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Domingues LS, Norte S, Thusing M, Neves MC. Is there a place for dorsal hemiepiphysiodesis of the first metatarsal in the treatment of pes cavovarus? J Pediatr Orthop B 2025; 34:151-156. [PMID: 39302844 PMCID: PMC11776887 DOI: 10.1097/bpb.0000000000001209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 09/01/2024] [Indexed: 09/22/2024]
Abstract
The objective of this study is to describe and evaluate dorsal hemiepiphysodesis of the first metatarsal as an osteotomy replacement technique. Retrospective analysis of patients with pes cavovarus (PCV) treated in our center with dorsal hemiepiphysodesis of the first metatarsal. Meary's angle, calcaneal pitch, and Moreau Costa Bartani were compared pre and post-operatively and the ratio between width and foot length was monitored. Between May 2012 and May 2022, eight patients (14 feet) with PCV underwent dorsal hemiepiphysiodesis of the first metatarsal combined with the Steindler procedure. Four patients (50%) were male. The average age for boys at surgery was 10.75 years (10-11) and for girls was 9.75 years (8-11). Most patients (87.5%) had idiopathic PCV and 12.5% had a neurological PCV. Median follow-up was 4.3 years (1.5-10) and a benefit was seen in all patients in Moreau Costa Bartani angle (112.64° vs. 120.59°; P value = 0.003), calcaneal pitch (26.48° vs. 25.36°; P value = 0.091) and Meary's angle (10.60° vs. 5.36°; P value = 0.008) after surgery. Supination improvement was also shown (0.21 vs. 0.24; P value = 0.039). Despite the limited number of patients, the results demonstrated that dorsal hemiepiphysiodesis of the first metatarsal can be a valid alternative to osteotomy of the base of the first metatarsal, with less morbidity and a gradual and dynamic correction throughout growth.
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Affiliation(s)
- Liliana S. Domingues
- Unidade de Ortopedia Infantil, Hospital CUF Descobertas, Lisboa
- Serviço de Ortopedia, Hospital Sant’Iago do Outão, Setúbal, Portugal
| | - Susana Norte
- Unidade de Ortopedia Infantil, Hospital CUF Descobertas, Lisboa
| | - Mónika Thusing
- Unidade de Ortopedia Infantil, Hospital CUF Descobertas, Lisboa
| | - Manuel C. Neves
- Unidade de Ortopedia Infantil, Hospital CUF Descobertas, Lisboa
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Michalski MP, Blough CL, Song JH, Pfeffer GB. Méary's angle decoded: 3D analysis of first ray plantarflexion deformity in Charcot-marie-tooth disease. Foot Ankle Surg 2025; 31:143-147. [PMID: 39168758 DOI: 10.1016/j.fas.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/12/2024] [Accepted: 08/06/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND The typical cavovarus deformity seen in patients with Charcot-Marie-Tooth (CMT) involves plantarflexion of the first ray. The exact apex of the deformity has never been proven, although it is presumed to be within the medial cuneiform. The aim of this study was to utilize weight-bearing computed tomography (WBCT) to localize and quantify first ray plantarflexion deformity in CMT patients. METHODS WBCTs of 16 CMT patients with lateral Méary's angle > 20 degrees were compared to controls utilizing semi-automated analysis software. A local coordinate system based on the first metatarsal was used to avoid bias of proximal deformity. The tarsometatarsal angle was subdivided into components (cuneiform-cuneiform joint normal, tarsometatarsal joint and metatarsal-metatarsal joint normal) and compared between CMT and controls. CMT patient's first, second and third rays were also compared. Means were compared with a 2-sample t test (p < .05). RESULTS CMT patients had significantly more plantarflexion of the first ray than controls (16.4 versus 8.8 degrees respectively(p < 0.001)). The largest difference of was found at the medial cuneiform with 20.6 degrees of plantarflexion in CMT patients versus 14.8 degrees in controls (p < .0001). There was also approximately 2 degrees of plantarflexion at the TMT joint (p < .001). CONCLUSIONS Plantarflexion deformity in CMT patients is primarily an osseous deformity at the level of the medial cuneiform with a lesser contribution from the tarsometatarsal joint. LEVEL OF EVIDENCE III Retrospective comparative study.
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Affiliation(s)
- Max P Michalski
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 S. San Vicente Blvd, Suite 603, Los Angeles, CA 90048, USA.
| | - Christian L Blough
- Department of Orthopaedic Surgery,Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jae Hwang Song
- Department of Orthopedic Surgery, Konyang University Hospital, Daejeon, Republic of Korea
| | - Glenn B Pfeffer
- Department of Orthopaedic Surgery,Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Chen S, Zhou W, Yan Y, Shan Y, Zhang Y, Zhang X, Bai L. Surgical correction of cavus foot may promote quality of life in patients with Charcot-Marie-Tooth disease: A retrospective study. J Foot Ankle Surg 2025:S1067-2516(25)00006-7. [PMID: 39778761 DOI: 10.1053/j.jfas.2024.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Revised: 12/05/2024] [Accepted: 12/30/2024] [Indexed: 01/11/2025]
Abstract
Charcot-Marie-Tooth disease (CMT) is a hereditary peripheral neuropathy leading to neuromuscular impairments, muscle atrophy, and functional limitations. Currently, no specific treatment exists to restore muscle strength in patients with CMT, and the disease can be severely disabling. Surgical correction of cavus foot has been suggested as a potential intervention to alleviate pain and improve gait in selected patients. This study aimed to evaluate the therapeutic effects and analyze the subsequent improvement in quality of life. A retrospective analysis was conducted on 45 patients (57 feet) who underwent surgical correction of cavus foot due to CMT. Annual follow-up assessments involved clinical symptoms, and patient-reported outcomes, including the Foot and Ankle Disability Index (FADI) and the Short-Form 12 (SF-12). Radiological evaluation was performed using the Meary angle, calcaneal pitch angle, talocalcaneal angle, talo-first metatarsal angle, and calcaneal-fifth metatarsal angle. After 2 years of follow-up, most radiographic and symptomatic outcomes improved significantly. Functional scales showed a significant increase (P < .001) in median FADI (23 vs. 40) and physical component score of the SF-12 (26 vs. 41). Therefore, surgical correction of cavus foot should be considered an effective intervention for patients with CMT, leading to sustained improvements in function and quality of life. LEVEL OF CLINICAL EVIDENCE: 4.
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Affiliation(s)
- Sumeng Chen
- Department of Sports medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Wen Zhou
- Department of Medical Imaging, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Yuxin Yan
- Department of Sports medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Ying Shan
- Clinical Research Academy, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Yiyu Zhang
- Department of Sports medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Xintao Zhang
- Department of Sports medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Lu Bai
- Department of Sports medicine, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China.
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Padgett AM, Kothari E, Conklin MJ. Two-stage corrective operation for the treatment of pes cavovarus in patients with spina bifida. World J Orthop 2024; 15:618-626. [PMID: 39070932 PMCID: PMC11271695 DOI: 10.5312/wjo.v15.i7.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/26/2024] [Accepted: 06/05/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Pes cavovarus has an estimated incidence of 8%-17% in patients with spina bifida (SB). The majority of the current literature on surgical treatment of cavovarus feet in children and adolescents includes a variety of diagnoses. There are currently no case series describing a treatment algorithm for deformity correction in this specific patient population. The authors of this study present the results of a retrospective case series performed to assess the radiographic outcomes of two-stage corrective surgery in patients with SB. AIM To assess the radiographic outcomes of a staged operation consisting of radical plantar release followed by osteotomy for pes cavovarus in patients with SB. METHODS Retrospective chart review was performed on patients with SB with a diagnosis of pes cavovarus at a freestanding children's hospital who underwent surgical correction of the deformity. Patients were excluded for lack of two-stage corrective operation, nonambulatory status, lack of at least six months follow-up, and age > 18 years at the time of surgery. This resulted in a cohort of 19 patients. Radiographic analysis was performed on 11 feet that had a complete series of preoperative and postoperative weightbearing X-rays. Preoperative and postoperative radiographic outcome measurements were compared using a two-sample t-test. RESULTS Significant changes between the preoperative and postoperative measurements were seen in Meary's angle, the anteroposterior talo-first metatarsal (AP TMT1) angle, and the talonavicular coverage. Mean values of Meary's angle were 17.9 ± 13.1 preoperatively and 4.7 ± 10.3 postoperatively (P = 0.016). Mean AP TMT1 angle was 20.6 ± 15.1 preoperatively and 9.3 ± 5.5 postoperatively (P = 0.011). Mean talonavicular coverage values were -10.3 ± 9.6 preoperatively and -3.8 ± 10.1 postoperatively (P = 0.025). CONCLUSION The two-stage corrective procedure demonstrated efficacy in correcting cavovarus deformity in patients with SB. Providers should strongly consider employing the staged surgical algorithm presented in this manuscript for management of these patients.
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Affiliation(s)
- Anthony Mack Padgett
- Department of Orthopedics, Indiana University, Indianapolis, IN 46202, United States
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Ezan Kothari
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Michael J Conklin
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, United States
- Department of Orthopedic Surgery, Children’s of Alabama, Birmingham, AL 35233, United States
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Bergamasco JMP, De Marchi Neto N, Costa MT. Nonneurologic Cavovarus Feet in Skeletally Immature Patients: Main Causes and Principles of Treatment. Foot Ankle Clin 2023; 28:889-901. [PMID: 37863542 DOI: 10.1016/j.fcl.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
The foot resembles a tripod. The 3 legs consist of (1) the tip of the heel, (2) the first metatarsal, and (3) the fifth metatarsal. This concept is useful to explain cavus or flat feet. When the tips of the tripod move closer, the arch becomes higher. The leg of the tripod that moves the most will determine the type of cavus feet, which can be hindfoot cavus, forefoot cavus, or first metatarsal cavus. Cavovarus foot denotes the presence of a three-dimensional deformity of the foot, but it is much more a descriptive feature than a diagnosis.
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Affiliation(s)
| | - Noé De Marchi Neto
- Foot and Ankle Group, Santa Casa de Misericórdia de São Paulo, 916 Angélica Avenue, (608) São Paulo - Brazil 01228-000
| | - Marco Túlio Costa
- Foot and Ankle Group, Santa Casa de Misericórdia de São Paulo, 916 Angélica Avenue, (608) São Paulo - Brazil 01228-000
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Abstract
In Charcot-Marie-Tooth (CMT) cavovarus surgery, a regimented approach is critical to create a plantigrade foot, restore hindfoot stability, and generate active ankle dorsiflexion. The preoperative motor examination is fundamental to the algorithm, as it is not only guides the initial surgical planning but is key in the decision making that occurs throughout the operation. Surgeons need to be comfortable with multiple techniques to achieve each surgical goal. There is no one operation that works for all patients with CMT. A plantigrade foot is the most important of the surgical goals as hindfoot stability and ankle dorsiflexion can be augmented with bracing.
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Affiliation(s)
- Glenn B Pfeffer
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA 90048, USA.
| | - Max P Michalski
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA 90048, USA
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Rambelli C, Mazzoli D, Galletti M, Basini G, Zerbinati P, Prati P, Mascioli F, Masiero S, Merlo A. Foot Assessment Clinical Scales in Charcot-Marie-Tooth Patients: A Scoping Review. Front Hum Neurosci 2022; 16:914340. [PMID: 35814949 PMCID: PMC9263827 DOI: 10.3389/fnhum.2022.914340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Charcot-Marie-Tooth disease (CMT) is a slow and progressive peripheral motor sensory neuropathy frequently associated with the cavo-varus foot deformity. We conducted a scoping review on the clinical scales used to assess foot deviations in CMT patients and analyzed their metric properties. Evidence Acquisition A first search was conducted to retrieve all scales used to assess foot characteristics in CMT patients from the Medline, Web of Science, Google Scholar, Cochrane, and PEDro databases. A second search was conducted to include all studies that evaluated the metric properties of such identified scales from the same databases. We followed the methodologic guidelines specific for scoping reviews and used the PICO framework to set the eligibility criteria. Two independent investigators screened all papers. Evidence Synthesis The first search found 724 papers. Of these, 41 were included, using six different scales: "Foot Posture Index" (FPI), "Foot Function Index", "Maryland Foot Score", "American Orthopedic Foot & Ankle Society's Hindfoot Evaluation Scale", "Foot Health Status Questionnaire", Wicart-Seringe grade. The second search produced 259 papers. Of these, 49 regarding the metric properties of these scales were included. We presented and analyzed the properties of all identified scales in terms of developmental history, clinical characteristics (domains, items, scores), metric characteristics (uni-dimensionality, inter- and intra-rater reliability, concurrent validity, responsiveness), and operational characteristics (normative values, manual availability, learning time and assessors' characteristics). Conclusions Our results suggested the adoption of the six-item version of the FPI scale (FPI-6) for foot assessment in the CMT population, with scoring provided by Rasch Analysis. This scale has demonstrated high applicability in different cohorts after a short training period for clinicians, along with good psychometric properties. FPI-6 can help health professionals to assess foot deformity in CMT patients over the years.
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Affiliation(s)
- Chiara Rambelli
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
- Department of Neuroscience, Section of Rehabilitation, University of Padova, Padua, Italy
| | - Davide Mazzoli
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
| | - Martina Galletti
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
| | - Giacomo Basini
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
| | - Paolo Zerbinati
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
- Neuro-Orthopedic Unit, Sol et Salus Hospital, Rimini, Italy
| | - Paolo Prati
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
| | | | - Stefano Masiero
- Department of Neuroscience, Section of Rehabilitation, University of Padova, Padua, Italy
| | - Andrea Merlo
- Gait & Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
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Jordà-Gómez P, Sánchez-Gonzalez M, Ortega-Yago A, Navarrete-Faubel E, Martínez-Garrido I, Vicent-Carsí V. Management of flexible cavovarus foot in patients with Charcot-Marie-Tooth disease: Midterm results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [DOI: 10.1016/j.recote.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Masrouha K, Chu A, Lehman W. Narrative review of the management of a relapsed clubfoot. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1102. [PMID: 34423014 PMCID: PMC8339836 DOI: 10.21037/atm-20-7730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/14/2021] [Indexed: 11/29/2022]
Abstract
The management of idiopathic clubfoot has transformed over the past several decades as the Ponseti method for the correction of this deformity became the standard of care, and surgical release has almost all but been abandoned. The Ponseti method has shown very high initial success rate and excellent long-term functional results. Relapse of the deformity, however, continues to be a major problem, occurring in up to 40% of patient, and there is no consensus on the definition and management of the relapsed clubfoot. This review discusses the available management options for the treatment of a relapsed clubfoot deformity following initial treatment with the Ponseti method [including repeat casting, tendo-Achilles lengthening, plantar fascia release, and tibialis anterior tendon transfer (TATT)] as well as following initial surgical treatment with posteromedial release (including casting, hemiepiphysiodesis, revised posteromedial release, osteotomies, fusion, and the use of gradual distraction with external fixators). These are discussed from the least to the most invasive. Available evidence, and limitations of the literature, for the management of relapses following both the Ponseti method and initial surgical release is reviewed along with along with the reported outcomes. Future efforts should be geared towards standardizing the definition of a relapse with objective criteria for its management.
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Affiliation(s)
- Karim Masrouha
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Alice Chu
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Wallace Lehman
- Division of Pediatric Orthopedics, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Sanpera I, Villafranca-Solano S, Muñoz-Lopez C, Sanpera-Iglesias J. How to manage pes cavus in children and adolescents? EFORT Open Rev 2021; 6:510-517. [PMID: 34267941 PMCID: PMC8246104 DOI: 10.1302/2058-5241.6.210021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pes cavus in its different forms is not a pathological entity, but rather the manifestation of multiple diseases. Cavovarus, a form of cavus foot, should never be considered a physiological deformity. A neurological condition should always be excluded. The evolution of pes cavovarus is unpredictable because of the large number of conditions involved in its aetiology, as well as their variable degree of expression. About 66% of cavovarus feet are the result of subtle neurological diseases, which only become evident later in life. Although surgery may not change quality of life, recent studies suggest that it may improve foot posture and reduce walking instability. The aim of treatment is to preserve a painless, plantigrade, mobile foot. Management consists of correcting bone deformity while preserving movement, and the wise use of rebalancing techniques. Arthrodesis should only be a salvage procedure. Cite this article: EFORT Open Rev 2021;6:510-517. DOI: 10.1302/2058-5241.6.210021
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Affiliation(s)
- Ignacio Sanpera
- Hospital Universitary Son Espases, Palma de Mallorca, Illes BalearsSpain
| | | | - Carmen Muñoz-Lopez
- Hospital Universitary Son Espases, Palma de Mallorca, Illes BalearsSpain
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Management of flexible cavovarus foot in patients with Charcot-Marie-Tooth disease: midterm results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021. [PMID: 33906827 DOI: 10.1016/j.recot.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Charcot-Marie-Tooth disease (CMT) is a hereditary motor sensory neuropathy that frequently results in a cavovarus foot in the adult. Surgical treatment allows correction of the deformity while preserving an adequate range of motion. OBJECTIVE The objective of this study was to assess the result of posterior tibial tendon transfer, first metatarsal ascent osteotomy, and calcaneal valgus osteotomy in the treatment of cavovarus foot secondary to CMT. MATERIAL AND METHODS Retrospective cohort of CMT patients who received surgical treatment of their cavovarus foot. Collected data included demographics, CMT genetic variant, neurologic involvement, surgical technique, range of motion, functionality, radiology, and postoperative satisfaction. RESULTS 16 patients met the inclusion criteria, mostly women (62.5%) with the CMT1A variant (62.5%), and a mean age of 39.5 years. 13 patients required additional surgical techniques: lengthening of the Achilles tendon, interphalangeal arthrodesis and/or plantar fascia section. 2 patients underwent a secondary procedure: subtalar arthrodesis due to persistence of the varus deformity, and a lengthening of the extensor hallux longus due to initial undercorrection. The mean follow-up was 42 months. Significant differences (p = 0.003) were observed between the pre-surgical AOFAS and at 12 months postoperatively (37.25 vs. 86.5). 75% of the patients reported «excellent» or «good» satisfaction after surgery. All radiographic parameters showed significant improvement. CONCLUSIONS The combination of the aforementioned surgical techniques for the cavovarus foot in CMT results in adequate functionality, good radiological correction and a high degree of satisfaction, avoiding primary arthrodescent surgery.
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Long term results of the revisited Meary closing wedge tarsectomy for the treatment of the fixed cavo-varus foot in adolescent with Charcot-Marie-Tooth disease. Foot Ankle Surg 2019; 25:834-841. [PMID: 30482439 DOI: 10.1016/j.fas.2018.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 10/28/2018] [Accepted: 11/05/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Various techniques have been proposed for the treatment of cavovarus feet (CVF). The aim of this study was to report outcomes of the revisited Meary's dorsal closing wedge tarsectomy for fixed CVF secondary to Charcot-Marie-Tooth (CMT) disease. METHODS All CVF operated on between 1977 and 2011 were included. The tarsectomy design was modified from its original description and systemically combined with a plantar fascia release, a Dwyer osteotomy and a proximal extension osteotomy of the 1st metatarsal bone if required. Outcomes were assessed by 2 functional scores and radiographically. RESULTS Among the 26 feet (20 patients), the Wicart and Seringe score was very good or good, fair and poor in respectively 58%, 23% and 19% of the feet. Hindfoot and midfoot AOFASs were of 95.5 and 75 respectively. All radiographic measures were significantly improved. CONCLUSIONS This complete revisited procedure is an efficient and safe surgical technique for the treatment of the CMT disease CVF. LEVEL OF EVIDENCE Level IV.
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Chen ZY, Wu ZY, An YH, Dong LF, He J, Chen R. Soft tissue release combined with joint-sparing osteotomy for treatment of cavovarus foot deformity in older children: Analysis of 21 cases. World J Clin Cases 2019; 7:3208-3216. [PMID: 31667171 PMCID: PMC6819307 DOI: 10.12998/wjcc.v7.i20.3208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/02/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cavovarus foot is a common form of foot deformity in children, which is clinically characterized by an abnormal increase of the longitudinal arch of the foot, and it can be simultaneously complicated with forefoot pronation and varus, rearfoot varus, Achilles tendon contracture, or cock-up toe deformity. Muscle force imbalance is the primary cause of such deformity. Many diseases can lead to muscle force imbalance, such as tethered cord syndrome, cerebral palsy, Charcot-Marie-Tooth disease, and trauma. At present, many surgical treatments are available for cavovarus foot. For older children, priority should be given to midfoot osteotomy and fusion. Since complications such as abnormal foot length, foot stiffness, and abnormal gait tend to develop postoperatively, it is important to preserve the joints and correct the deformity as much as possible. Adequate soft tissue release and muscle balance are the keys to correcting the deformity and avoiding its postoperative recurrence.
AIM To assess the efficacy of soft tissue release combined with joint-sparing osteotomy in the treatment of cavovarus foot deformity in older children.
METHODS The clinical data of 21 older children with cavovarus foot deformity (28 feet) who were treated surgically at the Ninth Department of Orthopedics of Jizhong Energy Xingtai Mining Group General Hospital from November 2014 to July 2017 were retrospectively analyzed. The patients ranged in age from 10 to 14 years old, with an average age of 12.46 ± 1.20 years. Their main clinical manifestations were deformity, pain, and gait abnormality. The patients underwent magnetic resonance imaging of the lumbar spine, electromyographic examination, weight-bearing anteroposterior and lateral X-rays of the feet, and the Coleman block test. Surgical procedures including metatarsal fascia release, Achilles tendon or medial gastrocnemius lengthening, "V"-shaped osteotomy on the dorsal side of the metatarsal base, opening medial cuneiform wedge osteotomy, closing cuboid osteotomy, anterior transfer of the posterior tibial tendon, peroneus longus-to-brevis transfer, and calcaneal sliding osteotomy to correct hindfoot varus deformity were performed. After surgery, long leg plaster casts were applied, the plaster casts were removed 6 wk later, Kirschner wires were removed, and functional exercise was initiated. The patients began weight-bearing walk 3 mo after surgery. Therapeutic effects were evaluated using the Wicart grading system, and Meary’s angles and Hibbs’ angles were measured based on X-ray images obtained preoperatively and at last follow-up to assess their changes.
RESULTS The patients were followed for 6 to 32 mo, with an average follow-up period of 17.68 ± 6.290 mo. Bone healing at the osteotomy site was achieved at 3 mo in all cases. According to the Wicart grading system, very good results were achieved in 18 feet, good in 7, and fair in 3, with a very good/good rate of 89.3%. At last follow-up, mean Meary’s angle was 6.36° ± 1.810°, and mean Hibbs’ angle was 160.21° ± 4.167°, both of which were significantly improved compared with preoperative values (24.11° ± 2.948° and 135.86° ± 5.345°, respectively; P < 0.001 for both). No complications such as infection, skin necrosis, or bone nonunion occurred.
CONCLUSION Soft tissue release combined with joint-sparing osteotomy has appreciated efficacy in the treatment of cavovarus foot deformity in older children.
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Affiliation(s)
- Zhen-Yu Chen
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
| | - Zhan-Yong Wu
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
| | - Yue-Hui An
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
| | - Li-Fei Dong
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
| | - Jia He
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
| | - Run Chen
- The Ninth Department of Orthopedics, Jizhong Energy Xingtai Mining Group General Hospital, Xingtai 054000, Hebei Province, China
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14
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Hamel J, Hörterer H, Gottschalk O, Harrasser N, Walther M. [Hindfoot-centred X-ray technique for the evaluation of cavovarus deformity : A proposal for the optimization of radiologic delineation]. DER ORTHOPADE 2019; 49:531-537. [PMID: 31486913 DOI: 10.1007/s00132-019-03800-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In surgical correction of cavovarus deformity bony hindfoot procedures are required in most cases. For treatment planning X‑rays in two or more planes are usually used. In conventional X‑ray-techniques the hindfoot and ankle joint are presented in a more or less outward rotated position. Moreover, the peritalar complex is not delineated in the most corrected position. Therefore, the frequently used talus-metatarsal-I-angle (Meary angle) cannot be measured correctly. By application of the Coleman block test and additional adjustment of the malrotation in the lateral view, the peritalar complex and ankle joint can be evaluated in the corrected and "hindfoot-centred" position. Also, the frequently seen anterior ankle impingement can be observed precisely. Planning of osteotomies or corrective peritalar fusions is supported thereby. Some treatment examples are presented.
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Affiliation(s)
- J Hamel
- Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München Harlaching, München, Deutschland.
| | - H Hörterer
- Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München Harlaching, München, Deutschland.,Klinik für Allgemeine‑, Unfall- und Wiederherstellungschirurigie, Klinikum der Universität München, LMU München, München, Deutschland
| | - O Gottschalk
- Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München Harlaching, München, Deutschland.,Klinik für Allgemeine‑, Unfall- und Wiederherstellungschirurigie, Klinikum der Universität München, LMU München, München, Deutschland
| | - N Harrasser
- Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München Harlaching, München, Deutschland.,Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, TU München, München, Deutschland
| | - M Walther
- Zentrum für Fuß- und Sprunggelenkchirurgie, Schön Klinik München Harlaching, München, Deutschland
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Lin T, Gibbons P, Mudge AJ, Cornett KM, Menezes MP, Burns J. Surgical outcomes of cavovarus foot deformity in children with Charcot-Marie-Tooth disease. Neuromuscul Disord 2019; 29:427-436. [DOI: 10.1016/j.nmd.2019.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/07/2019] [Accepted: 04/24/2019] [Indexed: 11/27/2022]
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Abstract
The treatment goal for pediatric cavovarus deformities is to neutralize plantar pressure distribution, reduce hindfoot varus deformity, and avoid or postpone ankle, midfoot, and hindfoot arthritis. If nonoperative treatment is not sufficient, surgical realignment must be discussed. Promising improvements in decision making and operative techniques have been published. To avoid disappointment owing to recurrence or failures of operative procedures, selection of the appropriate and preferably single operative procedure remains the most crucial factor for success. This article focuses on current treatment options depending on the localization of the anatomic pathology. Outcomes of nonoperative and operative treatments are presented.
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Ghanem I, Massaad A, Assi A, Rizkallah M, Bizdikian AJ, El Abiad R, Seringe R, Mosca V, Wicart P. Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept. J Child Orthop 2019; 13:134-146. [PMID: 30996737 PMCID: PMC6442506 DOI: 10.1302/1863-2548.13.180022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones. DESCRIPTION The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa. PURPOSE This paper is a review article of this concept and of its physiopathological applications.
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Affiliation(s)
- I. Ghanem
- Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon,Orthopedic Surgery Department, Hôtel-Dieu de France Hospital, University of Saint-Joseph, Beirut, Lebanon, Correspondence should be sent to I. Ghanem, MD, Hôtel-Dieu de France Hospital, A. Naccache Avenue- Achrafieh, University of Saint-Joseph, Beirut, Lebanon. E-mail:
| | - A. Massaad
- Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon
| | - A. Assi
- Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon
| | - M. Rizkallah
- Orthopedic Surgery Department, Hôtel-Dieu de France Hospital, University of Saint-Joseph, Beirut, Lebanon
| | - A. J. Bizdikian
- Faculty of Medicine, University of Saint-Joseph, Beirut, Lebanon
| | - R. El Abiad
- Orthopedic Surgery Department, Hôtel-Dieu de France Hospital, University of Saint-Joseph, Beirut, Lebanon
| | - R. Seringe
- Orthopedic Surgery Department, Cochin University Hospital – University of Rene Descartes, Paris, France
| | - V. Mosca
- Department of Orthopedic Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
| | - P. Wicart
- Orthopedic Surgery Department, Hôpital Necker-Enfants Malades, University of Paris Descartes, Paris, France
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18
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Kiskaddon EM, Meeks BD, Roberts JG, Laughlin RT. Plantar Fascia Release Through a Single Lateral Incision in the Operative Management of a Cavovarus Foot: A Cadaver Model Analysis of the Operative Technique. J Foot Ankle Surg 2018; 57:681-684. [PMID: 29627135 DOI: 10.1053/j.jfas.2017.11.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Indexed: 02/03/2023]
Abstract
Plantar fascia release and calcaneal slide osteotomy are often components of the surgical management for cavovarus deformities of the foot. In this setting, plantar fascia release has traditionally been performed through an incision over the medial calcaneal tuberosity, and the calcaneal osteotomy through a lateral incision. Two separate incisions can potentially increase the operative time and morbidity. The purpose of the present study was threefold: to describe the operative technique, use cadaveric dissection to analyze whether a full release of the plantar fascia was possible through the lateral incision, and examine the proximity of the medial neurovascular structures to both the plantar fascia release and calcaneal slide osteotomy when performed together. In our cadaveric dissections, we found that full release of the plantar fascia is possible through the lateral incision with no obvious damage to the medial neurovascular structures. We also found that the calcaneal branch of the tibial nerve reliably crossed the osteotomy in all specimens. We have concluded that both the plantar fascia release and the calcaneal osteotomy can be safely performed through a lateral incision, if care is taken when completing the calcaneal osteotomy to ensure that the medial neurovascular structures remain uninjured.
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Affiliation(s)
- Eric M Kiskaddon
- Resident Physician, Department of Orthopaedic Surgery, Sports Medicine, and Rehabilitation, Wright State University, Dayton, OH.
| | - Brett D Meeks
- Resident Physician, Department of Orthopaedic Surgery, Sports Medicine, and Rehabilitation, Wright State University, Dayton, OH
| | - Joseph G Roberts
- Medical Student, Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Richard T Laughlin
- Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Sports Medicine, and Rehabilitation, Wright State University, Dayton, OH
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Sanpera Jr I, Frontera-Juan G, Sanpera-Iglesias J, Corominas-Frances L. Innovative treatment for pes cavovarus: a pilot study of 13 children. Acta Orthop 2018; 89:668-673. [PMID: 29911919 PMCID: PMC6300739 DOI: 10.1080/17453674.2018.1486525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Pes cavovarus (PCV) is a complex deformity, frequently related to neurological conditions and associated with foot pain, callosities, and walking instability. The deformity has the tendency to increase during growth. Orthotic treatment is ineffective and surgery may be troublesome. We present the preliminary results of a new mini-invasive surgical technique for correction of this foot deformity. Patients and methods - We operated on 13 children (24 feet), age 7-13 years. In 7 children the deformity was neurological in origin. The surgical technique included a dorsal hemiepiphysiodesis of the 1st metatarsal, and a plantar fascia release. The clinical deformity, hindfoot flexibility, and foot callosities, together with a radiological assessment (Meary angle, calcaneal pitch, and talo-calcaneal angle), was done pre- and postoperatively. At final check-up, after a median of 28 months (12-40), the Oxford Ankle Foot Questionnaire for children (OXAFQ-C) was used to assess patient satisfaction. The primary outcome was the hindfoot varus correction. Results - All the operated feet improved clinically and radiologically. Heel varus improved from a mean 6° preoperatively to 5° valgus postoperatively. In those children where treatment was initiated at a younger age, full correction was achieved. Footwear always improved. Interpretation - This treatment may offer a less aggressive alternative in the treatment of PCV in young children and may eventually reduce the amount of surgery needed in the future.
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Affiliation(s)
- Ignacio Sanpera Jr
- Pediatric Orthopedic Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain; ,Correspondence:
| | | | | | - Laura Corominas-Frances
- Pediatric Orthopedic Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain;
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20
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Hamel J. Korrekturen und Indikationen einer Pes-cavovarus-Deformität bei Kindern und Jugendlichen. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2017; 29:473-482. [DOI: 10.1007/s00064-017-0520-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 07/04/2017] [Accepted: 07/04/2017] [Indexed: 11/24/2022]
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21
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d'Astorg H, Rampal V, Seringe R, Glorion C, Wicart P. Is non-operative management of childhood neurologic cavovarus foot effective? Orthop Traumatol Surg Res 2016; 102:1087-1091. [PMID: 27825708 DOI: 10.1016/j.otsr.2016.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 07/26/2016] [Accepted: 09/05/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- H d'Astorg
- Hôpital Saint-Vincent-de-Paul, université Paris Descartes, AP-HP, 75014 Paris, France; Hôpital Necker-Enfants-Malades, université Paris Descartes, AP-HP, 75015 Paris, France
| | - V Rampal
- Hôpitaux pédiatriques de Nice, CHU-Lenval, 57, avenue de la Californie, 06000 Nice, France.
| | - R Seringe
- Hôpital Saint-Vincent-de-Paul, université Paris Descartes, AP-HP, 75014 Paris, France
| | - C Glorion
- Hôpital Necker-Enfants-Malades, université Paris Descartes, AP-HP, 75015 Paris, France
| | - P Wicart
- Hôpital Saint-Vincent-de-Paul, université Paris Descartes, AP-HP, 75014 Paris, France; Hôpital Necker-Enfants-Malades, université Paris Descartes, AP-HP, 75015 Paris, France
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22
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Georgiadis AG, Spiegel DA, Baldwin KD. The Cavovarus Foot in Hereditary Motor and Sensory Neuropathies. JBJS Rev 2015; 3:01874474-201512000-00005. [PMID: 27490994 DOI: 10.2106/jbjs.rvw.o.00024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew G Georgiadis
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104
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23
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Abstract
Different types of posterior calcaneal osteotomy are used for calcaneal realignment in the management of hindfoot deformity. We describe a percutaneous technique of posterior calcaneal osteotomy that can be either a Dwyer-type closing wedge osteotomy or displacement osteotomy.
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Affiliation(s)
- Tun Hing Lui
- Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Sheung Shui, New Territory, Hong Kong Special Administrative Region, People's Republic of China.
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24
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Abstract
The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes.
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Affiliation(s)
- J George DeVries
- Orthopedics & Sports Medicine, BayCare Clinic, 501 North 10th Street, Manitowoc, WI 54220, USA; Orthopedics & Sports Medicine, BayCare Clinic, 2020 Riverside Drive, 2nd Floor, Green Bay, WI 54301, USA.
| | - Jeffrey E McAlister
- Orthopedic Surgery, CORE Institute, 1615 West Red Fox Road, Phoenix, AZ 85085, USA
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25
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Faldini C, Traina F, Nanni M, Mazzotti A, Calamelli C, Fabbri D, Pungetti C, Giannini S. Surgical treatment of cavus foot in Charcot-Marie-tooth disease: a review of twenty-four cases: AAOS exhibit selection. J Bone Joint Surg Am 2015; 97:e30. [PMID: 25788311 DOI: 10.2106/jbjs.n.00794] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Charcot-Marie-Tooth disease is the single most common diagnosis associated with cavus foot. The imbalance involving intrinsic and extrinsic muscles has been suggested as the main pathogenetic cause of cavus foot in this disease. The goal of surgical treatment is to correct the deformity to obtain a plantigrade foot. In the presence of a flexible deformity and the absence of degenerative arthritis, preserving as much as possible of the overall range of motion of the foot and ankle is advisable. Twenty-four cavus feet in twelve patients with Charcot-Marie-Tooth disease were included in the study. Clinical evaluation was summarized with the Maryland Foot Score. Radiographic evaluation assessed calcaneal pitch, Meary angle, Hibb angle, and absence of degenerative joint changes. Only patients who had a flexible deformity, with varus of the heel reducible in the Coleman-Andreasi test, and did not have degenerative joint arthritis were included in this study. Surgical treatment consisted in plantar fasciotomy, midtarsal osteotomy, extensor hallucis longus tendon transfer to the first metatarsal (Jones procedure), and dorsiflexion osteotomy of the first metatarsal. Mean follow-up was six years (range, two to thirteen years). The mean Maryland Foot Score was 72 preoperatively and 86 postoperatively. The postoperative result was rated as excellent in twelve feet (50%), good in ten (42%), and fair in two (8%). Mean calcaneal pitch was 34° preoperatively and 24° at the time of the latest follow-up, the mean Hibb angle was 121° preoperatively and 136° postoperatively, and the mean Meary angle was 25° preoperatively and 2° postoperatively. Plantar fasciotomy, midtarsal osteotomy, the Jones procedure, and dorsiflexion osteotomy of the first metatarsal yielded adequate correction of flexible cavus feet in patients with Charcot-Marie-Tooth disease in the absence of fixed hindfoot deformity. The fact that the improvement in the outcome score was only modest may be attributable to the lack of motor balance.
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Affiliation(s)
- Cesare Faldini
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
| | - Francesco Traina
- Department of Orthopaedics and Trauma Surgery, Rizzoli Orthopaedic Institute, via G.C. Pupilli 1, 40136 Bologna, Italy
| | - Matteo Nanni
- Department of Orthopaedics and Trauma Surgery, Rizzoli Orthopaedic Institute, via G.C. Pupilli 1, 40136 Bologna, Italy
| | - Antonio Mazzotti
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
| | - Carlotta Calamelli
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
| | - Daniele Fabbri
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
| | - Camilla Pungetti
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
| | - Sandro Giannini
- University of Bologna, via Zamboni 33, 40126 Bologna, Italy. E-mail address for C. Faldini:
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26
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Abstract
Flexible cavovarus feet in children and adolescents can be challenging. A careful history and physical examination are paramount for determining the best treatment strategy and a multitude of options are available. Specific treatment strategies should be individualized and any bony correction must be in conjunction with a muscle balancing procedure. Well-timed soft tissue and occasionally bony procedures can delay the progression of deformity. These patients are monitored long term because further treatment may be required.
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Affiliation(s)
- Kelly L VanderHave
- Department of Orthopaedic Surgery, Carolinas Medical Center, 1025 East Morehead, Suite 302, Charlotte, NC 28204, USA.
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Barton T, Winson I. Joint sparing correction of cavovarus feet in Charcot-Marie-Tooth disease: what are the limits? Foot Ankle Clin 2013; 18:673-88. [PMID: 24215832 DOI: 10.1016/j.fcl.2013.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Charcot-Marie-Tooth disease is an inherited neuropathy that results in lower limb muscle imbalance and a resultant cavovarus deformity of the foot. With recognized poor outcomes of triple arthrodeses in the young patient, joint sparing surgery is preferred, which takes the form of osteotomies, soft-tissue releases, and tendon transfers to achieve a plantigrade and balanced foot. Due to the variability in muscle involvement and the presence of both mobile and fixed deformities, surgery must be individualized to each patient.
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Affiliation(s)
- Tristan Barton
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath, BA1 3NG, UK.
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28
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Jung HG, Park JT, Lee SH. Joint-sparing correction for idiopathic cavus foot: correlation of clinical and radiographic results. Foot Ankle Clin 2013; 18:659-71. [PMID: 24215831 DOI: 10.1016/j.fcl.2013.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Adult cavovarus deformity patients present with rigid cavovarus deformity, where the correction can no longer be obtained using soft tissue procedures alone, and corrective arthrodesis or osteotomy must be performed to realign the deformity. Reconstructive surgeries for cavovarus foot deformities are variable and include hindfoot or midfoot osteotomy or arthrodesis, soft tissue release or lengthening, and tendon transfers. Recently adult cavovarus foot deformities have been more commonly addressed with joint preservation osteotomies and adjunctive soft tissue surgeries and less with triple arthrodesis. Clinical and radiographic outcomes are overall favorable.
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Affiliation(s)
- Hong-Geun Jung
- Department of Orthopedic Surgery, Konkuk University School of Medicine, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul 143-729, South Korea.
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29
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Lee WC, Ahn JY, Cho JH, Park CH. Realignment surgery for severe talar tilt secondary to paralytic cavovarus. Foot Ankle Int 2013; 34:1552-9. [PMID: 23832713 DOI: 10.1177/1071100713497001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Realignment surgeries for mild to moderate ankle osteoarthritis with minimal talar tilt have been reported to be effective. However, there has been no report on joint-sparing surgery of ankle osteoarthritis in patients with paralytic disorders who have severe talar tilt. We therefore investigated whether ankle osteoarthritis with severe talar tilt caused by paralytic disorders can be improved after operative treatment. METHODS This study included 12 ankles (11 patients) with varus ankle osteoarthritis from paralytic disorders with cavovarus deformity of the foot. Mean follow-up period was 3.0 years (range, 2-4.5 years). Causes of paralysis were residual polio in 7 ankles (6 patients), cerebral palsy in 2 ankles, and idiopathic in 3 ankles. Preoperative and postoperative clinical assessments were performed using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and a visual analogue scale (VAS). The Ankle Osteoarthritis Scale (AOS) was used for postoperative assessment. Pre- and postoperative radiographic parameters were compared. RESULTS Mean AOFAS score improved from 39.1 (range, 32-57) preoperatively to 77.9 (range, 72-85) postoperatively. Mean talar tilt improved from 17.4 degrees (range, 9.5-33.5 degrees) to 1.4 degrees (range, 0-4 degrees). Degree of osteoarthritis according to Takakura classification improved in all ankles except two. Mean heel alignment angle was reduced from 40.4 degrees (range, 2-65 degrees) of varus preoperatively to 11.2 degrees (range, -3 to 25.5 degrees) of varus postoperatively. CONCLUSION Medial varus ankle osteoarthritis from paralytic cavovarus may be improved even in cases of severe talar tilt. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Woo-Chun Lee
- Department of Orthopaedic Surgery, Seoul Paik Hospital, Institute for Research of Foot and Ankle Diseases, Inje University, Seoul, South Korea
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30
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Abstract
The talonavicular (TN) joint and the three subtalar (ST) joints are linked anatomically and functionally. Together they form the subtalar joint complex, where movement occurs between the calcaneopedal unit (CPU) (entire foot except the talus) and the talotibiofibular unit (talus held tightly by the ankle mortise). Many are unaware of the TN joint's dual membership: it is a component of the subtalar joint complex (talocalcaneonavicular joint) and also the transverse tarsal joint (with the calcaneal-cuboid joint). The anatomy of the articulating surfaces, movement of the CPU when unloaded, shifts and changes in CPU shape with weight bearing, application to clinical tests and X-ray interpretation, and the pathophysiology applications to pes cavovarus, pes planovalgus and congenital talipes equinovarus (club foot) will be reviewed here. The CPU concept corresponds to a horizontal segmentation of the foot. This is a useful supplement to the two other segmentation methods: frontal (hindfoot, midfoot and forefoot) and sagittal (medial and lateral columns). This horizontal segmentation solves the issues with the ST joint complex, which straddles the hindfoot and midfoot, and also the issues with the dual membership of the TN joint. This concept makes it easier to understand foot deformities, better interpret the clinical and radiological signs and deduce logical treatments.
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31
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Abstract
Pes cavus, defined as a high arch in the sagittal plane, occurs in various clinical situations. A cavus foot may be a variant of normal, a simple morphological characteristic, seen in healthy individuals. Alternatively, cavus may occur as a component of a foot deformity. When it is the main abnormality, direct pes cavus should be distinguished from pes cavovarus. In direct pes cavus, the deformity occurs only in the sagittal plane (in the forefoot, hindfoot, or both). Direct pes cavus may be related to a variety of causes, although neurological diseases predominate in posterior pes cavus. Pes cavovarus is a three-dimensional deformity characterized by rotation of the calcaneopedal unit (the foot minus the talus). This deformity is caused by palsy of the intrinsic foot muscles, usually related to Charcot-Marie-Tooth disease. The risk of progression during childhood can be eliminated by appropriate conservative treatment (orthosis to realign the foot). Extra-articular surgery is indicated when the response to orthotic treatment is inadequate. Muscle transfers have not been proven effective. Triple arthrodesis (talocalcanear, talonavicular, and calcaneocuboid) accelerates the mid-term development of osteoarthritis in the adjacent joints and should be avoided.
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Affiliation(s)
- P Wicart
- Paris Descartes University, Necker-Sick Children Hospital (AP-HP), 149, rue de Sèvres, Paris 75015, France.
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34
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Abstract
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. LEVEL OF EVIDENCE Therapeutic study-level IV.
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35
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Abstract
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.
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Affiliation(s)
- Protyush Chatterjee
- Department of Orthopaedics and Rehabilitation, Rehabilitation Centre for Children, 59, Motilal Gupta Road, Calcutta - 700 008, India,Address for correspondence: Dr. Protyush Chatterjee, H 4/4, Labony Estate, Salt Lake, Calcutta - 700 064. India. E-mail:
| | - M K Sahu
- Department of Orthopaedics and Rehabilitation, Rehabilitation Centre for Children, 59, Motilal Gupta Road, Calcutta - 700 008, India
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36
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Ward CM, Dolan LA, Bennett DL, Morcuende JA, Cooper RR. Long-term results of reconstruction for treatment of a flexible cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 2008; 90:2631-42. [PMID: 19047708 PMCID: PMC2663331 DOI: 10.2106/jbjs.g.01356] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cavovarus foot deformity is common in patients with Charcot-Marie-Tooth disease. Multiple surgical reconstructive procedures have been described, but few authors have reported long-term results. The purpose of this study was to evaluate the long-term results of an algorithmic approach to reconstruction for the treatment of a cavovarus foot in these patients. METHODS We evaluated twenty-five consecutive patients with Charcot-Marie-Tooth disease and cavovarus foot deformity (forty-one feet) who had undergone, between 1970 and 1994, a reconstruction consisting of dorsiflexion osteotomy of the first metatarsal, transfer of the peroneus longus to the peroneus brevis, plantar fascia release, transfer of the extensor hallucis longus to the neck of the first metatarsal, and in selected cases transfer of the tibialis anterior tendon to the lateral cuneiform. Each patient completed standardized outcome questionnaires (the Short Form-36 [SF-36] and Foot Function Index [FFI]). Radiographs were evaluated to assess alignment and degenerative arthritis, and gait analysis was performed. The mean age at the time of follow-up was 41.5 years, and the mean duration of follow-up was 26.1 years. RESULTS Correction of the cavus deformity was well maintained, although most patients had some recurrence of hindfoot varus as seen on radiographic examination. The patients had a lower mean SF-36 physical component score than age-matched norms, and the women had a lower mean SF-36 physical component score than the men, although this difference was not significant. Smokers had lower mean SF-36 scores and significantly higher mean FFI pain, disability, and activity limitation subscores (p < 0.0001). Seven patients (eight feet) underwent a total of eleven subsequent foot or ankle operations, but no patient required a triple arthrodesis. Moderate-to-severe osteoarthritis was observed in eleven feet. With the numbers studied, the age at surgery, age at the time of follow-up, and body mass index were not noted to have a significant correlation with the SF-36 or FFI scores. CONCLUSIONS Use of the described soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity results in lower rates of degenerative changes and reoperations as compared with those reported at the time of long-term follow-up of patients treated with triple arthrodesis.
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Affiliation(s)
- Christina M. Ward
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, 200 Hawkins Drive, 01023 JPP, Iowa City, IA 52242. E-mail address for J.A. Morcuende:
| | - Lori A. Dolan
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, 200 Hawkins Drive, 01023 JPP, Iowa City, IA 52242. E-mail address for J.A. Morcuende:
| | - D. Lee Bennett
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, 200 Hawkins Drive, 01023 JPP, Iowa City, IA 52242. E-mail address for J.A. Morcuende:
| | - Jose A. Morcuende
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, 200 Hawkins Drive, 01023 JPP, Iowa City, IA 52242. E-mail address for J.A. Morcuende:
| | - Reginald R. Cooper
- Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, 200 Hawkins Drive, 01023 JPP, Iowa City, IA 52242. E-mail address for J.A. Morcuende:
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Sraj SA, Saghieh S, Abdulmassih S, Abdelnoor J. Medium to long-term follow-up following correction of pes cavus deformity. J Foot Ankle Surg 2008; 47:527-32. [PMID: 19239862 DOI: 10.1053/j.jfas.2008.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Indexed: 02/03/2023]
Abstract
Pes cavus is a multiplanar deformity that involves the 3 foot-joint complexes. Description of the deformity is not well standardized and the surgical management does not have a comprehensive algorithm to follow. Treatment should be tailored to the patient's requirements, foot condition, and the potential for future progression of the deformity. This study describes a heterogeneous group of patients treated surgically and followed for 5 to 28 years. The benefits and risks are discussed, together with pitfalls encountered.
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Affiliation(s)
- Shafic A Sraj
- Department of Surgery, Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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38
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Abstract
This chapter addresses the etiology and diagnosis of forefoot and midfoot cavovarus deformities, the relevant anatomy and biomechanics, and specific procedures for correction of the forefoot and midfoot. Associated hindfoot and ankle procedures will be referenced; however, their specifics will be reserved for other chapters.
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Affiliation(s)
- Richard M Marks
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI 53226-0099, USA.
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