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The Akron Dome Midfoot Osteotomy as a Salvage Procedure for the Treatment of Rigid Pes Cavus: A Retrospective Review.
Weiner DS, Morscher M, Junko JT, Jacoby J, Weiner B. J Pediatr Orthop. 2008 January/February;28(1):68-80.
Quote:
OBJECTIVE:: In the early 1970s, the Akron dome osteotomy was developed as a salvage surgical option to manage rigid cavus deformity of the foot. This study represents an updated review of surgical cases between 1972 and 2001 constituting 89 patients representing 139 feet who were followed at least 2 years after the index operative procedure. Only cases achieving an unsatisfactory result followed less than 2 years were included.
STUDY DESIGN:: A retrospective review of cases (all operated by D.S.W.) was conducted by clinical examination and chart review of all 89 cases representing 139 feet.
RESULTS:: A satisfactory result was considered pain-free, at least 75% plantigrade foot in contact with the floor without abnormal symptomatic pressure areas, free of any significant deformity requiring surgical management. A satisfactory result was obtained in 106 (76%) and unsatisfactory result in 33 feet (24%). When separating the patients into those younger than 8 years and those older than 8 years, 67% of the patients younger than 8 years had a satisfactory result, and 82% older than 8 years had a satisfactory result. No significant complications were encountered. Because the surgery is located at the apex of the deformity in frontal, lateral, and plantar planes at the confluence of the longitudinal and transverse arches, multiplanar surgical correction was obtained in all cases at the time of the initial surgery. Currently, the most common causes of cavus deformity seen in our series were the sequelae of idiopathic talipes equinus varus clubfoot, congenital metatarsus varus, and assorted neuromuscular disorders, including Charcot-Marie-Tooth disease, cerebral palsy, and arthrogryposis.
CONCLUSIONS:: On the basis of this review, the Akron dome midfoot osteotomy is a very valuable salvage procedure in the management of the rigid cavus deformity in children.
BACKGROUND: The cavovarus foot has been defined as plantar flexion of the first ray. The usual cause is due to a muscle imbalance. The purpose of this study was to report our experience with selective, joint-sparing osteotomies of the foot that address each deformity in the cavovarus foot in a stepwise fashion. Most bony procedures for correction of cavus feet have centered on osteotomies across multiple joints or fusions.
METHODS: We report on stepwise osteotomies: (1) closing wedge to the first metatarsal, (2) opening plantar wedge of the medial cuneiform, (3) cuboid closing wedge, (4) and as needed second and third metatarsal osteotomies, calcaneal sliding osteotomies, and plantar fasciotomy and peroneus longus-to-brevis transfer. We measured all feet radiographically and clinically.
RESULTS: We studied 20 feet in 13 patients with multiple etiologies. Nearly all feet were graded good to excellent on our outcome scale. Correction in Meary and Hibb angles was observed. There were no significant complications.
CONCLUSIONS: By performing a double osteotomy on the first ray (cuneiform and metatarsal), the cavus can be nearly fully corrected. The cuboid osteotomy provides increased mobility of the forefoot. The sliding calcaneal osteotomy should be used to improve any residual hindfoot varus. We recommend transferring the peroneus longus to brevis to balance the paralytic foot. The cavus foot needs to be addressed at the apex, while sparing the midtarsal joints and avoiding fusion. This sequence of osteotomies addresses all of the components of a cavus foot.
PURPOSE OF THE STUDY: Anterior tarsectomy for pes cavus in adults is designed to relieve pain and correct the deformity. The present study reports radiological and clinical results with anterior tarsectomy in 39 cases of pes cavus.
MATERIAL AND METHODS: The study concerned 39 cavus feet in 33 patients (22 males, 11 females; mean age: 31 years, range 16-49 years). Clinical outcome was assessed in terms of pain, function and motion, using the AOFAS classification. Radiological assessment (anteroposterior and lateral stress X-ray, views with Méary superficial wire-marking) measured the Djian angle, talometatarsal alignment, talar slope, calcaneal slope, calcaneal valgus, and osteoarthritis stage in adjacent joints.
RESULTS: Mean follow-up was 9.8 years (range, 1-25). Mean AOFAS score at follow-up was 69.2/100 points (range, 14-100). Pain decreased considerably in 75% of cases, and 68% of patients recovered normal activity. The foot was aligned correctly in 67% of cases. At last follow-up, pes cavus remained undercorrected in 80% of feet, but mean Djian angle had improved from 100 degrees to 111.3 degrees . Calcaneal valgus improved from 30.8 degrees to 24.8 degrees and the podoscopic footprint was normal in 51% of feet. In 74% of feet, adjacent joints presented progressive osteoarthritic degeneration. Subjectively, 70% of patients were very satisfied or satisfied with minor reservations. Objective outcome was excellent or good in 66% of feet.
DISCUSSION AND CONCLUSION: Outcome in terms of function, motion, complications and satisfaction was good, although pain relief results were poor. Anterior tarsectomy is able to correct initial pes cavus deformity and compensate anomalies of the hindfoot, but its correction capacity is limited, and its efficacy in case of clawfoot is poor. Anterior tarsectomy spares the adjacent Chopart complex and Lisfranc joints while inducing hypermobility, and leads to arthritis in 74% of cases. Better results are obtained in cases of reestablishment of the Méary-Tomeno line and of hindfoot valgus, as well as in cases of correction of equinus and clawfoot deformities. Worse results are observed in case of neurological evolutive disease or insufficient correction of the preceding deformities
BACKGROUND: The cavovarus foot has been defined as plantar flexion of the first ray. The usual cause is due to a muscle imbalance. The purpose of this study was to report our experience with selective, joint-sparing osteotomies of the foot that address each deformity in the cavovarus foot in a stepwise fashion. Most bony procedures for correction of cavus feet have centered on osteotomies across multiple joints or fusions.
METHODS: We report on stepwise osteotomies: (1) closing wedge to the first metatarsal, (2) opening plantar wedge of the medial cuneiform, (3) cuboid closing wedge, (4) and as needed second and third metatarsal osteotomies, calcaneal sliding osteotomies, and plantar fasciotomy and peroneus longus-to-brevis transfer. We measured all feet radiographically and clinically. RESULTS: We studied 20 feet in 13 patients with multiple etiologies. Nearly all feet were graded good to excellent on our outcome scale. Correction in Meary and Hibb angles was observed. There were no significant complications.
CONCLUSIONS: By performing a double osteotomy on the first ray (cuneiform and metatarsal), the cavus can be nearly fully corrected. The cuboid osteotomy provides increased mobility of the forefoot. The sliding calcaneal osteotomy should be used to improve any residual hindfoot varus. We recommend transferring the peroneus longus to brevis to balance the paralytic foot. The cavus foot needs to be addressed at the apex, while sparing the midtarsal joints and avoiding fusion. This sequence of osteotomies addresses all of the components of a cavus foot.
A prospective study of Japas' osteotomy in paralytic pes cavus deformity in adolescent feet.
Chatterjee P, Sahu MK. Indian J Orthop. 2009 Jul;43(3):281-5.
Quote:
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.
Pes cavus is a complex foot deformity in which surgical correction remains challenging. We treated lesser-toe clawing in 11 feet of 8 patients (5 women, 1 bilateral; 3 men, 2 bilateral) with a modified Jones procedure and assessed long-term functional outcomes. We reviewed case notes and completed the Bristol Foot Score, the modified American Orthopaedic Foot & Ankle Society Midfoot Score, and a patient satisfaction questionnaire by means of telephone interviews. Mean age of the patients at the time of surgery was 30 years (range, 10-58 years). Mean time from surgery to the last clinical follow-up was 7 years (range, 0.5-17 years), and mean time from surgery to the telephone interview was 9 years (range, 1-18 years). At the final clinical review, all 11 feet were improved, although 6 had minor complications. The mean Bristol Foot Score was 27 (range, 16-55), and the mean modified American Orthopaedic Foot & Ankle Society Midfoot Score was 76 (range, 47-90), indicative of excellent results. Half of the patients had mild persistent foot pain, but all were satisfied with the outcome. Based on our experience with this group of patients, the modified Jones procedure yields satisfactory correction of lesser toe clawing in patients with flexible pes cavus
One thing that was omitted from the original post......
"Only cases achieving an unsatisfactory result followed less than 2 years were included."
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Last edited by drsarbes : 28th October 2009 at 12:40 PM.
Reason: correction
BACKGROUND:
The goals of cavus foot correction are to obtain a plantigrade foot with the heel in slight valgus position and to hopefully preserve joint motion in both the tarsal and metatarsal joints. The apex of many cavus deformities is near Chopart joint. We are reporting on a new technique involving navicular excision and cuboid osteotomy to correct severe stiff cavus feet.
METHODS:
A retrospective review of patients who underwent navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity was performed. A total of 11 children and 16 feet were treated during the past 8 years at 2 centers.
RESULTS:
All feet had navicular excision and a cuboid dorsal closing wedge osteotomy to correct a rigid cavus foot deformity. The etiology of the deformity was as follows: multiply operated congenital clubfoot (5 feet), arthrogryposis (6 feet), and neurological deficits (5 feet). At a mean follow-up of 4.9 years, all had a plantigrade foot.
CONCLUSIONS:
This salvage procedure offers an alternative method to correct a severe stiff cavus deformity. The procedure is performed at the apex of the deformity and thus maximum correction can be obtained by this "wedge resection." The curved articular surfaces of the cuneiforms articulate with the head of the talus post navicular excision if no fusion is desired. Navicular excision has been used to correct children with vertical talus, but not previously reported as a method to handle severe cavus. It is a salvage procedure that should be considered to address severe rigid cavus.
Background
This study reviewed patients undergoing correction of cavus foot deformity by metatarsal extension osteotomy with preservation of the plantar aponeurosis, and assessed the correction achieved of the claw deformity of the toe by radiographic assessment.
Method
15 patients (18 feet) were reviewed clinically and radiographically. All feet required extension osteotomy of the first metatarsal and four patients (5 feet) had extension osteotomy of the first to fourth metatarsals. Hallux extension angle in relation to the 1st metatarsal and in relation to the ground was measured in all feet to estimate the degree of clawing of the hallux.
Results
13 patients (15 feet) were satisfied with the outcome of their surgery and also the appearance of their foot. The mean radiographic change in the hallux extension angle in relation to the 1st metatarsal was 16°, and in relation to the ground was 7°. These changes were statistically significant.
Conclusion
Our results indicate an improvement in the claw toe deformity and we recommend preservation of the plantar aponeurosis in corrective surgery for cavus foot.
Pes Cavus Surgery
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