Cavus Foot

Pes Arcuatus

Kelvin A. Barry, Sr. February 25, 2005

• Foot with high arch • Can be a deformity of the forefoot, hindfoot, or both • Decrease in weight-bearing surface area of plantar aspect of foot • Rigidity of STJ, tarsal joints, MTP joints • Plantarflexed metatarsals • Inverted calcaneus⇒ external tibial rotation • Foot and ankle instability

Introduction

Types of Pes Cavus
• Based on location of APEX of the deformity • Anterior Cavus (Forefoot Cavus)
– Local – Global

• Metatarsus cavus • Posterior Cavus • Combined

Anterior Cavus (Forefoot Cavus)
• Local
– 1st and/or 2nd metatarsal (s) plantarflexed on rearfoot and relative to lesser metatarsals

• Global
– Entire forefoot (all metatarsals) is plantarflexed on rearfoot

• Rigid vs. Flexible
– Flexible cavus foot reduces on weightbearing – Rigid cavus foot remains the same off and on weightbearing

Etiology
• Muscle Imbalance
– Long extensors, long flexors, and intrinsics

• Congenital
– CMT – Cerebral palsy – Muscular dystrophy – Polio

• Acquired

Surgical Considerations
1. Rigid deformity usually requires osteotomy and/or fusion. 2. Flexible deformity can benefit from soft tissue released 3. After reduction of rigid deformity, flexible compensatory mechanisms spontaneously reduce 4. Correction of anterior cavus will sometimes reduce posterior cavus

Surgical Considerations
For Rigid Cavus foot • Cole midtarsal osteotomy • Japas V-osteotomy • Multiple DFWO or wedged tarsometatarsal arthrodesis
– In foot with more distal apex

• Triple arthrodesis
– If deformity is triplanar

• Calcaneal osteotomies

Cole
• Dorsal midfoot wedge osteotomy
– At cuboid navicular joint

• • • •

Reduces sagital plane deformity Stabilize with staples and screws NWB cast for 8 weeks post op Indications
– Anterior cavus with apex at midfoot

Japas
• Indications
– Anterior pes cavus

• Midtarsal V osteotomy
– Apex of V proximal to apex of deformity

• Medially through medial cuneiform and laterally through cuboid • Distal forefoot moves dorsally • Fixate with pins and screws • 8 week NWB post op course

• Wedge of bone removed from TM joint
– Amount removed depends on severity of rigid anterior cavus

Tarsometatarsal Wedge Arthrodesis

• Sagital and frontal plane correction • Contraindicated in rearfoot varus and STJ abnormalities

Metatarsal Osteotomies
• Indications
– Anterior pes cavus with apex distal to tarsometatarsal joint – Can correct in sagittal, frontal, transverse planes
• Forefoot vlagus, forefoot varus, met adductus

• Forefoot valgus may be corrected by elevating mets 1-3; forefoot varus corrected by elevating mets 4 and 5 • Anterior cavus foot and met adductus corrected by biplane osteotomy wedges

Dwyer Calcaneal Osteotomy
• Indications
– Rigid rearfoot varus when independent of forefoot influence

• Lateral closing wedge osteotomy of calcaneus
– Wedge resected parallel to peroneus longus

• Fixation with staples and screws • 8 week NWB post op care

Dorsiflexory Calcaneal Osteotomy
• Indications
– Posterior cavus foot – Corrects increased calcaneal inclination – Corrects calcaneal varus

• Crescentic, biplane osteotomy of posterior aspect of calcaneus
– Fragment rotated dorsally and laterally

Arthrodesis
• Start at midfoot, resecting smaller joints • Can be combined with tendon transfers, met osteotomies • Hoke: STJ and TNJ fusion • Reyerson: calcanealcuboid joint fusion • Used in anterior and posterior cavus foot with multiplanar deformity • Fusions will stabilize foot.