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CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS ARMEN S KELIKIAN MD.
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Transcript of CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS ARMEN S KELIKIAN MD.
CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS
ARMEN S KELIKIAN MD
CONFLICTS
INTRODUCTION/SUMMARY
Level IV- H&P Rx soft tissue disorders Realign osseous deformities Ubiquitous locked foot & cavus is
more of a musculoskeletal problem than PTD!
Questions?
Cavus foot incidence? 10,16, 23,43% If the hindfoot remains in varus with
the Coleman block test it should not be corrected? True/false
Cavovarus causes > anteromedial joint pressure in vitro at 15 degrees? True/false
Bilateral cavovarus in peds population regardless of FHx is most likely HSMN?Y/N
Cavus & sports mannifestations
23% all feet Most idiopathic not neurogenic Locked foot is ubiquitous ‘Peek a boo” heel-Manoli 1st metatarsal fat bulge Address underlying pathology Otherwise recurrence likely
Sports manifestations
Jones & Torg Fx- 5th metatarsal Stress Fx’s tibia/fibula Medial knee pain Varus ankle with arthritis Peroneal tendon tears & dislocation Anterolateral ankle instability
NORMAL ANATOMY OF PERONEAL TENDONS &
RETINACULUM
PERONEAL SUBLUXATION USN 100,85,90% (s/s/a)JBJS-
A 8/05
Complex peroneus brevis tear Rx tubularize
42% unable return
sports(Syeel-Deorio FAI 1/07)
Tears seen at groove,tubercle, or os in cuboid tunnel
Pl tears > cavovarus
Can excise peripheral tears <50%
Retinacular flap & groove deepening
PB repair & retinacular reefing
PL III Rx Pulvertaft weave
Peroneus longus overpull
Inability to raise lesser mt level with 1st
With forced pf 1st ray pf > lesser mts If TA weak transfer EHL to TA or M-1 Tenodese PL to PB
Dislocation-subluxation
2004 world series “bloody sock”
Acute-cast 4-6wks-seldom successful
Provocative stress-DF/EVERSION
USN-subtle cases Superior
retinaculum
Chronic Ankle Instability ANKLE SPRAINS
– COMMON INJURY
LATERAL COLLATERAL LIGAMENTS OF ANKLE Ant.
Talofibular Lig. Calcaneofibula
r Lig.
Calcaneal deformity-varus-Biomechanics
McEllvany-reciprocal relationship HF & FF
Coleman block test Carroll test Sarrafian twisted
plate
Twisted plate – rigid lamina pedis
Lamina pedis
Loose pack Ext rot load column Hindfoot varus Forefoot pronation Pf loose
Tight pack Int rot load column Hindfoot valgus Forefoot supination Pf taut
Cavovarus-Mosca 2014
Acquired sometimes progressive pronation deformity of the HF on FF
FF pronated,MF adducted, HF endorotaion
Ankle apparent equinus in child-more FF
Tibia ET Motor PL >> TA;Recruited EHL >FHL Flexibility HF vs FF flexible vs stiff
CLINICAL EVALUATION Wt. bearing exam Prone biomechanical exam ROM GSC strength Heel width & height Coleman block test Neurologic
PRINCIPLES Assume proper osseous realignments Identify motor deficits:
agonist/antagonist Access soft tissue contractures Rules of tendon
transfers:length,strength, in phase, rom, tension
Underlying pathologies Functional deficits
CLINICAL EVALUATION Wt. bearing exam Prone
biomechanical exam
ROM GSC strength &
contracture Coleman/Chestnut
block test Manoli “peek-a-
boo” H Kelikian “push-up
test” Neurologic
No correction w Carroll/Coleman
RADIOGRAPHS
AP/Lateral wt. bearing foot Broden’s Axial Weight bearing axial -Cosby
Coleman block Xray w Saltzman view
Considerations
Age Unilateral vs bilateral Progressive or static ? Idiopathic,traumatic,hereditary Rigid or flexible?-rom Agonist vs antagonist:PB/PT,PL/TA,E/F Hindfoot varus reciprocal to forefoot
pron.
Nonsurgical options
Cavovarus orthotic device Unload 1st mtp head Lateral heel sole wedge
CMT 30 TYPES-HSMN
Type I a-c 50% all case AD IA 80% of I ncvs are
10-30ms IB point mutation
severe demyelinating IC-? Defect rare
Others II, X,IV II-20%,AD,ncv
normal,indolent course
X-linked females clinically, male carriers,10-20%=defect conexin protein # 32
IV-AR,rare,absent myelin proteins
JM-HSMN
IMR
60 mo f/u
Bilateral TTC fusions
5th metatarsal banana
23 yo football 100kg
Removal 4mm retap insert 6.5mm & 1st ray DCWO
Calcaneal deformity-varus
Varus hinfoot Pronated 1st ray McEllvenny CO:1958; reciprical
relation Coleman block test Carroll test Hind foot alignment view
Cavovarus :Surgical Options
Dwyer osteotomy:1cm lateral closing wedge
Lateral displacement osteotomy <5mm Scarf triplane osteotomy 45 degree osteotomy Transfix with axial screw or staple Keep screw in lateral 1/3 of heel 2 incision technique 5cm bridge:Anderson/ Davis (AOFAS 8/04) for lat recon. Sx
1cm lateral cw osteotomy
Skin bridge 5cm
41yo ankle pain
Allograft ligament failed Brostrom with cavovarus
mobilization
1st MT & Z osteotomy
12mo post
AAAA @ 3mo
MA HF driven cavus Rx Dwyer/1st MTO
Cavovarus: Surgical Options
If 1st ray pronated Or Coleman block shows correction Modified Lapidus Dorsal closing wedge 1st TMT joint Cross screw,plate or staple fixation
1st MT DCW Osteotomy
1st ray Rx via dorsal cwo
Bibliography Kelikian AS.:Calcaneal
Osteotomies.Ch;#23.Operative Rx of the Foot & Ankle,Appleton & Lange,Stamford,Conn;417-32,1999.
Mosca, VS; Principle and management of pediatric foot & ankle deformities & malformations. Wolters Klumar,2014
Rodrigues RP.:Medial displacment calcaneal osteotomy in the Rx of PTD. Foot & Ankle Clinics.#3,545-67,2001.
Sammarco GJ, Taylor R.:Combined calcaneal & metatarsal osteotomies for the Rx of the cavus foot.Foot & Ankle Clinics.#3:533-43.2001