Surgical Management

of the Cavus Foot

Erin Klein, DPM, MS
[email protected]
 Definition

A cavus foot is defined as:

An equinus deformity of the forefoot
on the rearfoot
Andry, 1700s

Completely incomplete definition

 Easier to understand definition

High arched foot

Plantarflexed 1st ray
Heel varus

Can be flexible or rigid

The cavus foot & ankle deformity

The cavus foot is a complex deformity.

There are osseous deformities and compensations
There are soft tissue deformities and compensations
The influence of proximal structures (i.e. ankle, tibia, femur,
lower back) may or may not be present.
There may or may not be a neurological component of the
disease.

Unlike other complex deformities of the foot an ankle (i.e.

flatfoot, arthritidies), there is much less agreement on the
treatment of the cavus foot.
Classification Systems
If there is a classification system for it, there are
‘standardized’ test questions on it.
 Japas Classification

Anterior
Posterior
Combined
 Anterior Cavus

Equinus of the forefoot on the rearfoot

The anterior and lateral muscle groups may not be

functioning effectively
The posterior muscle group creates deformity

Apex of the deformity:

Midtarsal joint
Lesser tarsus
Tarso-metatarsal
 Anterior Cavus

Apex of the deformity:

Metatarsus cavus:
Lis Franc’s joint, prominence at midtarsal joint
Lesser tarsus cavus:
Entire lesser tarsus, prominence at lesser tarsal area
Forefoot cavus:
Chopart’s joint, lateral talar prominence
Combined:
More than 1 of the above
 Anterior Cavus

Lateral column
More flexible
Compensation = STJ pronation
May look similar to a forefoot varus

Medial column
May or may not be flexible
Compensation = STJ supination
May look similar to a forefoot valgus
 Posterior Cavus

STJ deformity
Increased calcaneal inclination

The posterior muscle groups are weak or paralyzed

Anterior and lateral groups can create deformity

Compensation = STJ pronation, forward shift of body

balance
 Ruch Classification – Stage 1

Stage 1
Deformity primarily restricted to the
metatarsals, MTP joints or digits
Surgical management:
Digital fusions
MPJ release
Extensor tenotomies
Flexor transfers
 Ruch Classification – Stage 2

Stage 2
Rigid plantarflexed 1st ray and rearfoot varus
Surgical management:
DFWO
Dwyer
STATT
Peroneal stop
Calcaneal scarf for varus
 Ruch Classification – Stage 3

Stage 3
Severe global deformity and probable
neuromuscular etiology
Surgical management:
Midtarsal osteotomies
Triple arthrodesis
Tendon transfers
 Etiology

Neuromuscular
Congenital-hereditofamilial
Traumatic
Idiopathic
 Etiology
Idiopathic NM

Keep Flaccid Spastic

searching?

Static Progressive Static Progressive

Polio CMT CP Spinal cord

Trauma
Peripheral neuropathy Trauma tumors
Friedreich’s ataxia Spina bifida
Msucular dystrophy Brain tumors
Syringomyelia
 Flaccid - Static

Most common causes:

Polio
Trauma
MOA:
RF plantarflexors are weak (achilles)
FF plantarflexors are stronger (intrinsics)
Metatarsals become plantarflexed
Resultant calcaneal dorsiflexion
 Flaccid - Progressive

CMT (50%)
Intrinsics loose function first
Peroneals
Tibialis anterior
Posterior tibial and gastroc
Peripheral neuropathy
Friedreich’s ataxia
Muscular dystrophy
 Spastic - Static

CP
Trauma
Spina bifida
Syringomyelia
 Spastic - Progressive

Spinal cord tumors

Brain tumors
 Idiopathic Pes Cavus

Metatarsus adductus
Tarsal rheumatoid arthritis
Plantar fascia contracture
Hyperactive peroneus longus
Paralyzed intrinsics
Infection
Overactive calf musculature
Lederhose disease
Inherited structure
 Associated Conditions
Forefoot varus
Forefoot valgus
Plantarflexed 1st ray
Hypermobile 1st ray
Metatarsus adductus
Rearfoot equinus
Pseudoequinus

Lateral ankle instability

Peroneal tendon pathology
Repetitive metatarsal stress fractures
Repetitive 5th metatarsal fractures
Ulcerations
Gait abnormalities
 The ‘subtle’ cavus foot

Definition:
The cavus foot that may not be readily obvious
The underlying pathology in lateral foot and ankle problems
Associated problems:
Peroneal tendon pathology
Lateral ankle instability
Surgical answer:
If you are going to fix the lateral ankle instability and associated
pathology, you MUST fix the underlying cavovarus deformity
 The Buzzwords
If you have buzzwords, they are easily testable material
from now until the end of your board exam taking days.
 How do you determine
the influence of the 1 st

ray on a rearfoot varus?

 How do you determine
the influence of the 1 st

ray on a rearfoot varus?

Coleman block test
 Coleman Block Test
The patient stands on the floor.
The patient stands on a 2-4 inch raised surface with the
lateral column being supported and the medial 3 rays
allowed to ‘dangle’ or ‘hang’. Foot is allowed to adjust to
this position.
Observation: The position of the heel in both situations.
 Coleman Block Test
In this case, the rearfoot comes to neutral.
This means that the 1st ray is influencing the position of the
hindfoot.
This also means that the subtalar joint is supple and mobile.
The 1st ray MUST be considered when planning management of
the hindfoot as the 1st ray may be a large part of the foot
deformity
 Coleman Block Test
In this case, the rearfoot stays inverted.
This means that the 1st ray has NO influence on the
position of the hindfoot.
This means that the hindfoot is more rigid.
The hindfoot is the primary deformity to be addressed
 How do you determine
the influence of the
forefoot on the rearfoot?
The Carroll Test
 The Carroll Test
Allow the forefoot to dangle off a block or a stair
Observe what happens to the hindfoot
Rearfoot comes to neutral  forefoot is driving the rearfoot
deformity; rearfoot deformity is supple/flexible
Rearfoot stays in varus  forefoot is less important; rearfoot is
rigid
A more practical look at
your patients….
What you will encounter in case presentations, board exams
and every day life.
The cavus foot is more common that people realize.
 History

Frequent falls
Frequent ankle sprains
Shoes wear out easily

Progressive deformity?
Associated problems
Development (mental and motor), This is a RIGHT
congenital, etc.
shoe.
 Physical Exam

Midline lesions?
Sensory exam
Motor exam
Strength and stability
Can they stand on one foot?
Gait analysis
Shoe wear

Neuro exam?
Rhomberg test, etc.
Normal Abnorma
l
 Psuedoequinus
If the talus is parallel to the weight bearing surface, how
can it dorsiflex through an adequate ROM?
 Imaging

X-rays
Foot and spine
MRI and/or CT
Foot, spine, brain, etc.
Radiographic Findings
 Radiology
Calcaneal inclination angle
Normal: 24.5o
Moderate cavus: 25 - 40o
Severe cavus: >40o
 Radiology

Hibb’s angle
Calcaneal inclination
Longitudinal bisection of the 1st metatarsal

>160 – pes planus

130 – 160 – normal
<130 – pes cavus
 Radiology
Meary’s angle
Longitudinal axis 1st metatarsal
Longitudinal axis of the talus
 Radiology
Meary’s angle
>4 convex upward (pes cavus)
0 – normal
<4 convex downward (pes planus)
 Radiology

Hindfoot alignment view

Compare the bisection of the
calcaneus to the bisection of
the tibia.
Axial calcaneal view
 Radiology
Ankle views
Talar tilt test
Joint congruity
Arthritic processes
 Talar Tilt/Talocrural Angle

Mortise view

Line between the two

malleoli
Line of the dorsal aspect of
the talus

Normal: 79 – 87

Difference <3-5 degrees

Plantar Pressures
 Labs & Consults

These are all best utilized when you suspect an underlying

neurological problem. Not ALL cavus foot patients require
labs.
Neurology consult
EMG/NCV
Labs
CPK, SGOT/LDH
EKG
Lumbar puncture, myelogram, spine CT/MRI
Genetic studies
Management of the
Cavus Foot
 Non surgical management

Orthotics
Full length top cover, 1st ray cutout
Arch fill
Bracing
Arizona brace, AFO
Shoes
Extra depth shoes
Stretching

The goal of non surgical management is a

plantigrade foot that is amenable to ambulation.
 Surgical History
Steindler (1912)
Jones (1916)
Hibbs (1919)
Hoke (1921)
Ryerson (1923)
Stuart (1924)
Sherb (1924)

Lambrinudi (1927)
Cole (1940)
Watkins (1954)
Dwyer (1963)
Japas (1968)
All of these authors
Weil (2001)
have an article in the literature that
describes their procedure to fix the cavus foot.
 Surgical Principles

The goal of surgical principles is to create a plantigrade

foot that is functional.

Surgical planning includes considering the following:

+/- neuromuscular disease
Apex of the deformity
Biomechanical function
The procedure of choice will:
Fix structural deformities
Transfer tendons as necessary without creating a dynamic muscle
imbalance
Address the achilles when necessary
 Surgical Management

When contemplating surgical management, you MUST:

Select your surgical patient correctly.

Do a good dx workup
Downplay the outcome
Over-estimate the recovery period
Under-estimate the amount of pain relief expected
Sequence of Cavus Foot Reconstruction

Soft tissue release

Many times the soft tissues have adapted and/or shortened over
time. Releasing the soft tissue allows mobilization of bones and
joints.
Rearfoot fusion or osteotomy
Correct the rearfoot deformity first.
The position of the subtalar joint is the most important as this will
influence all of the following procedures.
Midfoot fusion
Metatarsal/digital surgery
Tendon transfers
Soft Tissue Releases
 Pathologic Soft Tissue Anatomy

Spring ligament
Long plantar ligament
Plantar fascia
Plantar muscles
 Fasciotomy
Release the plantar fascia
Decreases the possibility of the plantar fascia being a soft
tissue deforming force.
 Steindler’s Stripping

Release the following structures:

Plantar fascia
1st layer of plantar muscles
Long plantar ligament (if needed)

May compromise NV structures

May cause hammered toes (long term sequela)

Video:
https://www.youtube.com/watch?v=zVOcJ1J5txc
Rearfoot Osteotomies
 Dwyer Osteotomy

Indication:
Varus calcaneus
Procedure:
Laterally based closing wedge of the calcaneus
This means that a wedge of bone, in the shape of a triangle, is removed.
The base of the triangle is on the lateral aspect of the bone.
The apex of the triangle is on the medial aspect of the bone.
Once the triangle is removed, the bone edges are reapproximated.
In doing this, the position of the posterior calcaneus is changed decreasing
the varus attitude of the bone.
Complications:
Sural neuritis
Malunion
 Dwyer Osteotomy

Video:
https://youtu.be/lQgtOeXMmk0
 Calcaneal Scarf Osteotomy

Indication:
Cavovarus deformity
Procedure:
Scarf of the calcaneus with a laterally based wedge taken from
long arm of the osteotomy
Complications:
Sural neuritis
Calcaneal Scarf Osteotomy
 Fusions
Fusion of the joint(s) that is the problem
 Triple Arthrodesis

Goals of procedure:
Stable statis re-alignment of the foot
Removal of deforming forces
Arrest the progression of the deformity
Eliminate pain and decrease gait abnormalities
Indication:
Significant arthrosis of the hindfoot (STJ, TN and CC joints)
 Triple Arthrodesis

Procedure:
Medial and lateral incisions
Release any capsule or ligamentous tissue that is preventing reduction of
the deformity
Resect the TN, the CC and then the STJ
Fixate the STJ, the TN and then the CC
Complications:
Delayed or non-union
Sural neuritis
Stiffness
Adjacent joint arthrosis
Triple Arthrodesis – Fixation Constructs
Midfoot Osteotomies
 Cole Osteotomy

Indications:
Rigid global anterior cavus
Procedure:
Dorsally based wedge osteotomy of the midfoot
Spares the TN and CC joints
Plantar fascia release
Video of this procedure:
Complications: https://www.youtube.com/
Non union/malunion watch?
Shortening of the foot feature=player_embedded&v=A
NV compromise XdKsXD1boM
 Japas Osteotomy

Indications:
Rigid anterior global cavus
Procedure:
V osteotomy with the apex in the navicular
Arms in medial cuneiform and cuboid
joints
Dorsiflex the distal portion of the foot
Complications:
Non union/malunion
Arthrosis
Dorsal hump
NV compromise
 Miscellaneous

Gianninni et al
Closing wedge of the cuboid
Navicular-cuneiform fusion
Plantar fascia release
?
Closing wedge of the cuboid
Opening wedge of the medial cuneiform
Tendon Transfers
 Principles of Tendon Transfers

Pre-operatively
Adequate strength
ROM after transfer
In phase transfer: the tendon transferred is active at the same phase of gait as the tendon
that it is replacing
Out of phase: the tendon transferred is active at a DIFFERENT phase of gait as the
tendon that it is replacing. This type of transfer requires a longer course of post-operative
rehab and the patient may ALWAYS require a brace.
Intra-operatively
Smooth channel for excursion
Maintain NV supply
Straight line of contracture
Reattach under sufficient tension
Post-operatively
Need for post operative therapy
This is NOT optional
 Jones Tenosuspension

Indications:
Flexible plantarflexed 1st ray
Procedure:
Detatch the extensor hallucis
longus from the midshaft of the
proximal phalanx
Reattach to the 1st metatarsal
head
Complications:
Loss of extensor power? Video of this procedure:
Creation of muscle imbalance? https://www.youtube.com/
watch?
Creation of a new deformity? v=DjExa2IOzog&has_verifi
ed=1
 Hibbs Tenosuspension

Indications:
Flexible HDS
Procedure:
Detatach the extensor digitorum longus tendons of toes 2-5
Anchor these tendons to the 3rd cuneiform
Theory:
Decreased DF at the MTP joints  decreased retrograde pressure on
the metataral heads  decreased metatarsalgia
Complications:
Instability of the MTP joints
NV compromise
 Heyman

Indications:
Extensor substitution hammer toes 1-5
Procedure:
Detatch the extensor hallucis longus and the extensor digitorum
longus tendons
Anchor to the respective metatarsal heads
Theory:
Decreased extensor substitution effect
Complications:
Instability of the lesser MTP joints
 Split Tibialis Anterior Tendon Transfer
(STATT)
Video of this procedure:
Indications: https://youtu.be/
Swing phase supinatus LIvRy3C_xJQ
Tibialis anterior is a deformity force
Procedure:
Tibialis anterior is split in half.
The medial ½ stays attached to the cuneiform
The lateral ½ is attached to the 3rd/lateral cuneiform
Complications:
Loss of function
Over correction of the rearfoot deformity
 Tibialis Posterior Tendon Transfer
(TPTT)

Indications:
Drop foot, spastic equinus
Procedure:
Tibialis posterior is detatched from its insertion
Transferred through the interosseous membrane to the dorsum of
the foot
Complications: Videos of this procedure:
Loss of PT tendon function https://youtu.be/xJRCizZXK6o
Forefoot deformities 1. https://youtu.be/mvuvPD1aSok
Peroneus Longus Tendon Transfer

Indications:
Drop foot, PF 1st ray
Procedure:
½ or all of the PL is transferred to the 3rd
cuneiform
Complications:
Loss of PL function
 Peroneal Stop Procedure

Indications:
Overactive/spastic PL that is causing PF of the 1st ray
Procedure:
Tenotomize the peroneus longus
Suture the longus to the brevis
Complications:
Alterations in peroneal function
External Fixation
 External Fixation in the Cavus Foot

Circular frames
These frames contain multiple ring structures,
half pins, k-wires.
Originally described by Illizarov
Unilateral frames
These frames contain half pins and the fixator.
These are only applied to 1 side of the bone in
question (much like their name suggests)
Hybrid frames
Contain components of the previous two
Taylor spatial frames
Modified Illizarov frame that is dynamic.
This can correct deformity in 6 planes at the
same time.
 Taylor Spatial Frames
The original procedure typically involved a corticotomy
and frame application.
Each week the mobilization pins are adjusted to gradually
obtain deformity correction.
Once deformity correction is obtained, the frame is set in
that position for a period of time.
The frame is then removed.
 Conclusions

The cavus foot/ankle is a complex deformity

A true understanding of the etiology of the problem along
with any structural compensation is required prior to
surgical correction being attempted.
The goal of surgical correction is a plantigrade foot that is
amenable to shoes with or without bracing.
 The End!
Contact me with any questions:
[email protected]