5.

Case Report

Cavus Foot Correction Using a Full

Percutaneous Procedure: A Case
Series

Rodrigo Schroll Astolfi, José Victor de Vasconcelos Coelho, Henrique César Temóteo Ribeiro ,
Alexandre Leme Godoy dos Santos and José A. Dias Leite

Special Issue
Advances in Foot Disorders and Its Treatment
Edited by
Prof. Dr. Gabriel Domínguez-Maldonado

https://doi.org/10.3390/ijerph181910089
 International Journal of
Environmental Research
and Public Health
Case Report
Cavus Foot Correction Using a Full Percutaneous Procedure:
A Case Series
Rodrigo Schroll Astolfi *, José Victor de Vasconcelos Coelho, Henrique César Temóteo Ribeiro,
Alexandre Leme Godoy dos Santos and José A. Dias Leite






Citation: Astolfi, R.S.; de
Vasconcelos Coelho, J.V.; Ribeiro,
H.C.T.; Santos, A.L.G.d.; Leite, J.A.D.
Cavus Foot Correction Using a
Full Percutaneous Procedure:
A Case Series. Int. J. Environ. Res.
Public Health 2021, 18, 10089.
https://doi.org/10.3390/
ijerph181910089
Academic Editors: Joshua F. Yarrow
and Gabriel Domínguez-Maldonado
Received: 15 August 2021
Accepted: 22 September 2021
Published: 25 September 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 10089. https://doi.org/10.3390/ijerph181910089
Department of Surgery, Faculty of Medicine, Campus Porangabussu, Federal Universiy of Ceará,
Fortaleza 60430-160, Brazil; jose_victor97@alu.ufc.br (J.V.d.V.C.); henriqueribeiro@ufc.br (H.C.T.R.);
alexandrelemegodoy@gmail.com (A.L.G.d.S.); josealberto_leite@hotmail.com (J.A.D.L.)
* Correspondence: dr.rodrigoastolfi@gmail.com; Tel.: +55-85-986755960
Abstract: Cavus foot is a tri-planar deformity that requires correction in several bones and soft tissue.
Minimally invasive surgeries are less aggressive, faster and easier to recover from. Here, we describe
the initial results of a technique for percutaneous cavus foot correction. The procedure consists of
calcaneal dorsal/lateral closing wedge osteotomy (with fixation), cuboid, medial cuneiform and
first metatarsal closing wedge osteotomy (without fixation), and plantar fascia and tibialis posterior
tenotomy with the patient in the prone position. Immediate weight bearing is permitted. Twenty
patients were selected to undergo the procedure. The mean follow-up was 4.2 months and mean age
42.3 years. Eight of the 20 patients were submitted to cuboid and first metatarsal osteotomy, and 12
(60%) only calcaneal osteotomy. The median time for complete bone healing was 2.2 months. No
wound complications were observed. No cases of non-consolidation of the cuboid or first metatarsal
osteotomies were detected. The most common complication was sural nerve paresthesia. This is the
first description of cavus foot correction using a minimally invasive technique. Complete bone healing
is obtained even with immediate weight bearing and without cuboid and first metatarsal fixation.
Keywords: cavus foot; hindfoot osteotomy; minimally invasive
1. Introduction
Cavus foot deformity is a common pathology in foot and ankle surgery [1] and
although it has long been treated by orthopedic surgeons, since it is one of the most
prominent deformities in poliomyelitis, numerous doubts and less-than-perfect surgical
results persist [2,3]. Cavus foot repercussions include Achilles tendinosis, plantar pressure
point formation and ankle instability [2,4,5].
The surgical treatment for cavus foot involves calcaneal valgization osteotomy, as
described by Dwyer [6,7], dorsal wedge osteotomies [8–10], accessory procedures such
as cuboid closing wedge osteotomy, first metatarsal or medial cuneiform dorsal closing
wedge and soft tissue elongation [8,11,12]. Bone osteotomies are believed to be insufficient
for severe cases and some professionals advocate the use of hindfoot arthrodesis even in
healthy cartilage [13].
The open techniques are well described, and minimally invasive surgery (MIS) tech-
niques have become increasingly popular in the last few years [10,11]. Some of the potential
advantages of percutaneous techniques include faster procedures, because the soft tissue is
left intact, low cost, fewer soft tissue complications, and less fixation, since weight-bearing
naturally reduces longitudinal arch stiffness [10,11,14].
A number of percutaneous calcaneus osteotomies have been reported [10,11], but we
were unable to find any articles describing three-dimensional deformity correction using
percutaneous procedures. This article describes a technique for cavus foot MIS correction
and presents some initial results.
https://www.mdpi.com/journal/ijerph
 percutaneous procedures. This article describes a technique for cavus foot MIS correcti
and presents some initial results.

2. Materials
Int. J. Environ. Res. Public Health 2021, 18, 10089 2 of 7
Patients attended by to the Foot and Ankle Group of Federal University of Cea
were requested to participate in this study, twenty patients who subsequently met t
inclusion criteria underwent minimally invasive surgery for cavus foot correcti
2. Materials
between 07/2019 and 02/2020.
Patients attended by to theInclusion criteria
Foot and Ankle were
Group Meary`s
of Federal angle 
University of 0Ceará
or calcaneal
were pit
anglerequested
 30 intopatients
participatewith
in thispain
study,caused by misaligned
twenty patients feet. All
who subsequently metpatients assigned t
the inclusion
institutional informedminimally
criteria underwent consentinvasive
as recommend
surgery forby thefoot
cavus Declaration of Helsinki.
correction between July 2019
and February 2020. Inclusion criteria were Meary’s angle > 0 or calcaneal pitch angle >
Were considered pain due to the misalignment: pain on the lateral side of the fo
30◦ in patients with pain caused by misaligned feet. All patients assigned the institutional
specially at cuboid
informed consentand fifth metatarsal
as recommend base; pain
by the Declaration of on the antero-lateral side of the ank
Helsinki.
pain on Achilles tendon insertion
Were considered pain due todue to high calcaneal
the misalignment: pain pitch
on the and pain
lateral sideonof the foot pressu
the foot,
points associated with callosity.
specially at cuboid and fifth metatarsal base; pain on the antero-lateral side of the ankle,
pain on Achilles tendon insertion due to high calcaneal pitch and pain on the foot pressure
points associated with callosity.
Technique Description
The procedure
Technique Descriptionis performed with the patient in the prone position with one scia
nerve block. Two k-wires
The procedure are placed
is performed with(Figure 1A–C)
the patient in thepercutaneously
prone position withlateral to the bone
one sciatic
nerve block. Two k-wires are placed (Figure 1A–C) percutaneously lateral to the bone
that the burr passage becomes limited by the k-wires, in the safe zone determined
so that the burr passage becomes limited by the k-wires, in the safe zone determined by
Durston et al.
Durston et [15], ininorder
al. [15], todetermine
order to determine the amount
the amount of boneof bone
that that
has to has to be
be removed for removed
the f
the lateral/dorsal closing
lateral/dorsal closing wedge.
wedge. SinceSince x-ray images
x-ray images arethe
are essential, essential, the surgeon
surgeon must be aware must
awarethat
that
thethe perfect
perfect lateral
lateral view
view of of the calcaneus
the calcaneus is not the is not view
lateral the lateral viewfoot.
of the cavus of the cavus fo

Figure 1. (A) The1. entire

Figure (A) Theprocedure can be
entire procedure canperformed
be performed with
withthe patientinin
the patient thethe prone
prone position
position and C-arm
and C-arm position.position.
(B) Two (B) Two
k-wires arek-wires
positioned in a “v”inshape,
are positioned mostmost
a “v” shape, of the proximal
of the proximalk-wire
k-wire isisplaced
placed at the
at the limitlimit
of theof“safe
the zone”,
“safe zone”,
which iswhich
halfwayis halfway
between thebetween the calcaneal spur and fibula, and the position of the distal k-wire depends on the amount of correction needed. needed.
calcaneal spur and fibula, and the position of the distal k-wire depends on the amount of correction
Note that Note
the that
lateral calcaneal
the lateral calcanealview
view is anoblique
is an oblique
view view of the
of the ankle. (C) ankle. (C) are
How k-wires How k-wires
positioned in aare
X-raypositioned
view, showingin a X-ray
view,showing how
how the "v"the "v"has
shape shape haslike
to looks to in
looks like in pratice.
pratice.

A lateral portal is made, a 4.3 mm burr inserted (using a self-irrigated low-speed

A lateral portal is made, a 4.3 mm burr inserted (using a self-irrigated low-spe
high-torque drill), and a windshield wiper movement performed between both k-wires
high-torque
to removedrill), and
all the a windshield
lateral, wiper bone.
dorsal and plantar movement performed
The movement between
should both k-wires
be continuous
remove all the
to allow lateral,
a more dorsal
uniform andofplantar
amount bone.
bone to be The movement
removed. should
More dorsal bone be continuous
is removed if
allow a more uniform amount of bone to be removed. More dorsal bone is removed if t
the cavus is due to high calcaneal pitch, and more lateral bone if the varus aspect is more
cavusimportant
is due to (Figure 2). A 20 mm/2.2 mm Shannon burr is inserted and the medial cortical
high calcaneal pitch, and more lateral bone if the varus aspect is mo
bone transected. Screw fixation parallels open techniques and the reduction can be verified
important (Figure 2).axial
in both lateral and A 20views.
mm/2.2 mm Shannon burr is inserted and the medial corti
bone transected. Screw fixation parallels open techniques and the reduction can
verified in both lateral and axial views.
 Int. J. Environ. Res. Public Health 2021, 18, 10089 3 of 7
Int. J. Environ. Res. Public Health 2021, 18, x 3 of 7

(a) (b)
Figure 2. (a) Dorsal base closing wedge resected according to preoperative planning. (b) Dorsal base wedge cl
(a) (b)
Figure 2.
Figure 2. (a)
(a) Dorsal
Dorsal base Another
base closing
closing wedge portal
wedge resected
resected is made
according
according under aplanning.
to preoperative
to preoperative fluoroscopic
planning. view,
(b) Dorsal
(b) Dorsal a lateral
base wedge
base wedge closing
closure.
closure. wedg
at theAnother
centerportal
Another of the
portal is cuboid
made
is made (Figure
under
under 3), and
aa fluoroscopic
fluoroscopic a punctual
view,
view, aa lateral incision
lateral closing
closing wedgemade
wedge lateral to
performed
performed
site
at of center
at the
the the superficial
center of the
of cuboidperoneal
the cuboid 3), nerve.
(Figure 3),
(Figure Next,incision
and aa punctual
and punctual the burr
incision made
made is lateral
inserted
lateral to perpendicularl
to the
the expected
expected
to avoid dissection or the passage of the burr through the soft tissue
site
site of
of the
the superficial
superficial peroneal
peroneal nerve.
nerve. Next,
Next, the
the burr
burr is
is inserted
inserted perpendicularly
perpendicularly to
to in this are
the bone
the bone
to avoid dissection or the passage of the burr through the soft tissue in this area, given that
to avoid dissection or the passage of the burr through the soft tissue in this area, given that
numerous unpredictable
numerous unpredictable branches
branches of the superficial
of the superficial peroneal nerve peroneal nerve
present. Once
are present. are prese
Once the
the
burr
burrisis inserted into
inserted into the bone,
the bone, the windshield
the windshield movement
wiper movement wiper movement
is repeated.
is repeated. Forced
Forcedis forefoot
repeated. Fo
forefoot
abduction completes
abduction completes
completes the the osteotomy,
the osteotomy,
osteotomy, which
which doeswhich
does not doesinclude
notusually
usually not
include usually
fixation.include fixation.
fixation.

Figure 3. Cuboid view with the patient in the prone position.

With the patient still in the prone position, the first metatarsal base and/or medial
cuneiform dorsal closing wedge can be performed with a 12/2.2 mm Shannon burr, always
Figure
making
Figure 3.incomplete
3. an Cuboid
Cuboid view thewith
osteotomy,
view with the
patientalso patient
without
in the in the prone
fixation.
prone position. position.
For this procedure, an additional
regional block may be necessary.
With
A softthe patient
tissue still in the
procedure suchprone position, the
as fasciotomy first metatarsal
or flexor digitorumbase and/or
brevis medial
tenotomy is
With
cuneiform the
dorsal patient
closing still
wedge in
can the
be prone
performed position,
with a 12/2.2the
mm first
Shannon
performed at calcaneal insertion. In severe cases, tibialis posterior tenotomy is executed
metatarsal
burr, alwaysbase an
cuneiform
making
only at an dorsal
navicularclosing
theincomplete osteotomy,
insertion,wedge canthe be
also without
leaving performed
fixation.
tibialis For thiswith
posterior aligament
procedure,
spring 12/2.2 mm Shannon
an additional
insertion
making an incomplete osteotomy, also without fixation. For this procedure, a
regional
intact. block may
Weight-bearing be necessary.
is allowed immediately.
A soft tissue procedure such as fasciotomy or flexor digitorum brevis tenotomy is
regional
performed block may be necessary.
3. Results at calcaneal insertion. In severe cases, tibialis posterior tenotomy is executed
onlyA soft
at the tissueinsertion,
navicular procedure leavingsuch as fasciotomy
the tibialis posterior springorligament
flexor insertion
digitorumintact.brevis
Mean patient age and BMI were 42.3 years (SD 35.54–48.45) and 24.2 (SD 22.33–25.66),
performed
respectively. at calcaneal
follow-upinsertion.
time was 4.2In
Weight-bearing is allowed immediately.
Mean severe
months (SD cases,
3.4–4.5). tibialis posterior
Eight of the 20 patientstenotomy
(n
only
= 20),at theunderwent
(40%) navicular insertion,
cuboid leavingosteotomy,
and first metatarsal the tibialisand 12 posterior
(60%) only spring
calcaneal ligame
intact. Weight-bearing is allowed immediately.

3. Results
Int.
Int. J.
J. Environ.
Environ. Res.
Res. Public
Public Health 2021, 18,
Health 2021, 18, x10089 44of
of 77
Int. J. Environ. Res. Public Health 2021, 18, x 4 of 7

osteotomy.
3. Results The median time for complete bone healing was 2.2 months (SD 1.9–2.6). Mean
osteotomy. The median time for complete bone healing was 2.2 months (SD 1.9–2.6). Mean
hindfoot
Mean varus correction
patient age and was BMI 23.4°
were (SD
42.3 21.3°–25.6°).
years Twelve patients
(SD 35.54–48.45) (60%) complained
hindfoot varus correction was 23.4° (SD 21.3°–25.6°). Twelveand 24.2
patients (SD 22.33–25.66),
(60%) complained
of sural nerve
respectively. pain,
Mean 75% of
follow-up whom recovered completely, the other three (25%)20kept one
of sural nerve pain, 75% of time
whom was 4.2 months
recovered (SD 3.4–4.5).
completely, Eightthree
the other of the(25%)patients
kept one
small hypoesthesic
= 20), hypoesthesic
(n small rea
(40%) underwent on the nerve
cuboid territory.
and territory.
first metatarsal osteotomy, and 12 (60%) only cal-
rea on the nerve
canealOne patient with
osteotomy. The amedian
Charcot sequela
time for deformity
complete evolved
bone healing to was
delayed consolidation
2.2 months with
(SD 1.9–2.6).
One patient with a Charcot sequela◦ deformity evolved to delayed consolidation with
screw
Mean fracture (Figure
hindfoot varus 4). Three was
correction cases23.4
(15%) (SDevolved
21.3 to incomplete
◦ –25.6 ◦ ). Twelve correction,
patients but com-
(60%) only
screw fracture (Figure 4). Three cases (15%) evolved to incomplete correction, but only
one (33.33%)
plained required
of sural additional
nerve pain, 75% ofsurgery. These incomplete
whom recovered completely, correction
the othercases
threebelonged
(25%) keptto
one (33.33%) required additional surgery. These incomplete correction cases belonged to
the initial cases. No wound complications
one small hypoesthesic rea on the nerve territory. or non-consolidation of the cuboid bone or first
the initial cases. No wound complications or non-consolidation of the cuboid bone or first
metatarsal osteotomies
One patient with a were
Charcotobserved.
sequela(Figure 5). evolved to delayed consolidation with
deformity
metatarsal osteotomies were observed. (Figure 5).
screw Patients’
fractureinitial
(Figure complaints
4). Threeresolved
cases (15%)completely,
evolved as to the median follow
incomplete up time
correction, but until
only
Patients’ initial complaints resolved completely, as the median follow up time until
this
one report
(33.33%) was small (4.2
required months) surgery.
additional some unspecific complaintscorrection
These incomplete related tocases
the rehabilitation
belonged to
this report was small (4.2 months) some unspecific complaints related to the rehabilitation
program
the initialwere
cases.still
No present especially muscular
wound complications pain on long of
or non-consolidation distance walks
the cuboid andornon-
bone first
program were still present especially muscular pain on long distance walks and non-
painful
metatarsallimp.osteotomies were observed. (Figure 5).
painful limp.

Figure 4. Delayed calcaneal consolidation in a Charcot sequela deformity.

Figure
Figure 4. Delayed
4. Delayed calcaneal
calcaneal consolidation
consolidation in ainCharcot
a Charcot sequela
sequela deformity.
deformity.

(A) (B)
(A) (B)
Figure 5. (A) We had full consolidation of cuboid and first metatarsal bones without fixation and with immediate weight
Figure
bearing.
Figure 5. Clinical
5.(B)
(A) (A)
WeWehadhad
fullfull consolidation
improvement of cuboid
of hindfoot
consolidation andand
firstfirst
alingment.
of cuboid metatarsal
metatarsal bones
bones without
without fixation
fixation andand with
with immediate
immediate weight
weight
bearing. (B) Clinical improvement of hindfoot alingment.
bearing. (B) Clinical improvement of hindfoot alingment.
Int. J. Environ. Res. Public Health 2021, 18, 10089 5 of 7

Patients’ initial complaints resolved completely, as the median follow up time until
this report was small (4.2 months) some unspecific complaints related to the rehabilitation
program were still present especially muscular pain on long distance walks and non-
painful limp.

4. Discussion
Cavus foot deformities occur in several planes and must be corrected in different
bones in a multiplanar fashion. Traditional techniques are time-consuming and, in many
cases, require changing the patient’s position on the operating table. Here, we presented
a number of modifications to the usual descriptions of MIS, which allow the correction
and good x-ray control in both views in only one position. The patient is moved from the
transport trolley to the operating table in the prone position, where the sciatic block is
made and the surgery performed immediately.
One of the principles of minimally invasive techniques is to preserve soft tissue since
it can provide some stability to osteotomies and promote faster consolidation. Based on
this principle, less fixation and immediate weight-bearing can be safely performed [14,15].
Immediate weight-bearing and the fact that the entire procedure can be performed with a
regional block make it available for patients with severe comorbidities.
The safety of the lateral approach and the use of a Shannon burr has been well
established [15]. The most widely used in dangerous structures are the medial calcaneal
branch of the tibial nerve and posterior branches of the sural nerve. In cadaveric studies,
although osteotomy crosses the nerve passages, soft tissue structures such as the quadratus
plantaris protect them [15]. We believe that the high number of sural nerve complications,
most of which are temporary, is due to overheating of the burr. Despite being irrigated
throughout the procedure, it may still overheat because a large amount of bone must be
removed from the same site.
The percutaneous approach requires a different set of surgical skills, and x-ray expo-
sure is greater than in open techniques [15]. The learning curve was noteworthy, since the
latest cases were all totally corrected, and procedure time declined from 1 hr 40 min to
40 min, reducing the x-ray exposition from 74 x-ray views to about 25 in the latest cases.
Our first impression was that only non-severe cases could be addressed with MIS, but this
is not the case. The most difficult cases are large feet with severe deformities. Making the
closing wedge both lateral and dorsal allowed better correction in severe cases. Time to
consolidation and amount of correction are similar to the ones commonly described for
open techniques [16–18].
Cuboid osteotomies or opening wedge osteotomies of the medial cuneiform are
important in cavus foot correction [1] because the forefoot adducts and rotates internally
with the hindfoot varus [19,20]. Given that cuboid fractures usually evolve to shortening
of the lateral column and that cuboid pseudarthrosis are not common, the percutaneous
lateral closing wedge is expected to exhibit good consolidation [21]. The cuboid wedge is
easily performed in the prone position and as expected, we had no problem with the eight
cases that did not use fixation.
We prefer to do two incomplete dorsal closing wedge osteotomies with the thinner
12/2.2 mm Shannon burr in the first metatarsal and medial cuneiform rather than large
wedges in only one bone, due to the lower risk for plantar cortical fracture and faster
healing of these osteotomies.
Soft tissue procedures are carried out in most cases, with percutaneous release at the
calcaneal insertion of the plantar fascia and flexor digitorum brevis, and in cases of more
severe deformity, percutaneous tenotomy of the tibialis posterior only at the navicular
insertion, maintaining the spring ligament insertion, in order to lengthen the tendon
without totally transecting it. Soft tissue lengthening is commonly described as crucial to
good correction [14].
Int. J. Environ. Res. Public Health 2021, 18, 10089 6 of 7

This report has several limitations; we reported a small group of patients with a
small follow up time and no standardized pre and post operatory quality of life score
was applied.

5. Conclusions
To the best of our knowledge, this is the first description of successful MIS correction
of cavus foot deformity and its initial results. Operating in the prone position made it
possible to perform calcaneal, cuboid, medial cuneiform, and first metatarsal osteotomies
and plantar and tibialis posterior tenotomies. The natural stretching of the plantar arch
with weight-bearing makes the low fixation system of the minimally invasive procedure
efficient. The most common complication is transitory sural nerve neuralgia.

Author Contributions: R.S.A., conception, design, intellectual and scientific content of the study,
acquisition and interpretation of data, and manuscript writing. H.C.T.R., A.L.G.d.S., J.A.D.L. respon-
sible for research, manuscript editing, interpretation of data and critical review and submission of
manuscript. J.V.d.V.C. involved in technical procedures and manuscript writing. The authors declare
no conflict of interest. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical review and approval were waived for this research,
due to the fact that this article is a retrospective review study based on an analysis of medical
records. No patient data were exposed and no conduct was outlined. Therefore, there was only an
analysis and description of procedures performed in a certain period, in some individuals and from
a specific technique.
Informed Consent Statement: In this study, the consent form is not required, because only an
analysis of medical records was performed. This analysis was carried out retrospectively and did
not involve interventions or prescribed new approaches. Thus, only a description and analysis of a
specific technique was made and there was no contact with the patient, which makes the application
of the consent form unfeasible.
Conflicts of Interest: The authors declare no conflict of interest.

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