Cavovarus foot treated with combined calcaneus and metatarsal osteotomies

A Smaller Tibiotalar Sector Is a Risk Factor for Recurrent Anterolateral Ankle Instability after a Modified Broström-Gould Procedure

BACKGROUND

Several demographic and clinical risk factors for recurrent ankle instability have been described. The main objective of this study was to investigate the potential influence of morphologic characteristics of the ankle joint on the occurrence of recurrent instability and the functional outcomes following a modified Broström-Gould procedure for chronic lateral ankle instability.

METHODS

Fifty-eight ankles from 58 patients (28 males and 30 females) undergoing a modified Broström-Gould procedure for chronic lateral ankle instability between January 2014 and July 2021 were available for clinical and radiological evaluation. Based on the preoperative radiographs, the following radiographic parameters were measured: talar width (TW), tibial anterior surface (TAS) angle, talar height (TH), talar radius (TR), tibiotalar sector (TTS), and tibial lateral surface (TLS) angle. The history of recurrent ankle instability and the functional outcome using the Karlsson Score were assessed after a minimum follow-up of 2 years.

RESULTS

Recurrent ankle instability was reported in 14 patients (24%). The TTS was significantly lower in patients with recurrent ankle instability (69.8 degrees vs 79.3 degrees) (P < .00001). The multivariate logistic regression model confirmed the TTS as an independent risk factor for recurrent ankle instability (OR = 1.64) (P = .003). The receiver operating characteristic curve analysis revealed that patients with a TTS lower than 72 degrees (=low-TTS group) had an 82-fold increased risk for recurrent ankle instability (P = .001). The low-TTS group showed a significantly higher rate of recurrent instability (58% vs 8%; P = .0001) and a significantly lower Karlsson score (65 points vs 85 points; P < .00001).

CONCLUSION

A smaller TTS was found to be an independent risk factor for recurrent ankle instability and led to poorer functional outcomes after a modified Broström-Gould procedure.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Joint preserving procedures for painful plantar callosities in patients with flexible cavovarus foot

BACKGROUND

The outcome of a constant joint preserving procedure for painful plantar callosities with cavovarus foot remains unclear.

METHODS

Eleven patients (11 feet) who underwent lateral displacement calcaneal osteotomy (LDCO), dorsiflexion first metatarsal osteotomy (DFMO), and plantar fasciotomy (PF), simultaneously were included. The presence of painful callosities, heel alignment of standing (HA), and the Japanese Society for Surgery of the Foot ankle/hindfoot (JSSF) score were evaluated. Radiographically, the talonavicular coverage angle (TNCA), lateral talo-first metatarsal angle (LTMA), calcaneal pitch angle (CPA), and heel alignment angle (HAA) were measured.

RESULTS

Postoperatively, painful plantar callosities disappeared in 10 patients and remained in one patient. The postoperative HA and JSSF score significantly improved. The postoperative TNCA, LTMA, CPA, and HAA significantly improved.

CONCLUSIONS

In patients with flexible cavovarus foot, LDCO, DFMO, and PF yielded good outcomes at mid-term follow-up with preservation of the foot and ankle joints.

Failed Cavovarus Reconstruction: Reconstructive Possibilities and a Proposed Treatment Algorithm

This article provides an overview of the techniques and strategies to address a failed cavovarus deformity correction. These problems pose significant challenges to the treating surgeons and should be accurately planned before embarking on surgery.

Joint Preservation Surgery for Varus Ankle Arthritis with Large Talar Tilt

BACKGROUND

Varus ankle arthritis with large talar tilt (TT) is a challenging condition when considering joint preservation surgery. Three-dimensional deformity of the talus has been demonstrated with weightbearing computed tomography in varus ankle arthritis with large TT. The aim of this study was to investigate the clinical and radiographic results of posterior tibial tendon (PTT) transfer generally combined with bony realignment for varus ankle arthritis with large TT in nonparalytic ankle arthritis and to determine the indications for PTT transfer.

METHODS

This study includes 23 ankles with varus arthritis and TT larger than 7.5 degrees. Patients were categorized into improved (19 ankles) and unimproved (4 ankles) groups according to the postoperative clinical results at the last follow-up. Clinical and radiographic results were compared between the groups. A cut-off point for preoperative TT that indicated a borderline between improved and unimproved groups was determined to suggest the appropriate indication for joint preservation surgery.

RESULTS

In the improved group, TT, radiographic stage, Meary angle, and hindfoot alignment significantly improved at 6 months after surgery and were maintained at the last follow-up. In the unimproved group, the radiographic parameters mentioned above did not improve at 6 months after surgery, and TT decreased to 0.8 degrees as radiographic stage had progressed to end-stage arthritis at the last follow-up. In this small series, the cut-off point for predicting failure of surgery was 14.3 degrees of preoperative TT.

CONCLUSION

PTT transfer often combined with bony realignment procedures may be a reasonable option for treating painful varus ankle arthritis with TT less than 14 degrees and hindfoot varus.

LEVEL OF EVIDENCE

Level IV, case series.

Management of Midfoot Cavus

There is a deficiency in publications on the topic of midfoot cavus. The limited research available does not have a standard definition for the diagnosis of this deformity and lacks a reliable algorithm for its surgical management. The authors performed an extensive review of the literature that found a majority of patients are satisfied with the Cole osteotomy and the dorsiflexory first metatarsal osteotomy for treatment of this condition. High patient satisfaction has been observed with lateralizing calcaneal osteotomies in the setting of midfoot cavus with a secondary rigid rearfoot deformity. Further research on this topic is encouraged.

Staples and locking plates provide comparable outcomes for fixation of first metatarsal dorsiflexion osteotomies in pes cavovarus

BACKGROUND

One commonly encountered deformity within the cavovarus foot is plantarflexion of the first metatarsal which may be a primary or secondary deformity. Correcting the plantarflexion may be achieved through a dorsiflexion osteotomy although the optimal fixation device for this osteotomy has not been determined. This clinical study compared the outcomes using staples and locking plates.

METHODS

A retrospective evaluation was performed of 52 feet that had undergone dorsiflexion osteotomy of the first metatarsal as part of a cavovarus foot correction with a minimum follow-up of two years. Data was collected on deformity correction, complications and cost-analysis.

RESULTS

As a cohort, Meary's angle improved from 13.4° to 7.72° (p < 0.001), Hibbs' angle improved from 117.1° to 124.2° (p < 0.001) and navicular height dropped from 52.7 mm to 47.7 mm (p < 0.001) while calcaneal inclination changed from 20.9° to 21.2° but this did not reach significance (p = 0.66). These indices and the number of complications were not significantly different between the staple and locking plate group. The overall cost of using staples was less than using locking plates.

CONCLUSIONS

Both staples and locking plates are effective devices for fixation of the first metatarsal after a dorsiflexion osteotomy in cavovarus foot surgery. They were both able to provide comparable fixation, although staples were less expensive to use in our study.

Making Things Easier: A Simple Novel Method to Fix a Dorsiflexion Osteotomy of the First Metatarsal

A first ray dorsiflexion osteotomy is commonly performed for cavovarus foot correction. There are multiple techniques to fix this osteotomy, ranging from wires, screws, and plates or a combination of these. We present our results using a varisation staple (Biomet©) as an alternative fixation device. We performed a retrospective outcome analysis of a consecutive series of 10 cavovarus feet that underwent a dorsiflexion osteotomy (dorsal closing wedge) of the first metatarsal fixed with two varisation staples. The results were measured at a mean three monthly follow-ups and included union and complication rates, as well as clinical and radiographic assessment of cavus deformity correction. There was a 100% union rate with no complications or cases of delayed union. No metalwork removal was requested in any case at follow-up. First ray dorsiflexion osteotomies are most commonly fixed using a 3.5mm cortical screw. We demonstrate that our alternative and novel technique using varisation staples achieved a 100% union rate while avoiding the prominent hardware complications known to occur with cortical screws or plates.

Soft tissue release combined with joint-sparing osteotomy for treatment of cavovarus foot deformity in older children: Analysis of 21 cases

BACKGROUND

Cavovarus foot is a common form of foot deformity in children, which is clinically characterized by an abnormal increase of the longitudinal arch of the foot, and it can be simultaneously complicated with forefoot pronation and varus, rearfoot varus, Achilles tendon contracture, or cock-up toe deformity. Muscle force imbalance is the primary cause of such deformity. Many diseases can lead to muscle force imbalance, such as tethered cord syndrome, cerebral palsy, Charcot-Marie-Tooth disease, and trauma. At present, many surgical treatments are available for cavovarus foot. For older children, priority should be given to midfoot osteotomy and fusion. Since complications such as abnormal foot length, foot stiffness, and abnormal gait tend to develop postoperatively, it is important to preserve the joints and correct the deformity as much as possible. Adequate soft tissue release and muscle balance are the keys to correcting the deformity and avoiding its postoperative recurrence.

AIM

To assess the efficacy of soft tissue release combined with joint-sparing osteotomy in the treatment of cavovarus foot deformity in older children.

METHODS

The clinical data of 21 older children with cavovarus foot deformity (28 feet) who were treated surgically at the Ninth Department of Orthopedics of Jizhong Energy Xingtai Mining Group General Hospital from November 2014 to July 2017 were retrospectively analyzed. The patients ranged in age from 10 to 14 years old, with an average age of 12.46 ± 1.20 years. Their main clinical manifestations were deformity, pain, and gait abnormality. The patients underwent magnetic resonance imaging of the lumbar spine, electromyographic examination, weight-bearing anteroposterior and lateral X-rays of the feet, and the Coleman block test. Surgical procedures including metatarsal fascia release, Achilles tendon or medial gastrocnemius lengthening, "V"-shaped osteotomy on the dorsal side of the metatarsal base, opening medial cuneiform wedge osteotomy, closing cuboid osteotomy, anterior transfer of the posterior tibial tendon, peroneus longus-to-brevis transfer, and calcaneal sliding osteotomy to correct hindfoot varus deformity were performed. After surgery, long leg plaster casts were applied, the plaster casts were removed 6 wk later, Kirschner wires were removed, and functional exercise was initiated. The patients began weight-bearing walk 3 mo after surgery. Therapeutic effects were evaluated using the Wicart grading system, and Meary’s angles and Hibbs’ angles were measured based on X-ray images obtained preoperatively and at last follow-up to assess their changes.

RESULTS

The patients were followed for 6 to 32 mo, with an average follow-up period of 17.68 ± 6.290 mo. Bone healing at the osteotomy site was achieved at 3 mo in all cases. According to the Wicart grading system, very good results were achieved in 18 feet, good in 7, and fair in 3, with a very good/good rate of 89.3%. At last follow-up, mean Meary’s angle was 6.36° ± 1.810°, and mean Hibbs’ angle was 160.21° ± 4.167°, both of which were significantly improved compared with preoperative values (24.11° ± 2.948° and 135.86° ± 5.345°, respectively; P < 0.001 for both). No complications such as infection, skin necrosis, or bone nonunion occurred.

CONCLUSION

Soft tissue release combined with joint-sparing osteotomy has appreciated efficacy in the treatment of cavovarus foot deformity in older children.

Clinical and radiological outcomes of midfoot derotational osteotomy for midfoot-forefoot varus deformity

BACKGROUND

Moderate to severe midfoot-forefoot varus deformities are commonly found in several conditions. However, few techniques are available to correct these deformities. So, we evaluated the clinical and radiological outcomes of patients who underwent midfoot derotational osteotomy to achieve plantigrade foot.

METHODS

From 2006 to 2014, 6 patients (7 feet) underwent midfoot derotational osteotomy. A visual analog scale (VAS) pain and the American Orthopedic Foot & Ankle Society (AOFAS) functional score were evaluated. Radiographic parameters, including tibiocalcaneal angle (TCA) and navicular height (NH), were assessed.

RESULTS

The mean patient age at surgery was 48.0 years (37-58). From before the operation to the final follow-up, the mean VAS score decreased from 6.5 (2-9) to 1.3 (0-4) and the mean AOFAS score improved from 42.7 (34-58) to 77 (68-87). All patients were satisfied with outcomes. The mean TCA significantly improved from 33.8° (9.9-66.7) to 12.7 (5.1-27.6) (p = 0.018)and the mean NH decreased from 46.7 mm (32.8-67) to42.6 (30.1-60.8) (p = 0.018).

CONCLUSION

Severe midfoot-forefoot varus deformities can be efficiently corrected by midfoot derotational osteotomy resulting in favorable clinical and radiological outcomes and high patient satisfaction.

LEVEL OF EVIDENCE

IV, case series.

Neurologic Deficit Associated With Lateralizing Calcaneal Osteotomy for Cavovarus Foot Correction

BACKGROUND

Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified.

METHODS

Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted.

RESULTS

The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury.

CONCLUSIONS

Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

[Dwyer osteotomy : Lateral sliding osteotomy of calcaneus]

OBJECTIVE

To correct the underlying inframalleolar varus deformity and to restore physiologic biomechanics of the hindfoot.

INDICATIONS

Neurologic, posttraumatic, congenital, and idiopathic cavovarus deformity. In patients with end-stage ankle osteoarthritis with varus heel malposition as additional single-stage procedure complementing total ankle replacement. Severe peroneal tendinopathy with concomitant cavovarus deformity.

CONTRAINDICATIONS

General surgical or anesthesiological risks, infections, critical soft tissue conditions, nonmanageable hindfoot instability, neurovascular impairment of the lower extremity, neuroarthropathy (e. g., Charcot arthropathy), end-stage osteoarthritis of the subtalar joint, severely reduced bone quality, high age, insulin-dependent diabetes mellitus, smoking.

SURGICAL TECHNIQUE

The lateral calcaneus cortex is exposed using a lateral incision. The osteotomy is performed through an oscillating saw. The posterior osteotomy fragment is manually mobilized and shifted laterally. If needed, a laterally based wedge can be removed and/or the osteotomy fragment can be translated cranially. The osteotomy is stabilized with two cannulated screws, followed by wound closure.

POSTOPERATIVE MANAGEMENT

A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 with 15 kg partial weight bearing using a stabilizing walking boot or cast for 6 weeks. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is initiated step by step.

RESULTS

Between January 2009 and June 2013, a Dwyer osteotomy was performed in 31 patients with a mean age of 45.7 ± 16.3 years (range 21.5-77.4 years). All patients had a substantial inframalleolar cavovarus deformity with preoperative moment arm of the calcaneus of -17.9 ± 3.3 mm (range -22.5 to -10.5 mm), which has been improved significantly to 1.6 ± 5.9 mm (range -16.9 to 9.9 mm). Significant pain relief from 6.3 ± 1.9 (range 4-10) to 1.1 ± 1.1 (range 0-4) using the visual analogue scale was observed. The American Orthopaedic Foot and Ankle Society score significantly improved from 33.1 ± 14.2 (range 10-60) to 78.0 ± 10.5 (range 55-95).

Use of Ilizarov External Fixation Without Soft Tissue Release to Correct Severe, Rigid Equinus Deformity

The purpose of the present retrospective study was to report the correction of severe, rigid equinus deformities using an Ilizarov external fixator alone, without adjunctive open procedures. Ten feet in 10 patients with rigid equinus deformities were enrolled and underwent gradual correction using an Ilizarov external fixator alone, without additional open procedures. The range of ankle joint motion was measured preoperatively and at the last follow-up visit. The radiographic outcome was assessed using the lateral tibiotalar angle on ankle radiographs taken preoperatively, immediately after removal of the Ilizarov fixator, and at the last follow-up visit. The mean duration of external fixator treatment was 40.1 ± 13.5 days. The preoperative mean ankle range of motion was -55.5° ± 22.2° of dorsiflexion and 63.0° ± 20.8° of plantarflexion. At the last follow-up visit, the mean dorsiflexion had increased to -2.5° ± 6.8° and the mean plantarflexion had decreased to 30.5° ± 12.6°. The mean lateral tibiotalar angle was 152.9° ± 19.7° preoperatively, 103.9° ± 9.4° immediately after removal of the Ilizarov external fixator, and 113.9° ± 11.6° at the last follow-up visit. Immediately after fixator removal, all the patients had clinical correction of their deformity to a plantigrade foot using the Ilizarov external fixator alone, with a mean correction of 49.0° ± 17.4°. Some recurrence was noted at the last follow-up examination, with a final mean correction of 39.0° ± 18.0°. The present study has demonstrated successful correction of severe, rigid equinus deformity with the use of an Ilizarov external fixator without the need for adjunctive soft tissue procedures. This method can be effective for patients with a high risk of complications after open procedures owing to their poor soft tissue envelope.

Surgical treatment of cavus foot in Charcot-Marie-tooth disease: a review of twenty-four cases: AAOS exhibit selection

Charcot-Marie-Tooth disease is the single most common diagnosis associated with cavus foot. The imbalance involving intrinsic and extrinsic muscles has been suggested as the main pathogenetic cause of cavus foot in this disease. The goal of surgical treatment is to correct the deformity to obtain a plantigrade foot. In the presence of a flexible deformity and the absence of degenerative arthritis, preserving as much as possible of the overall range of motion of the foot and ankle is advisable. Twenty-four cavus feet in twelve patients with Charcot-Marie-Tooth disease were included in the study. Clinical evaluation was summarized with the Maryland Foot Score. Radiographic evaluation assessed calcaneal pitch, Meary angle, Hibb angle, and absence of degenerative joint changes. Only patients who had a flexible deformity, with varus of the heel reducible in the Coleman-Andreasi test, and did not have degenerative joint arthritis were included in this study. Surgical treatment consisted in plantar fasciotomy, midtarsal osteotomy, extensor hallucis longus tendon transfer to the first metatarsal (Jones procedure), and dorsiflexion osteotomy of the first metatarsal. Mean follow-up was six years (range, two to thirteen years). The mean Maryland Foot Score was 72 preoperatively and 86 postoperatively. The postoperative result was rated as excellent in twelve feet (50%), good in ten (42%), and fair in two (8%). Mean calcaneal pitch was 34° preoperatively and 24° at the time of the latest follow-up, the mean Hibb angle was 121° preoperatively and 136° postoperatively, and the mean Meary angle was 25° preoperatively and 2° postoperatively. Plantar fasciotomy, midtarsal osteotomy, the Jones procedure, and dorsiflexion osteotomy of the first metatarsal yielded adequate correction of flexible cavus feet in patients with Charcot-Marie-Tooth disease in the absence of fixed hindfoot deformity. The fact that the improvement in the outcome score was only modest may be attributable to the lack of motor balance.

Geometry of the lateral sliding, closing wedge calcaneal osteotomy: review of the two methods and technical tip to minimize shortening

BACKGROUND

A lateral closing wedge osteotomy is used for correction of varus hindfoot deformities. Since its original description, different techniques and geometries of the calcaneal bone wedge resection have been described. Even though the techniques seem similar, very different final bone architectures result from each technique, the effects of which are not known. This paper explores several of these techniques and the implications in deformity correction as well as the secondary effects of calcaneal shortening.

METHODS

Mathematical and geometric analysis is performed in 2-dimensions for several hypothetical calcaneal osteotomies as described by the original authors. The resulting changes are calculated and compared.

RESULTS

The shape of the bone resection for the lateral closing wedge osteotomy does not result in significantly different final calcaneal architectures. Both techniques studied result in the same amount of calcaneal shortening and deformity correction. However, when lateral calcaneal wedge resection is combined with lateral translation of the tuberosity for additional deformity correction, more calcaneal shortening is seen with posteriorly directed osteotomies than those that are transverse.

CONCLUSION

The lateral closing wedge osteotomy of the calcaneus results in correction of varus hindfoot deformity at the expense of some calcaneal shortening. Lateral translation of the tuberosity may result in additional calcaneal. The clinical effects of calcaneal shortening or medial soft tissue or nerve tethering from these different techniques are unknown and deserve further investigation.

LEVEL OF EVIDENCE

Level V, expert opinion.

Joint sparing correction of cavovarus feet in Charcot-Marie-Tooth disease: what are the limits?

Charcot-Marie-Tooth disease is an inherited neuropathy that results in lower limb muscle imbalance and a resultant cavovarus deformity of the foot. With recognized poor outcomes of triple arthrodeses in the young patient, joint sparing surgery is preferred, which takes the form of osteotomies, soft-tissue releases, and tendon transfers to achieve a plantigrade and balanced foot. Due to the variability in muscle involvement and the presence of both mobile and fixed deformities, surgery must be individualized to each patient.

Management of the rigid cavus foot in children and adolescents

This article reviews historical approaches to the various osteotomies in the treatment of rigid cavus feet in children, with an emphasis on the biplanar nature of historical osteotomies. The Akron dome midfoot osteotomy is performed at the apex of the rigid cavus deformity and allows for maximum correction in any plane, and for varus, valgus, dorsal, plantar, and rotational correction. In that regard, the Akron dome midfoot osteotomy provides the greatest amount of multiplanar correction. It does not, however, provide correction of hindfoot deformities or deformity distal to the neck of the metatarsal.

Joint-sparing correction for idiopathic cavus foot: correlation of clinical and radiographic results

Adult cavovarus deformity patients present with rigid cavovarus deformity, where the correction can no longer be obtained using soft tissue procedures alone, and corrective arthrodesis or osteotomy must be performed to realign the deformity. Reconstructive surgeries for cavovarus foot deformities are variable and include hindfoot or midfoot osteotomy or arthrodesis, soft tissue release or lengthening, and tendon transfers. Recently adult cavovarus foot deformities have been more commonly addressed with joint preservation osteotomies and adjunctive soft tissue surgeries and less with triple arthrodesis. Clinical and radiographic outcomes are overall favorable.

Realignment surgery for severe talar tilt secondary to paralytic cavovarus

BACKGROUND

Realignment surgeries for mild to moderate ankle osteoarthritis with minimal talar tilt have been reported to be effective. However, there has been no report on joint-sparing surgery of ankle osteoarthritis in patients with paralytic disorders who have severe talar tilt. We therefore investigated whether ankle osteoarthritis with severe talar tilt caused by paralytic disorders can be improved after operative treatment.

METHODS

This study included 12 ankles (11 patients) with varus ankle osteoarthritis from paralytic disorders with cavovarus deformity of the foot. Mean follow-up period was 3.0 years (range, 2-4.5 years). Causes of paralysis were residual polio in 7 ankles (6 patients), cerebral palsy in 2 ankles, and idiopathic in 3 ankles. Preoperative and postoperative clinical assessments were performed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and a visual analogue scale (VAS). The Ankle Osteoarthritis Scale (AOS) was used for postoperative assessment. Pre- and postoperative radiographic parameters were compared.

RESULTS

Mean AOFAS score improved from 39.1 (range, 32-57) preoperatively to 77.9 (range, 72-85) postoperatively. Mean talar tilt improved from 17.4 degrees (range, 9.5-33.5 degrees) to 1.4 degrees (range, 0-4 degrees). Degree of osteoarthritis according to Takakura classification improved in all ankles except two. Mean heel alignment angle was reduced from 40.4 degrees (range, 2-65 degrees) of varus preoperatively to 11.2 degrees (range, -3 to 25.5 degrees) of varus postoperatively.

CONCLUSION

Medial varus ankle osteoarthritis from paralytic cavovarus may be improved even in cases of severe talar tilt.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Is deltoid and lateral ligament reconstruction necessary in varus and valgus ankle osteoarthritis, and how should these procedures be performed?

Varus and valgus ankle deformities represent a challenge to the foot and ankle surgeons. The presence of degenerative changes of the tibiotalar joint articular surfaces introduces an additional layer of complexity. Reconstruction of such deformities requires a customized approach to each patient. Surgical intervention often requires joint-sparing realignment, arthroplasty, and/or arthrodesis, depending on the severity of deformity and the joint surface integrity. The ligamentous stability of the ankle plays an essential role in the preservation and optimization of function. This article reviews the role of deltoid and lateral ligament reconstruction in the treatment of varus and valgus ankle osteoarthritis.

The underlying osseous deformity in plantar plate tears: a radiographic analysis

PURPOSE

Plantar plate tears can cause pain and deformity of the forefoot. The purpose of this study is to correlate common radiographic findings with observed intra-operative pathology in patients with plantar plate pathology.

METHODS

Bilateral weight-bearing radiographs were reviewed for 88 patients (106 feet) who underwent surgical repair of suspected plantar plate pathology. Parameters reviewed included the first intermetatarsal angle, the metatarsus adductus angle, the second and third metatarsophalangeal angles, splaying of the second and third toes, evaluation of the metatarsal parabola by 3 different methods, the first and second lateral declination angles, and the second lateral metatarsophalangeal angle.

RESULTS

Of 106 feet, 97 had intra-operative plantar plate tears. The radiographs of patients with plantar plate tears had an increased amount of digital splay on the anteroposterior radiograph compared to patients without pathology. For patients with unilateral plantar plate pathology, the metatarsal parabola of the symptomatic foot was compared with that of the asymptomatic foot. A significantly increased second metatarsal protrusion distance as measured by 2 different methods was noted in the symptomatic foot. Odds ratios revealed that patients with an intermetatarsal angle >12, medial deviation of the second toe, and splaying of the digits were more likely to be diagnosed with a plantar plate tear intra-operatively.

CONCLUSION

Although radiographs do not definitively diagnose plantar plate tears, understanding osseous forefoot architecture will aid with diagnosis in the absence of other osseous pathology. Furthermore, these data suggest that parabola should be corrected to maintain long-term correction of plantar plate pathology.

LEVEL OF EVIDENCE

Prognostic, Level II.

Cavovarus foot realignment to treat anteromedial ankle arthrosis

BACKGROUND

Adult patients with cavovarus feet were seen with symptomatic anteromedial ankle arthrosis and, frequently, lateral hindfoot instability. Static and dynamic realignment was performed to redistribute joint contact pressures and restore stability.

METHODS

Thirteen patients with fixed cavovarus feet (6 neurogenic, 7 idiopathic; 6 with hindfoot instability, 7 without) and mild to moderate anteromedial ankle arthrosis were treated by osteotomies and tendon transfers but no lateral ligament reconstruction. Anteromedial cheilectomy of the ankle was added to increase dorsiflexion and alleviate anteromedial impingement.

RESULTS

Failure occurred in 2 patients, who required additional procedures. The remaining 11 patients improved from preoperative 45 to 71 points (American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score) at the latest follow-up (average 84 months). Ankle dorsiflexion improved 7 degrees on average. There was no recurrent hindfoot instability and no progression of anteromedial ankle arthrosis over time.

CONCLUSION

Cavovarus foot realignment with anteromedial ankle cheilectomy reliably improved patients' symptoms related to ankle arthrosis, restored lateral hindfoot stability, and stabilized the extent of anteromedial ankle arthrosis when talar varus tilt was reduced.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The varus ankle and instability

Varus ankle associated with instability can be simple or complex. Multiple underlying diseases may contribute to this complex pathologic entity. These conditions should be recognized when attempting proper decision-making. Treatment options range from conservative measures to surgical reconstruction. Whereas conservative treatment might be a possible approach for patients with simple varus ankle instability, more complex instabilities require extensive surgical reconstructions. However, adequate diagnostic workup and accurate analysis of varus ankle instability provide a base for the successful treatment outcome.

Indications for supramalleolar osteotomy in patients with ankle osteoarthritis and varus deformity

BACKGROUND

Osteotomies are reported to be effective for the treatment of most cases of primary and traumatic moderate osteoarthritis of the ankle joint. Because of unsatisfactory results following supramalleolar tibial osteotomy in several of our patients, we investigated the cause of the unsatisfactory results and the indications for this surgical procedure.

METHODS

Supramalleolar tibial osteotomy combined with fibular osteotomy was performed in sixteen ankles (sixteen patients) to treat moderate medial ankle osteoarthritis. The median duration of follow-up was 2.3 years (range, one to 6.5 years). Clinical assessment was performed with use of the American Orthopaedic Foot & Ankle Society (AOFAS) scale, and the osteoarthritis stage was determined radiographically with use of the modified Takakura classification system. Clinical and radiographic results were compared among groups defined by high (≥9.5°) or low (≤4°) postoperative talar tilt and by the presence or absence of postoperative lateral subfibular pain. The optimal threshold of preoperative talar tilt for predicting high postoperative talar tilt was determined with use of receiver operating characteristic curve analysis.

RESULTS

The mean AOFAS score, mean Takakura stage, and mean values of all radiographic parameters were improved significantly after surgery. The preoperative talar tilt was correlated with the postoperative talar tilt (Spearman rho = 0.75, p < 0.01). The mean AOFAS score was higher (p = 0.02) and the mean radiographic stage was lower (p = 0.03) in the group with low postoperative talar tilt than in the group with high talar tilt. The optimal threshold for predicting high postoperative talar tilt was 7.3° of preoperative talar tilt, with a sensitivity of 100% and a specificity of 91.7%. The patients with lateral subfibular pain had a lower mean AOFAS score, a greater angle between the tibia and the ankle surface postoperatively, and greater postoperative heel valgus than those without lateral subfibular pain.

CONCLUSIONS

Supramalleolar osteotomy is indicated for the treatment of ankle osteoarthritis in patients with minimal talar tilt and neutral or varus heel alignment.

Correction of rigid equinovarus deformity using a multiplanar external fixator

BACKGROUND

The rigid equinovarus foot deformity is a challenging condition treated by the orthopaedic foot and ankle surgeon. Rapid surgical correction of the deformity may lead to skin and neurologic complications. Gradual correction of the deformity with a multiplanar external fixator may decrease these complications. The purpose of this study was to present the results of a group of patients with rigid equinovarus deformities corrected using a multiplanar external fixator.

MATERIALS AND METHODS

We retrospectively reviewed the results of correction of a rigid equinovarus deformity using multiplanar external fixation in a small group of patients. All patients underwent open Achilles lengthening, posterior capsule release, tibialis posterior tendon lengthening, flexor digitorum longus and flexor hallux longus lengthening, followed by application of a multiplanar external fixator with gradual correction of the deformity over a period of several weeks. Preoperative and postoperative deformity and AOFAS ankle-hindfoot scores were assessed.

RESULTS

A total of eight rigid equinovarus deformities in six patients were treated with a multiplanar external fixator. The average patient age at the time of surgery was 37.2 (range, 17 to 59 ± 15.0) years. Causes of the deformity included trauma in three patients, traumatic brain injury in two patients, and long-standing rheumatoid arthritis in one patient. The average preoperative AOFAS ankle-hindfoot score was 28.3 (range, 12 to 38 ± 7.7). The average postoperative AOFAS ankle-hindfoot score was 68.1 (range 38 to 86 ± 15.5) at an average followup of 71.9 (30 to 120 ± 36.2) weeks. All deformities were gradually corrected to a plantigrade foot using a multiplanar external fixator over an average time of 5 (range, 4 to 6 ± 0.8) weeks. After correction of the deformity, the external fixator was left in place for a time period equal to or twice the length of time it took to achieve correction. The average duration of external fixation was 10.8 (range, 8 to 16 ± 2.8) weeks. Seven of eight deformities maintained correction at final followup. There was one case of recurrence.

CONCLUSION

Correction of a rigid equinovarus deformity using a multiplanar external fixator was a viable treatment option. It allowed for correction of the deformity in a controlled manner, helping to reduce the risk of neurovascular complications that may result from single stage surgical correction. The risk of wound complications still exists with the correction of such a complex deformity.

Relationship of the Scarf valgus-inducing osteotomy of the calcaneus to the medial neurovascular structures

BACKGROUND

The Scarf valgus inducing osteotomy of the calcaneus is an operative technique to correct varus deformity of the hindfoot. It is versatile with significant corrective power; however, the neurovascular structures are in close proximity on the medial side and thus may be harmed during the osteotomy. Moreover, because this type of osteotomy can cause a great lateral translation, traction of the medial neurovascular structures is possible. We performed an anatomic study to evaluate the medial soft tissues after a lateralizing Scarf-type calcaneal osteotomy.

MATERIALS AND METHODS

The osteotomies were carried out on ten fresh-frozen cadaver specimens. We performed the osteotomy and induced valgus. Then we performed a medial dissection to identify the important medial structures: the medial and lateral plantar nerve (MPN , LPN) and the posterior tibial artery (PTA). We noted their relation to the osteotomy and their integrity.

RESULTS

In several cases, one or more of the structures were sectioned. In five cases, all the structures crossed the osteotomy, four of which even a transection of one or both of the plantar nerves occurred. Although the PTA crossed the osteotomy in eight specimens, there was no transection of this structure.

CONCLUSION

Scarf osteotomy of the calcaneus is a highly corrective osteotomy. However, caution must be exercised when performing as the medial neurovascular structures cross the osteotomy lines and transection can occur.

CLINICAL RELEVANCE

When performing the osteotomy one should keep in mind that vigorous sawing and large displacement can cause damage to the medial neurovascular structures.

Salvage of severe ankle varus deformity with soft tissue and bone rebalancing

The etiology of ankle varus is multifactorial. Treatment recommendations after failed conservative care include hindfoot and ankle fusions or total ankle arthroplasty (TAA) with ligament rebalancing. The purpose of this study was to evaluate chronic varus ankle deformities through corrective calcaneal osteotomies and lateral soft tissue reconstruction. All skeletally mature patients with at least 5 degrees of ankle varus were included in the study. Pre and postoperative radiographs were retrospectively reviewed measuring talar tilt. All patients had a lateral closing wedge (Dwyer) calcaneal osteotomy, joint debridement, and lateral ankle ligament reconstruction. Eight feet were included in the study. The average follow-up time was 20.6 months. Six patients (six feet) were asymptomatic and did not have any additional surgery at their most recent follow-up. Two patients failed treatment, requiring surgical intervention for persistent pain and/or deformity. The average postoperative ankle varus correction overall was 4.9 degrees. We found ankle varus on average of less than 10 degrees can be reliably corrected with a combination of lateral ligament reconstruction and calcaneal osteotomy. Approximately 50% of the deformity was corrected when comparing pre and postoperative talar tilt values. In patients with varus deformity greater than 10 degrees preoperatively, persistent varus may occur.

Surgical management of pes cavus deformity with an underlying neurological disorder: a case presentation

Charcot-Marie-Tooth disease is a complex group of motor and sensory disorders presenting with varying levels of deformity dependent on the chronology and specific subgroup of the disease. In this report, we discuss a 19-year-old man with Charcot-Marie-Tooth 1A, a progressive and aggressive form of hereditary sensorimotor neuropathy, with rigid forefoot and rearfoot deformity. The authors discuss the etiology, tests, and sequential surgical management of this condition, focusing on a triple arthrodesis including a closingwedge subtalar joint fusion and a dorsal closing wedge osteotomy of the first metatarsal.

Surgical management and treatment algorithm for the subtle cavovarus foot

BACKGROUND

Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup.

MATERIALS AND METHODS

Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years.

RESULTS

The mean AOFAS ankle hindfoot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal.

CONCLUSION

The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction.

Ankle joint pressure changes in a pes cavovarus model after lateralizing calcaneal osteotomies

BACKGROUND

Tendon transfers and calcaneal osteotomies are commonly used to treat symptoms related to medial ankle arthrosis in fixed pes cavovarus. However, the relative effect of these osteotomies in terms of lateralizing the ground contact point of the hindfoot and redistributing ankle joint contact stresses are unknown.

MATERIALS AND METHODS

Pes cavovarus with fixed hindfoot varus was simulated in eight cadaver specimens. The effect of three types of calcaneal osteotomies on the migration of the center of force and tibiotalar peak pressure at 300 N axial static load (half-body weight) were recorded using pressure sensors.

RESULTS

A significant lateral shift of the center of force was observed: 4.9 mm for the laterally closing Z-shaped osteotomy with additional lateralization of the tuberosity, 3.4 mm for the lateral sliding osteotomy of the calcaneal tuberosity, and 2.7 mm for the laterally closing Z-shaped osteotomy (all p < 0.001). A significant peak pressure reduction was recorded: -0.53 MPa for the Z-shaped osteotomy with lateralization, -0.58 MPa for the lateral sliding osteotomy of the calcaneal tuberosity, and -0.41 MPa for the Z-shaped osteotomy (all p < 0.01).

CONCLUSION

This cadaver study supports the hypothesis that lateralizing calcaneal osteotomies substantially help to normalize ankle contact stresses in pes cavovarus.

Flexible cavovarus feet in Charcot-Marie-Tooth disease treated with first ray proximal dorsiflexion osteotomy combined with soft tissue surgery: a short-term to mid-term outcome study

OBJECTIVES

The purpose of this paper was to retrospectively evaluate the short-term to mid-term results of combined first ray proximal dorsiflexion osteotomy and soft tissue surgery in treatment of pes cavovarus with a fixed plantar flexed first ray and a passively correctable tarsus due to Charcot-Marie-Tooth disease.

PATIENTS AND METHODS

Between January 1995 and July 2005, thirty-three patients with pes cavovarus deformity due to Charcot-Marie-Tooth disease were included. All patients had in common that prior to surgery the hindfoot was passively still adequate correctable at the talonavicular joint. The Coleman block test was performed to establish with certainty that hindfoot varus was a secondary deformity. Fourteen patients were male (21 feet) and nineteen were female (31 feet). Mean age at surgery was 28.1 years (range 13-59 years). Mean follow-up time was 56.9 months (range 13-153 months). Evaluation consisted of physical examination of all patients with assessment of early and late complications. The validated Foot Function Index (FFI) was used to measure pain and impairment. Patients' satisfaction was assessed by a Quality of Care Through the Patients' Eyes (QUOTE) questionnaire.

INTERVENTION

Surgical correction of cavovarus foot deformity consisted of dorsiflexion osteotomy at the base of the first metatarsal combined with tendon transfers. Secondary calcaneal osteotomy was performed in case of persistent varus of the calcaneus.

RESULTS

No major complications were seen. Recurrence of cavovarus deformity in two feet resulted in triple arthrodesis 37 and 64 months postoperatively. The FFI 5-point score for pain improved from a mean 29.3% to a mean 14.8% (p=0.005). The score for disability improved from a mean 37.8% to a mean 23.5% (p<0.001). Patients' satisfaction was assessed by the QUOTE questionnaire. Seventy percent of the patients could walk barefoot after the operation and 77% of the patients had less pain after surgery. Pressure callosities diminished in 81%. Foot function was considered better after surgery by 84%. Ninety percent was satisfied with the correction of the deformity.

CONCLUSIONS

First ray dorsiflexion osteotomy combined with tendon transfers is a good and consistent solution to realign the foot and provides short-term to mid-term satisfactory results in 90% of patients with a rigid forefoot cavus deformity due to plantar flexion of the first ray and with a still passively reducible tarsus.

Arteriovenous fistula and pseudoaneurysm of the posterior tibial artery after calcaneal slide osteotomy: a case report

Level of Evidence: V, Expert Opinion

Tibial nerve palsy associated with lateralizing calcaneal osteotomy: case reviews and technical tip

Level of Evidence: V, Expert Opinion

Cadaveric simulation of a pes cavus foot

BACKGROUND

The pes cavus deformity has been well described in the literature; relative bony positions have been determined and specific muscle imbalances have been summarized. However, we are unaware of a cadaveric model that has been used to generate this foot pathology. The purpose of this study was to create such a model for future work on surgical and conservative treatment simulation.

MATERIALS AND METHODS

We used a custom designed, pneumatically actuated loading frame to apply forces to otherwise normal cadaveric feet while measuring bony motion as well as force beneath the foot. The dorsal tarsometatarsal and the dorsal intercuneiform ligaments were attenuated and three muscle imbalances, each similar to imbalances believed to cause the pes cavus deformity, were applied while bony motion and plantar forces were measured.

RESULTS

Only one of the muscle imbalances (overpull of the Achilles tendon, tibialis anterior, tibialis posterior, flexor hallucis longus and flexor digitorum longus) was successful at consistently generating the changes seen in pes cavus feet. This imbalance led to statistically significant changes including hindfoot inversion, talar dorsiflexion, medial midfoot plantar flexion and inversion, forefoot plantar flexion and adduction and an increase in force on the lateral mid- and forefoot.

CONCLUSION

We have created a cadaveric model that approximates the general changes of the pes cavus deformity compared to normal feet. These changes mirror the general patterns of deformity produced by several disease mechanisms.

CLINICAL RELEVANCE

Future work will entail increasing the severity of the model and exploring various pes cavus treatment strategies.

A prospective study of Japas' osteotomy in paralytic pes cavus deformity in adolescent feet

BACKGROUND

Pes cavus is a progressive and ugly deformity of the foot. Although initially the deformity is painless, with time, painful callosities develop under metatarsal heads and arthritis supervenes later in feet. Mild deformities can be treated with corrective shoes, or foot exercises. However, in others, operative treatment is imperative. Soft tissue operations are largely unsatisfactory and temporary. Bony operations give permanent correction. We present our series of 18 patients of pes cavus in the adolescent age group, treated by Japas' V-osteotomy of the tarsus.

MATERIALS AND METHODS

18 patients of paralytic pes cavus deformity were treated by Japas osteotomy, between March 1995 and 2005, at our institute. The age of the patients ranged from 8.6 to 15 years (mean 11.3); 10 were boys and 8 girls. All cases had unilateral involvement, and all, but one, were post-polio cases.

RESULT

The mean follow-up is 5.4 years. Of the 18 patients, 14 had excellent or good corrections; 4 had poor correction/complications. However, those patients could be salvaged by triple arthordesis or Dwyer's calcaneal osteotomy.

CONCLUSION

Japas' osteotomy is a satisfactory option for correction of pes cavus deformity in adolescents. In patients who have rigid hind foot equinus or varus, however, the results are compromised.

Long-term results of reconstruction for treatment of a flexible cavovarus foot in Charcot-Marie-Tooth disease

BACKGROUND

Cavovarus foot deformity is common in patients with Charcot-Marie-Tooth disease. Multiple surgical reconstructive procedures have been described, but few authors have reported long-term results. The purpose of this study was to evaluate the long-term results of an algorithmic approach to reconstruction for the treatment of a cavovarus foot in these patients.

METHODS

We evaluated twenty-five consecutive patients with Charcot-Marie-Tooth disease and cavovarus foot deformity (forty-one feet) who had undergone, between 1970 and 1994, a reconstruction consisting of dorsiflexion osteotomy of the first metatarsal, transfer of the peroneus longus to the peroneus brevis, plantar fascia release, transfer of the extensor hallucis longus to the neck of the first metatarsal, and in selected cases transfer of the tibialis anterior tendon to the lateral cuneiform. Each patient completed standardized outcome questionnaires (the Short Form-36 [SF-36] and Foot Function Index [FFI]). Radiographs were evaluated to assess alignment and degenerative arthritis, and gait analysis was performed. The mean age at the time of follow-up was 41.5 years, and the mean duration of follow-up was 26.1 years.

RESULTS

Correction of the cavus deformity was well maintained, although most patients had some recurrence of hindfoot varus as seen on radiographic examination. The patients had a lower mean SF-36 physical component score than age-matched norms, and the women had a lower mean SF-36 physical component score than the men, although this difference was not significant. Smokers had lower mean SF-36 scores and significantly higher mean FFI pain, disability, and activity limitation subscores (p < 0.0001). Seven patients (eight feet) underwent a total of eleven subsequent foot or ankle operations, but no patient required a triple arthrodesis. Moderate-to-severe osteoarthritis was observed in eleven feet. With the numbers studied, the age at surgery, age at the time of follow-up, and body mass index were not noted to have a significant correlation with the SF-36 or FFI scores.

CONCLUSIONS

Use of the described soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity results in lower rates of degenerative changes and reoperations as compared with those reported at the time of long-term follow-up of patients treated with triple arthrodesis.

Charcot-Marie-tooth disease

Charcot-Marie-Tooth disease (CMT) or hereditary motor and sensory neuropathy constitutes a genetically heterogeneous group of diseases that affect the peripheral nervous system. CMT is characterized by degeneration or abnormal development of the peripheral nerve and is transmitted with different genetic patterns. In most cases, the disease starts in infancy. Its symptoms, among others, are an awkward gait; muscular atrophy of the 4 extremities, particularly distally; and foot deformities, such as cavus foot. People with CMT have an altered gait; most have a high stepping gait and frequently trip or fall. CMT disease can be classified according to the pattern of inheritance (autosomal dominant, autosomal recessive, or X-linked), electrophysiological findings (evidence of demyelination or axonal degeneration), or the mutated gene that causes the disease. This classification of CMT is complex and continually updated as new genes and mutations are found. CMT should be suspected in any patient with cavus foot, particularly if other members of the family have been diagnosed with the disease. Treatment decisions must be individualized and based on a clear history, careful examination, and well-defined patient goals.

Minimally invasive soft-tissue and osseous stabilization (MISOS) technique for midfoot and hindfoot deformities

The surgical repair of unstable midfoot and hindfoot deformities in the high-risk patient remains a challenge with little guidance available in the literature. The author presents a proposed surgical intervention for midfoot and hindfoot deformities utilizing a minimally invasive soft-tissue and osseous stabilization (MISOS) approach. The article presents a detailed, step-by-step description of the procedure used for these difficult limb salvage cases.

Corrective midfoot osteotomies

Corrective midfoot osteotomies involve complete separation of the forefoot and hindfoot through the level of the midfoot, followed by uni-, bi-, or triplanar realignment and arthrodesis. This technique can be performed through various approaches; however, in the high-risk patient, percutaneous and minimum incision techniques are necessary to limit the potential of developing soft tissue injury. These master level techniques require extensive surgical experience and detailed knowledge of lower extremity biomechanics. The authors discuss preoperative clinical and radiographic evaluation, specific operative techniques used, and postoperative management for the high-risk patient undergoing corrective midfoot osteotomy.

Management of the varus arthritic ankle

Treatment of the arthritic varus ankle presents a significant surgical challenge. The recognition of the causes and associated deformities directs the treatment of the individual patient and optimizes functional outcome. Arthrodesis and total ankle replacement often will need to be augmented by corrective hind- and midfoot procedures and by careful soft tissue balancing. Often multiple procedures are required to achieve the desired result, and patients need to be advised that surgery may need to be staged.

Charcot-Marie-Tooth disease and the cavovarus foot

This article focuses on the cavovarus foot shape, with particular emphasis on those patients who have Charcot-Marie-Tooth disease. Recent greater understanding of this deformity has led to a better appreciation of how the underlying condition drives deformity progression and treatment of the problems associated with it. The basic science underpinning the development of Charcot-Marie-Tooth disease is reviewed and some elements of the importance of the genetic variability are emphasized. The mechanics of the development of the cavovarus foot deformity in patients who have this neuromuscular condition are reviewed and the evaluation of such patients is described. The surgical options for treatment are reviewed and the outcomes of studies relevant to surgical planning for this patient population are summarized.

The subtle cavus foot and association with ankle instability and lateral foot overload

The subtle cavus foot alignment is associated with many injuries occurring in the athletic population, most commonly ankle instability and lateral foot overload. Although correction of the primary injury may address the manifestations of the subtle cavus foot, it does not change the alignment. Without recognition of this alignment, the injury likely will recur. The goal is to recognize the posture of the subtle cavus, treat the cavus and the injury, and prevent future recurrence.

Tibial compartment syndrome and the cavovarus foot

Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.

Midfoot and forefoot issues cavovarus foot: assessment and treatment issues

This chapter addresses the etiology and diagnosis of forefoot and midfoot cavovarus deformities, the relevant anatomy and biomechanics, and specific procedures for correction of the forefoot and midfoot. Associated hindfoot and ankle procedures will be referenced; however, their specifics will be reserved for other chapters.