1. CAVUS- NOT SO SUBTLE & ALLIED CONDITIONS ARMEN S KELIKIAN MD

2. CONFLICTS

3. INTRODUCTION/SUMMARY Level IV- H&P Level IV- H&P Rx soft tissue disorders Rx soft tissue disorders Realign osseous deformities Realign osseous deformities Ubiquitous locked foot & cavus is more of a musculoskeletal problem than PTD! Ubiquitous locked foot & cavus is more of a musculoskeletal problem than PTD!

4. Questions? Cavus foot incidence? 10,16, 23,43% 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 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 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 Bilateral cavovarus in peds population regardless of FHx is most likely HSMN?Y/N

5. Cavus & sports mannifestations 23% all feet 23% all feet Most idiopathic not neurogenic Most idiopathic not neurogenic Locked foot is ubiquitous Locked foot is ubiquitous ‘Peek a boo” heel-Manoli ‘Peek a boo” heel-Manoli 1 st metatarsal fat bulge 1 st metatarsal fat bulge Address underlying pathology Address underlying pathology Otherwise recurrence likely Otherwise recurrence likely

6. Sports manifestations Jones & Torg Fx- 5 th metatarsal Jones & Torg Fx- 5 th metatarsal Stress Fx’s tibia/fibula Stress Fx’s tibia/fibula Medial knee pain Medial knee pain Varus ankle with arthritis Varus ankle with arthritis Peroneal tendon tears & dislocation Peroneal tendon tears & dislocation Anterolateral ankle instability Anterolateral ankle instability

7. NORMAL ANATOMY OF PERONEAL TENDONS & RETINACULUM

8. PERONEAL SUBLUXATION USN 100,85,90% (s/s/a)JBJS-A 8/05 PERONEAL SUBLUXATION USN 100,85,90% (s/s/a)JBJS-A 8/05

9. Complex peroneus brevis tear Rx tubularize Complex peroneus brevis tear Rx tubularize 42% unable return sports(Syeel-Deorio FAI 1/07) 42% unable return sports(Syeel-Deorio FAI 1/07) Tears seen at groove,tubercle, or os in cuboid tunnel Tears seen at groove,tubercle, or os in cuboid tunnel Pl tears > cavovarus Pl tears > cavovarus Can excise peripheral tears <50% Can excise peripheral tears <50%

10. Retinacular flap & groove deepening

11. PB repair & retinacular reefing

12. PL III Rx Pulvertaft weave

13. Peroneus longus overpull Inability to raise lesser mt level with 1 st Inability to raise lesser mt level with 1 st With forced pf 1 st ray pf > lesser mts With forced pf 1 st ray pf > lesser mts If TA weak transfer EHL to TA or M-1 If TA weak transfer EHL to TA or M-1 Tenodese PL to PB Tenodese PL to PB

14. Dislocation-subluxation 2004 world series “bloody sock” 2004 world series “bloody sock” Acute-cast 4-6wks- seldom successful Acute-cast 4-6wks- seldom successful Provocative stress- DF/EVERSION Provocative stress- DF/EVERSION USN-subtle cases USN-subtle cases Superior retinaculum Superior retinaculum

15. Chronic Ankle Instability ANKLE SPRAINS – COMMON INJURY ANKLE SPRAINS – COMMON INJURY LATERAL COLLATERAL LIGAMENTS OF ANKLE LATERAL COLLATERAL LIGAMENTS OF ANKLE Ant. Talofibular Lig. Ant. Talofibular Lig. Calcaneofibular Lig. Calcaneofibular Lig.

16. Calcaneal deformity-varus- Biomechanics McEllvany-reciprocal relationship HF & FF McEllvany-reciprocal relationship HF & FF Coleman block test Coleman block test Carroll test Carroll test Sarrafian twisted plate Sarrafian twisted plate

17. Twisted plate – rigid lamina pedis

19. Lamina pedis Loose pack Loose pack Ext rot load column Ext rot load column Hindfoot varus Hindfoot varus Forefoot pronation Forefoot pronation Pf loose Pf loose Tight pack Tight pack Int rot load column Int rot load column Hindfoot valgus Hindfoot valgus Forefoot supination Forefoot supination Pf taut Pf taut

20. Cavovarus-Mosca 2014 Acquired sometimes progressive pronation deformity of the HF on FF Acquired sometimes progressive pronation deformity of the HF on FF FF pronated,MF adducted, HF endorotaion FF pronated,MF adducted, HF endorotaion Ankle apparent equinus in child-more FF Ankle apparent equinus in child-more FF Tibia ET Tibia ET Motor PL >> TA;Recruited EHL >FHL Motor PL >> TA;Recruited EHL >FHL Flexibility HF vs FF flexible vs stiff Flexibility HF vs FF flexible vs stiff

21. CLINICAL EVALUATION Wt. bearing exam Wt. bearing exam Prone biomechanical exam Prone biomechanical exam ROM ROM GSC strength GSC strength Heel width & height Heel width & height Coleman block test Coleman block test Neurologic Neurologic

22. PRINCIPLES Assume proper osseous realignments Assume proper osseous realignments Identify motor deficits: agonist/antagonist Identify motor deficits: agonist/antagonist Access soft tissue contractures Access soft tissue contractures Rules of tendon transfers:length,strength, in phase, rom, tension Rules of tendon transfers:length,strength, in phase, rom, tension Underlying pathologies Underlying pathologies Functional deficits Functional deficits

23. CLINICAL EVALUATION Wt. bearing exam Wt. bearing exam Prone biomechanical exam Prone biomechanical exam ROM ROM GSC strength & contracture GSC strength & contracture Coleman/Chestnut block test Coleman/Chestnut block test Manoli “peek-a-boo” Manoli “peek-a-boo” H Kelikian “push-up test” H Kelikian “push-up test” Neurologic Neurologic

24. No correction w Carroll/Coleman

25. RADIOGRAPHS AP/Lateral wt. bearing foot AP/Lateral wt. bearing foot Broden’s Broden’s Axial Axial Weight bearing axial -Cosby Weight bearing axial -Cosby

26. Coleman block Xray w Saltzman view

27. Considerations Age Age Unilateral vs bilateral Unilateral vs bilateral Progressive or static ? Progressive or static ? Idiopathic,traumatic,hereditary Idiopathic,traumatic,hereditary Rigid or flexible?-rom Rigid or flexible?-rom Agonist vs antagonist:PB/PT,PL/TA,E/F Agonist vs antagonist:PB/PT,PL/TA,E/F Hindfoot varus reciprocal to forefoot pron. Hindfoot varus reciprocal to forefoot pron.

28. Nonsurgical options Cavovarus orthotic device Cavovarus orthotic device Unload 1 st mtp head Unload 1 st mtp head Lateral heel sole wedge Lateral heel sole wedge

29. CMT 30 TYPES-HSMN Type I a-c 50% all case 50% all case AD AD IA 80% of I ncvs are 10-30ms IA 80% of I ncvs are 10-30ms IB point mutation severe demyelinating IB point mutation severe demyelinating IC-? Defect rare IC-? Defect rare Others II, X,IV II-20%,AD,ncv normal,indolent course II-20%,AD,ncv normal,indolent course X-linked females clinically, male carriers,10- 20%=defect conexin protein # 32 X-linked females clinically, male carriers,10- 20%=defect conexin protein # 32 IV-AR,rare,absent myelin proteins IV-AR,rare,absent myelin proteins

30. JM-HSMN

31. IMR

32. 60 mo f/u

33. Bilateral TTC fusions

34. 5 th metatarsal banana

35. 23 yo football 100kg

36. Removal 4mm retap insert 6.5mm & 1 st ray DCWO

37. Calcaneal deformity-varus Varus hinfoot Varus hinfoot Pronated 1 st ray Pronated 1 st ray McEllvenny CO:1958; reciprical relation McEllvenny CO:1958; reciprical relation Coleman block test Coleman block test Carroll test Carroll test Hind foot alignment view Hind foot alignment view

38. Cavovarus :Surgical Options Dwyer osteotomy:1cm lateral closing wedge Dwyer osteotomy:1cm lateral closing wedge Lateral displacement osteotomy <5mm Lateral displacement osteotomy <5mm Scarf triplane osteotomy Scarf triplane osteotomy 45 degree osteotomy 45 degree osteotomy Transfix with axial screw or staple Transfix with axial screw or staple Keep screw in lateral 1/3 of heel Keep screw in lateral 1/3 of heel 2 incision technique 5cm bridge:Anderson/ 2 incision technique 5cm bridge:Anderson/ Davis (AOFAS 8/04) for lat recon. Sx Davis (AOFAS 8/04) for lat recon. Sx

39. 1cm lateral cw osteotomy

40. Skin bridge 5cm

42. 41yo ankle pain

43. Allograft ligament failed Brostrom with cavovarus

44. mobilization

45. 1 st MT & Z osteotomy

46. 12mo post

47. AAAA @ 3mo

48. MA HF driven cavus Rx Dwyer/1 st MTO

49. Cavovarus: Surgical Options If 1 st ray pronated If 1 st ray pronated Or Coleman block shows correction Or Coleman block shows correction Modified Lapidus Modified Lapidus Dorsal closing wedge 1 st TMT joint Dorsal closing wedge 1 st TMT joint Cross screw,plate or staple fixation Cross screw,plate or staple fixation

50. 1 st MT DCW Osteotomy

51. 1 st ray Rx via dorsal cwo

52. Bibliography Kelikian AS.:Calcaneal Osteotomies.Ch;#23.Operative Rx of the Foot & Ankle,Appleton & Lange,Stamford,Conn;417- 32,1999. 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 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. 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 Sammarco GJ, Taylor R.:Combined calcaneal & metatarsal osteotomies for the Rx of the cavus foot.Foot & Ankle Clinics.#3:533-43.2001