surgical management and treatment algorithm for the subtle cavovarus foot

FOOT & ANKLE INTERNATIONAL

Copyright © 2010 by the American Orthopaedic Foot & Ankle SocietyDOI: 10.3113/FAI.2010.1057

Surgical Management and Treatment Algorithm for the Subtle Cavovarus Foot

Michael P. Maskill, DPM; John D. Maskill, MD; Gregory C. Pomeroy, MDPortage, MI

ABSTRACT

Background: Subtle cavovarus foot is a condition that can leadto significant foot pain and disability. We review the results ofour treatment algorithm at medium-term followup. Materialsand Methods: Thirty-five consecutive patients with lateralbased symptoms due to an underlying congenital subtle cavo-varus foot type were surgically corrected. Various procedureswere utilized, including some combination of the following:lateral displacement calcaneus osteotomy, peroneus longus tobrevis transfer, dorsiflexion first metatarsal osteotomy, andAchilles tendon lengthening. Twenty-three patients, with 29 feet,returned for followup examination. The mean patient age atthe time of surgery was 43.4 years, and the mean followupto date was 4.4 years. Results: The mean AOFAS ankle hind-foot score preoperatively was 45, and postoperatively was 90.Radiographically, the medial cuneiform to floor height changedfrom 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 tofusions or revisions. Ten feet (34%) required hardware removal.All patients had resolution of their symptoms following hard-ware removal. Conclusion: The surgical management for thesubtle cavovarus foot based on the proposed treatment algo-rithm provided symptomatic relief, longstanding correction, andhigh patient satisfaction.

Level of Evidence: III, Case Control Study

Key Words: Cavovarus; Subtle Cavus Foot; Ankle Instability;Peroneal Tendon Disorders

INTRODUCTION

In the past few years there has been increased interestin the diagnosis and treatment of the subtle cavovarus foot

No benefits in any form have been received or will be received from a commercialparty related directly or indirectly to the subject of this article.

Corresponding Author:Michael P. Maskill, DPMOrthopaedic Associates of Kalamazoo3810 Centre AvenuePortage, MI 49024E-mail: [email protected] information on pricings and availability of reprints, call 410-494-4994, x232.

(SCF).7 Pes planovalgus deformities have been discussed andunderstood, but the SCF deformity and its resultant patho-logical conditions have not been given equal emphasis. Thecavovarus foot has traditionally been associated with neuro-muscular conditions and severe deformity. Lately, a lesssevere form has been identified in the general population.7

The subtle cavovarus foot typically presents with lateralsymptoms commonly seen in patients with ankle/hindfootinstability, peroneal tendon injury, lateral column pain (painalong the anterior process of the calcaneus, cuboid, fourth,and fifth metatarsal), and even stress fractures of the fourthand fifth rays. Authors have thus placed increased emphasison this deformity as a probable underlying cause for thesesymptoms. The importance of identification and correction ofthis deformity along with its associated pathology has beenshown.11,24

The incidence of the SCF is probably higher than reportedas it often goes undiagnosed.7 Most often the presentingsymptoms are attended to, but the SCF deformity goeswithout correction potentially leading to a higher risk ofrecurrence of symptoms.16 An algorithm for surgical correc-tion of the SCF has not been formulated to date. Proceduresthat have been typically utilized in the past have been Dwyercalcaneus osteotomies for hindfoot varus, peroneus longus tobrevis tendon transfers, and dorsiflexion first metatarsal andlesser metatarsal osteotomies to correct the residual forefootbony deformity. The purpose of this study was to evaluateclinical and radiographic outcomes of the surgical manage-ment of the SCF and present a surgical treatment algorithm.

MATERIALS AND METHODS

Between May 1997 and November 2008, thirty-fiveconsecutive patients with a symptomatic subtle cavovarusdeformity were treated with a combination of procedures.Twenty-three patients (29 feet) were available for followup.Six patients had bilateral deformities that were treated. Theaverage time to followup was 4.4 (range, 1 to 10.1) years.There were 15 females and eight males with a mean age attime of operation of 43.4 (range 13, to 72) years.

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1058 MASKILL ET AL. Foot & Ankle International/Vol. 31, No. 12/December 2010

Table 1: Procedures Performed

Procedure# ofFeet % Patients

Lateral displacementcalcaneus osteotomy

29 100%

Peroneus longus toperoneus brevistransfer

25 86%

Dorsiflexion firstmetatarsal osteotomy

25 86%

Percutaneoustendo-achilleslengthening

8 28%

Gastrocnemiusrecession

5 17%

∗Peroneal tendon repair 9 31%∗Ankle ligament

reconstruction5 17%

All patients presented with lateral sided pain. Fourteen ofthe 29 feet (13 patients) had lateral sided pain secondary toa traumatic inversion ankle injury. Five of the 14 feet (36%)developed ankle instability, and nine of 14 (64%) sustainedperoneal tendon tears. Fifteen of the 29 feet presentedwith persistent lateral column pain. This was characterizedas pain along the calcaneocuboid joint, fourth and fifthtarsometatarsal joints, and/or fourth and fifth metatarsals.

The decision for operative intervention followed beingtreated conservatively for a minimum of 6 months withcustom-molded orthotics, various physical therapy modali-ties, bracing, and immobilization, if necessary. All patientsin the study failed conservative management and had persis-tent pain upon performing activities of daily living. Thegoal of operative intervention was to correct the underlyingsubtle cavovarus deformity using a combination of proce-dures. The procedures performed included a lateral displace-ment calcaneus osteotomy (LCO), peroneus longus to brevistendon transfer, dorsiflexion first metatarsal osteotomy, andan Achilles tendon lengthening (Table 1). All operationswere performed by the senior author (G.C.P.).

Clinical evaluation included a motor and sensory exam torule out a neurological etiology as the cause of the SCF. Allpatients with a neurological etiology were excluded from thestudy.

Evaluating the SCF without a neurological cause wasdone using a systematic approach. The Silverskiold testwas first performed to evaluate for the presence and typeof equinus.23 This test distinguished between an isolatedgastrocnemius contracture and a combined gastrocnemiusand soleus contracture.

Next, the hindfoot position was examined. All patients inthe study were noted to have a positive “peek-a-boo” heel

sign.3,8,19 The hindfoot varus was then evaluated with theColeman block test. The Coleman block test was performedby having the patient stand full weightbearing with the footand heel on a block, allowing the first ray to drop offmedially. It was used to isolate the hindfoot by eliminatingthe forefoot influence. If the hindoot corrected completely,the hindfoot varus deformity was thought to be forefootdriven. If the hindfoot remained in a varus position and didnot correct completely, the hindfoot was then noted to be acomponent of the deformity. All patients in the study werenoted to have a residual varus deformity.

After the above examination, the forefoot was then evalu-ated intraoperatively. After the equinus and residual hindfootvarus deformities were corrected, the forefoot could properlybe evaluated. If the first ray was hypermobile and manu-ally reducible to the level of the lesser metatarsal heads,then no persistent forefoot deformity was present. If therewas noted resistance to dorsiflexion of the first ray uponrange of motion, plantarflexion of the first ray was presentthus indicating a portion of the deformity was forefoot-driven. Twenty-five feet (86% of patients) had a forefootdeformity.

Radiographic evaluation was performed to assess theamount of structural correction obtained. Several radio-graphic parameters were measured, comparing preopera-tive and postoperative weightbearing radiographs (Figures 1to 4). The lateral talo-first metatarsal angle, calcaneal incli-nation angle (CIA), the antero-posterior talo-calcaneal angle(TCA), and the medial cuneiform height (MCH) were allused to assess the degree of radiographic correction.1,6,15 Thetalo-first metatarsal angle evaluated the amount of correc-tion obtained with a dorsiflexion first metatarsal osteotomy(Figure 1). The CIA and the antero-posterior TCA weremeasured to assess the overall cavus foot correction. TheMCH was utilized to best show the radiographic change inarch height. The AOFAS ankle hindfoot score (AHS) wasutilized preoperatively and postoperatively to assess clinicaland functional outcome.

Operative technique

The patients were placed supine on the operative table witha bolster under their ipsilateral hip to allow for exposure tothe lateral aspect of the foot and ankle. It was imperativethat an Achilles contracture was addressed prior to any otherprocedure because it allowes the surgeon to more accuratelyassess the residual varus deformity.

Intraoperatively, the Silfverskiold test was repeated. Anec-dotally, with anesthesia the patient was more relaxed, thusthe examination was more reliable. If the patient had a globalgastrocnemius-soleus contracture, a tendo-Achilles length-ening was performed percutaneously using the triple hemi-section technique. If an isolated gastrocnemius contracturewas present, then an isolated gastrocnemius recession wasdone using a postero-medial approach.10

Copyright © 2010 by the American Orthopaedic Foot & Ankle Society

Foot & Ankle International/Vol. 31, No. 12/December 2010 SUBTLE CAVOVARUS FOOT TREATMENT 1059

Fig. 1: Preoperative lateral view showing the elevated medial cuneiform height, increased calcaneal inclination angle, and an increased talo-first metatarsalangle.

Fig. 2: Preoperative talocalcaneal angle.Fig. 4: Postoperative talocalcaneal angle.

Fig. 3: Postoperative radiograph shows a restored talo-first metarsal angle (A), lowered calcaneal inclination angle (B) and medial cuneiform height (C).



Residual hindfoot deformity, clinically noted with a posi-tive Coleman block test, was addressed utilizing a lateraldisplacement calcaneus osteotomy. The lateral displacementcalcaneus osteotomy was made in an oblique fashion fromlateral to medial and the posterior tuber was then shiftedlaterally 5 to 10 mm until the hindfoot was in neutral tomild valgus. The osteotomy was fixated with two parallel6.5 partially threaded cancellous screws. The lateral borderof the displaced tuber was smoothed down using a powerrasp to avoid a painful prominence and/or sural neuritis.

Following correction of the equinus and residual hindfootvarus deformities, the forefoot examination was performed. Ifthere was no residual forefoot deformity (the first ray reducedto the level of the lesser metatarsal heads), then no furtherprocedures were required. If there was residual deformity ofthe first ray (the first metatarsal head was plantarflexed to thatof the lesser metatarsal heads), a PL to PB was performed.

A curvilinear incision was made beginning 1 cm proximaland posterior to the lateral malleolus. The incision wascarried distally to the interval between the peroneal tendonsand the lateral aspect of the posterior tuber of the calcaneus.Care was taken to protect the sural nerve during thedissection. Dissection was first carried anteriorly where thePL and PB tendons were identified distal to the superiorperoneal retinaculum (SPR). Their sheaths were incised, andthe PL tendon was then transferred to the PB tendon in aside to side manner. Care was taken not to disrupt the SPR.

If residual plantarflexion of the first ray was notedfollowing the PL to PB, then a dorsiflexion first metatarsalosteotomy was performed. This was done through a 4 cmdorsal incision beginning just proximal to the first tarsometa-tarsal joint (TMT) extending distally over the first metatarsalshaft. The extensor hallucis longus (EHL) tendon wasprotected, and the first TMT joint was identified. Measuring1cm distal to the first TMT joint, a dorsal wedge osteotomywas performed in the first metatarsal. The first metatarsalwas dorsiflexed to the level of the lesser metatarsal heads.A 3.5-mm cortical screw was placed from dorsal-distal toplantar-proximal. Care was taken not to encroach on the firstTMT joint.

Lastly, in the presence of ankle instability, an anterolateralcurvilinear incision was made for the modified Brostrum

procedure. This incision was utilized in addition to the otheradjunct incisions. Most importantly, the ligament repair wasperformed last to avoid disruption of the repair during theother procedures.

Postoperatively, the foot was placed in a bulky Jonescompression dressing with a posterior splint in neutralposition for 2 weeks. The foot was then placed in anonweightbearing fiberglass cast for the remaining 6 weeks.Ambulation was permitted 8 weeks following surgery withprogression of activities and return to regular shoewear atthat point.

RESULTS

Assessment of patient outcome was performed using theAOFAS ankle-hindfoot rating system.13 Twenty-nine feet, 23patients, were evaluated and had an average improvementfrom 45 to 90 points with an average followup of 4.4years (Figure 5). The Wilcoxon Signed Rank Test wasused which was expressed as the median and the rangewith a p value of 0.00004. Of the 13 patients (14 feet)that presented with a traumatic etiology, the postoperativescore was 92. The remaining patients with non-traumaticetiologies had a mean postoperative score of 89. Twenty ofthe 23 patients were extremely satisfied with their surgeryand functional outcome, with near to complete resolutionof their preoperative symptoms. All of these patients wereable to return to activities of daily living and recreationalactivities without restrictions. Three patients had continuedpain postoperatively and were not completely satisfied withtheir surgical result, though all stated it was improvedsubjectively when compared to their preoperative symptoms.However, all patients felt as though their symptoms improvedfollowing surgery and no patient felt that their symptomswere worse after operative treatment.

Radiographic parameters were examined as well. Therewas a significant improvement noted in the talo-firstmetatarsal angle as it improved from a mean of +9.9 degreespreoperatively to an average postoperative mean of +2.4degrees. The Wilcoxon Signed Rank Test was used for thisparameter and was expressed as the median and the range(Figure 6) (p < 0.00005). In a similar manner, the calcaneal

Fig. 5: The distribution of preoperative and postoperative AOFAS scores among all patients in the study.



Fig. 6: Changes in radiographic measurements noted preoperatively and postoperatively.

inclination angle (CIA) was measured preoperatively andpostoperatively and evaluated using the Wilcoxon SignedRank Test expressed as the median and the range. The meanpreoperative CIA was 26.1 degrees and postoperatively was22.7 degrees. This resulted in a mean decrease in the CIA of3.4 degrees (p < 0.00001) (Figure 6). The medial cuneiformto floor height was significantly improved as well. Themean medial cuneiform height (MCH) preoperatively was3.5 cm and the mean postoperative MCH was 3.0 cm givingan average correction of 0.5 cm (p < 0.00001) (Figure 6).Every patient had a lateral displacement calcaneal osteotomyin which the average amount of shift was 7.5 (range, 5 to10) mm.

To date, using our proposed treatment algorithm, no patienthas had recurrence of their subtle cavovarus deformity. Therewere no delayed unions, nonunions, or malunions noted ofthe lateral displacement calcaneal osteotomies or dorsiflexionfirst metatarsal osteotomies. There were three minor surgicalcomplications. Three patients developed superficial woundinfections. All of these patients received local wound careand oral antibiotics and went on to heal uneventfully.

Nine patients and ten of 29 feet (34%), experienced painlocated over the os calcis screws plantarly after beginningto weightbear. These patients required hardware removal.The hardware was removed at a mean of 11 monthspostoperatively. The removal of the screws resulted incomplete resolution of their symptoms. One patient hadscrews removed from bilateral heels.

The average time to return to work was 11 weeks. All 23patients returned to their preoperative employment, or levelof activity if retired or still in school. All patients workingreturned to work initially part-time, working 4 hours per daylight duty beginning at 10 weeks, then returned to work full-time without restrictions at 12 weeks.

DISCUSSION

The treatment for the SCF has not been equally describedor pursued in the literature when compared to the pesplanovalgus deformity. Most likely it is due to the lackof awareness of the subtle deformity. The incidence hasnot been described in the literature, however it is not asuncommon as we once thought. It has been shown that apersistent cavovarus foot position leads to chronic lateralankle instability with subsequent ankle arthritis,11,12,19,20

peroneal tendinopathy,4,16 and lateral column overload withrecurrent stress fractures along the lateral column.5,16 Recog-nition of this foot type and position is very important in theconservative and surgical management of the SCF.

Historically, the foot has been viewed as a tripod. There-fore, when the heel is in a varus position, it causes peroneuslongus overuse and further plantarflexes the first ray.4,16

Subsequently, the metatarsal declination angle increases,causing increased stress on the forefoot, potentially leadingto symptoms such as metatarsalgia of the first ray. In addi-tion, the plantar fascia contracts due to the shortened distance



between the first metatarsal head and calcaneus. It is unclearas to whether forefoot deformity causes hindfoot varus, orwhether the hindfoot varus causes the forefoot deformity.Perhaps in each patient it is different. Either way, the tripodfavors the lateral direction in the presence of varus. There-fore, the stress dramatically increases on the lateral sidecausing lateral sided pathology as previously mentioned.Remembering the tripod stance of the foot, biomechani-cally it is important to correct the varus deformity beforecorrecting any lateral pathology. If left uncorrected, recur-rence of the presenting complaint may be more frequent.24

Few associations have been made connecting lateral footand ankle pathologies with the SCF.16 The incidence of otherlateral foot pathology in the presence of a SCF deformityshould be evaluated in future studies. In our study, 48%(14 of 29) patients underwent concomitant lateral sidedsurgery along with the SCF reconstruction. No failureshave been noted to date. The only lateral ankle pathologiesoperated on were lateral ankle instability and peroneal tendontears.

Lateral ankle instability is one example of lateral pathologyassociated with the SCF. Larson and Angermann found ahigher frequency of cavovarus feet in patients who hadchronic lateral ankle instability compared to patients withnormal feet.14 Vienne et al. reported on four patients withidiopathic hindfoot varus that presented with ankle instabilitythat underwent a lateral displacement calcaneus osteotomy.24

All of their patients on initial presentation had an under-lying hindfoot varus deformity that was missed prior totheir lateral ankle ligament reconstruction that subsequentlyfailed. Colville stated that patients with chronic lateral ankleinstability and hindfoot varus alignment require a calcaneusosteotomy in order to avoid a ligament reconstruction failuredue to mechanical malalignment.9 Both groups of patientsdid very well and had complete resolution of their symp-toms. If left untreated, ankle instability can lead to ankledeformity and subsequent arthritis.11 Our study included fivepatients that presented with lateral ankle instability. Of thefive patients, all of them had a lateral displacement calca-neus osteotomy, and three had an additional PL to PB tendontransfer and a dorsiflexion first metatarsal osteotomy.

Of the lateral sided foot pathologies listed, generalizedlateral column pain seems to be the most common presentingsymptom associated with the SCF. The SCF can also besymptomatic in and of itself. Fifteen patients in our studyhad an isolated SCF foot that presented with generalizedlateral column foot pain. The patients failed conservativemanagement due to a residual varus hindfoot that wasuncorrectable with orthotics. Surgical correction was theironly option. The AOFAS scores in patients with isolatedSCF deformity were evaluated and this subset of patientsimproved dramatically. Therefore, one cannot say that thecorrection of the lateral ankle pathology (ankle instabilityor peroneal tendon tears) was the reason for the improvedpostoperative AOFAS scores.

The SCF is often accompanied by an equinus contracture.2

If an equinus contracture is present, the forefoot cavusmay be more pronounced. The peroneus longus tendon isa direct antagonist to the tibialis anterior tendon. As thefoot becomes more plantarflexed secondary to the equinuscontracture, the peroneus longus overpowers the tibialisanterior, which further plantarflexes the first ray.4,16 TheAchilles tendon further enhances the varus stress secondaryto the plantarflexed first ray and varus heel alignmentwhich alters the transmission of axial forces through theankle joint. In our study, 45% (13 of 29 feet) had antriceps surae lengthening. Of the 13 patients, eight had apercutaneous tendo-Achilles lengthening and five patientshad a gastrocnemius recession. All but one of these patientshad a peroneus longus to brevis tendon transfer and adorsiflexion first metatarsal osteotomy. This supports thefact that an equinus contracture leads to increased forefootdeformity and the need for forefoot correction.

Whenever possible, osteotomies are preferred overfusions.17,18 An isolated dorsiflexion first metatarsalosteotomy is typically all that is needed to correct the forefootdeformity in the SCF. If the deformity is more significant,then occasionally lesser metatarsal osteotomies are needed aswell.21,22 Fusions were not required in our study. All patientswere treated with a dorsiflexion first metatarsal osteotomyand a peroneus longus to brevis tendon transfer.

After the combined operative treatment, the overall satis-faction rate was very high. All patients improved postoper-atively and were pleased with their result. Pain and stabilitysignificantly improved postoperatively. The combined proce-dures did not impair the range of motion of the hindfoot orankle. No patients in our series developed severe arthriticchanges of the hindfoot or forefoot after an average of 53months postoperatively.

The radiographic parameters were shown to improvesignificantly as well (Figure 6). Thus, the authors came tothe conclusion that the improvement in deformity correlatedwith the improvement in patients’ symptoms. Due to thepaucity of data on radiographic analysis, we chose theseangles based on the pediatric literature for equinocavovarusfeet in comparison to the normal adult angles of the foot.These are the parameters that need to be evaluated whenperforming this correction.

One of the weaknesses of the study was the relativelysmall number of patients. Ideally, we would have likedto have more patients to increase the power of the study.Perhaps as we gain more knowledge of the deformity andmore corrections are performed, future studies will havehigher patient numbers. Also, the AOFAS scores wereassigned preoperatively and used postoperatively. While notvalidated, they have been accepted in the literature. Half ofour study was done with concomitant procedures making itdifficult to differentiate the improvement in patient outcomes.However, we did show significance with both the lateralankle procedures and the isolated SCF reconstructions. Not



only was this treatment effective, but it was a safe way toreconstruct the foot as there were very few complicationsencountered, and all were minor in nature.

Overall, the treatment algorithm presented to correct SCFfoot was both safe and reproducible. The results of this studysuggest that combining the proper operative procedures usingthe treatment algorithm provides good results and relief ofsymptoms of lateral ankle and foot pathologies associatedwith the SCF.

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surgical management and treatment algorithm for the subtle cavovarus foot

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