calcaneocuboid ligament Calcaneofibular ligament

Anterior tibial muscle Soleus muscle

Posterior tibial muscle

Flexor hallucis longus

the midfoot is “reduced” to the vertically oriented talus and

peroneals are only mildly contracted, they should not be

FIG. 19.78 Complete medial talocalcaneal bridge in the foot of a A

particularly running on uneven surfaces. A history of fre- B

The subtalar joint is a complex consisting of three parts:

FIG. 19.82 Massive tarsal coali-

FIG. 19.84 Tarsal coalition (ar-

FIG. 19.85 Calcaneonavicular coalition. (A)

FIG. 19.86 “Anteater’s nose” associated with a calcaneonavicular

of bone wax into the bony interstices at the areas of resec-

FIG. 19.91 Cavus deformity of the foot. (A)

FIG. 19.92 (A and B) Pes cavovarus. Note the

the abductor digiti quinti, the interossei, the posterior tibi-

FIG. 19.8 Os trigonum in a 12-year-old child. Note also the ac-

STANDING such as Charcot-Marie-Tooth disease. If parents report foot

only possible solution despite long-term studies show-

Operative Technique (B) Z-plasty lengthening is performed in the anteropos-

Plate 19.6 Japas V-Osteotomy of the Tarsus

Plate 19.6 Japas V-Osteotomy of the Tarsus—cont’d