Chapter 21: Surgery of the

Congenital Foot
Flatfoot Surgery (flexible)
Subtalar Joint Blocking Procedures:
(Arthroereisis and Arthrodesis)
Flatfoot Surgery (rigid): Convex Pes Piano Valgus
Metatarsus Adductus Surgery
Cavus Foot Surgery
Clubfoot Surgery
SURGERY OF THE CONGENITAL
FOOT
Flatfoot Surgery (Flexible),
1. Etiology of Flexible Flatfoot (pes planovalgus):
a. Rare syndromes: (Down's, Ehler's-Danlos, Marfan's, and Morquio's
syndromes)
b. Calcaneovalgus: (not all cases)
c. Biomechanical:
i. Forefoot varus
ii. Forefoot valgus
iii. Equinus
iv. Torsional abnormalities
v. Muscle imbalance (weakness of the supinators)
vi. Ligamentous laxity
d. Neurotrophic feet (early stages)
e. Enlarged or accessory navicular
f. Limb length inequality

2. Biomechanical alterations:
a. The subtalar joint is pronated
b. The midtarsal joint becomes unstable and unlocked: this is because the STJ
is in a pronated position with the calcaneus everted, the T-N joint and the C-C
joint become divergent from each other, their axes become more parallel.
This allows for independent range of motion of each of these joints and
increases the range of motion of the MTJ itself. The pronated STJ allows for
compromised function of the peroneus longus and tibialis posterior muscles.
This results in loss of osseous stability as the heel comes off the ground. The
reactive force of gravity produces a dorsiflexory force on the forefoot. The
following are the changes to the foot:
i. Arch fatigue
ii. Hypermobile first metatarsal
iii. Subluxation of the first ray
iv. Contraction of the digits
v. A medial distribution of body weight when the calcaneus everts beyond 4-
5° of eversion.
vi. Collapse of the MTJ
vii. The axis of the STJ in the normal patient is approx. 42° from the
transverse plane 16° from the sagittal plane. Any change in this will result in
changes to motion on the various planes. In clinically examining each patient,
it may be necessary to estimate the primary plane of motion of the STJ to
predict the ability (biomechanically or surgically) to control the STJ. In
examining the ROM of the joints of the foot, the predominant axis of motion
can be estimated.
NOTE* IF frontal plane motion (inversion/eversion) is predominant the joint
axis will be more horizontal. If transverse plane motion
(abduction/adduction) is more predominant, the joint axis is more vertical.
If sagittal plane motion (dorsiflexion/plantarflexion) is more predominant,
the axis will lie closer to the frontal and horizontal planes.

3. Radiographic Alterations:
a. If transverse plane dominance:
i. Increase in the dorsoplantar T-C angle
ii. Increase in the cuboid abduction angle
iii. Decrease in the percentage of T-N congruency
b. If frontal plane dominance:
i. Widening of the lesser tarsus on dorsoplantar view
ii. Decrease of the first metatarsal declination angle
iii. Decrease in the height of the sustentaculum tall
c. If sagittal plane dominance:
i. Increase in the talar declination angle
ii. Naviculocuneiform breach
iii. Increased T-C angle on the lateral view
iv. Decreased calcaneal inclination angle
d. The stress dorsiflexion lateral view (charger view) is used to determine
osseus blocks of the ankle joint.
e. Harris-Beath views are helpful in determining T-C coalitions (taken from
posterior and superior with the x-ray beam at 35°, 40°, and 45° to the
perpendicular).

4. Evaluation, Criteria. and Goals:

a. First ascertain the available range of motion: then differentiate rigid vs.
flexible flatfoot.

Note* Procedures that are effective for flexible flatfoot are usually ineffective
for rigid flatfoot, and the foot with bony adaptation secondary to forefoot
varus/supinatus also requires a different approach

b. Determine the planar dominance: because the foot that presents a high
degree of transverse plane motion is extremely difficult to control
nonsurgically.
c. Surgery must be avoided in the normal low arched foot (pes planus), which
must be distinguished from the collapsing pes planovalgus deformity as we
are describing.
d. Consider the age of the patient and the percentage of bone growth
remaining.
e. Consider the presence of other related medical conditions
f. Consider the presence of other superstructural deforming forces (tibial
torsion)
g. Other surgical criteria for flexible flatfoot:
i. Symptoms are resistant to conservative therapy
ii. The unstable foot is not controllable by mechanical devices
iii. Secondary changes are present or can be definitely predicted
h. Goals of surgery:
i. Relief of pain
ii. Biomechanical control of excessive pronation
iii. Prevention of progression of the deformity

5. Soft Tissue Approaches: (Medial Column Procedures)

a. Kidner procedure:
i. Requires the removal of an accessory navicular (changes the leverage of
the tibialis posterior ms.).
ii. Removal of any hypertrophied tuberosity of the navicular
iii. Transposition of the insertion of the tibialis posterior tendon into the
underside of the navicular.
b. Lowman procedure:
i. Achilles tendon lengthening
ii. T-N wedge arthrodesis
iii. Rerouting the tibialis anterior tendon under the navicular and suture to the
spring ligament.
iv. Tenodesis of the medial arch with a slip of the Achilles tendon, which is
left attached to the calcaneus and folded forward along the medial arch as an
accessory ligament (this helps maintain the calcaneus and forefoot in
adduction).
v. Desmoplasty of the T-N ligaments
c. Young procedure:
i. Tendoachilles lengthening
ii. Rerouting of the tibialis anterior tendon through a slot in the navicular
without detaching the tendon from its insertion.
iii. Tibialis posterior reattachment beneath the navicular
6. Osseous Approaches: (medial column procedures)
a. Hoke arthrodesis:
i. Tendo achilles lengthening
ii. navicular to the medial and intermediate cuneiform

Note * The Hoke procedure is now used as an adjuctive procedure in b.

combination with a TAL, calcaneal osteotomy, or arthroereisis. It is T-
utilized in the presence of severe N-C sagging, and is reserved for N
patients whose bone growth is complete and when secondary
changes. have occurred in a joint
arthrodesis:
i. Generally used in combination with other procedures (TAL, calcaneal
osteotomies, medial column tendon balancing
ii. Blocks all MTJ motion and almost all STJ motion
iii. When the T-N joint is wedged the procedure can reduce some
forefoot varus deformity, and can be combined with an Evans calcaneal
osteotomy.
iv. Most useful in degenerative joint changes/severe collapse at the T-N joint,
part of a repair of a ruptured tibialis posterior, and paralytic deformity.
c. Miller procedure:
i. Lengthening of the tendo achilles
ii. Raising an osteoperiosteal flap left in place proximally, along the
medial arch (this includes the spring ligament and tibialis posterior tendon
insertion) and reattaches in an advanced position.
iii. Arthrodesis of the navicular-medial cuneiform joint
iv. Arthrodesis of the 1st metatarsal-medial cuneiform joint
d. Osteotomies of the talus:
i. Stokes:
ii. Perthes: closing wedge at the talar neck
e. Osteotomies of the medial cuneiform:
i. Anderson and Fowler: plantar flexory wedge in conjunction with an
Evans calcaneal osteotomy.
ii. Cotton: opening wedge to produce plantarflexion of the medial column

7. Osseous Approaches: Calcaneal osteotomies (3 types): Calcaneal

osteotomies allow some margin for error, because joint motion is still
present. You must be specific in choosing procedures for the appropriate
problem. You must correct the etiology, not the symptoms. During the
procedure, dorsiflex the foot and make sure it is in neutral in all planes
before being satisfied on wedge size and fixation. These procedures are
basically designed to replace the triple arthrodesis and allow maintenance of
joint motion after the foot is corrected.
a. Extra-articular:
i. Chambers:
 A procedure to limit STJ motion by placing a bone graft under the sinus
tarsi (similar to arthroereisis)
ii. Baker-Hill: (to reduce heel valgus and excessive pronation)
 A refined Chambers concept for use in patients with CP
 They used a vertical-lateral approach to perform a horizontal osteotomy
inferior to the posterior facet of the STJ
 A wedge shaped graft is inserted.
iii. Selakovich:
 Through a medial approach performing an osteotomy and grafting of the
sustentaculum tali
 Tightening of the spring ligament
 Repositioning of the tibialis posterior
 Transfer of all/part of the tibialis anterior into the navicular

b. Anterior:
i. Evans (refined by Ganley): good when the forefoot abducts severely when
the STJ is in neutral. This procedure is contraindicated in neurological
disorders that may generate spasticity and varus due to functional
overcorrection. The rationale for this procedure is that as the lateral column
is lengthened, the entire forefoot is forced to pivot around the head of the
talus, effectively adducting the forefoot and tightening the structures of the
arch
NOTE* If there is excess lengthening of the lateral column, an equinus may
be produced (talus abducts and dorsiflexes)

 Due to scarring the incision has been changed, to one parallel to the skin
tension lines in an oblique/transverse fashion on the lateral side of the foot
over the C-C joint (avoid the sural nerve inferiorly and the intermediate
dorsal cutaneous nerve superiorly; they are found at the extreme poles of
the incision)
 The peroneals are retracted inferiorly
 Reflection of the EDB ms. dorsally while preserving the dorsal
calcaneocuboid ligament

NOTE* This ligament is critical in limiting the dorsal shift of the anterior beak
of the calcaneus

 Osteotomy of the calcaneus parallel and 1.5 cm proximal to the C-C joint
from lateral to medial
 insertion of tibial bone graft or bone bank iliac crest, which is tapped into
position, and any void filled with bone chips
 Suture the EDB back into place: impossible to achieve good closure of this
muscle layer

Note* This procedure straightens the lateral column with reduction of heel
valgus. In most cases it is still necessary to reduce the amount of forefoot
varus and stabilize the medial column by doing a T-N fusion, wedge
osteotomy of the cuneiform, naviculocuneiform fusion, or medial arch
tenosuspension (predominant)

 Complications include undercorrection/overcorrection, delayed/nonunion,

and if there is a met. adductus present It will be made worse.

Note* One of the most difficult pes planovalgus foot types to treat is one with
a vertical STJ axis. This foot compensates for deforming forces mainly in the
transverse plane. This foot is recalcitrant to mechanical control and medial
column procedures. Lateral column lengthening procedures are indicated
(Evans procedure)

 When the Evans procedure is done in conjunction with a medial arch

tenosuspension the cuboid abduction angle is decreased, the forefoot
abduction angle is decreased by an average of 170 and the calcaneal
inclination angle is increased by 7°.
c. Posterior (varus producing osteotomies): Are designed to place the weight-
bearing surface of the calcaneus in neutral or varus, preserve STJ motion
while changing the ratio of available inversion/eversion
i. Gleich
 Oblique calcaneal osteotomy displaced anteriorly, helps increase the
calcaneal inclination angle
ii. Dwyer
 Most commonly performed as an opening wedge (can be closing wedge
also) from the lateral side
 Slightly overcorrect with the osteotomy
iii. Silver
 Lateral opening wedge osteotomy with the direction from just posterior to
the posterior facet running inferiorly.
iv. Koutsogiannis
 Lateral approach with a transection osteotomy of the calcaneus (oblique)
-Posterior fragment is medially displaced until it lies below the
sustentaculum tali

Note* Posterior calcaneal osteotomies are most useful in the least prevalent
type of pes planovalgus, where there is frontal plane dominance. These
osteotomies are most useful in conjunction with medial column procedures

v. Additional procedures:
 Sullivan (a dorsal anterior sliding osteotomy of the posterior aspect of the
calcaneus to treat equinus)
 Moeller (triplane closing wedge osteotomy of the lateral cortex, for cavus
foot)
 Keck and Kelly (dorsal closing wedge osteotomy just anterior to the
achilles; it will decrease the inclination angle and remove pressure from a
Haglund's deformity)
 Reinhart (for pes cavus deformity where a through and through osteotomy
is done)

8. Ancillary Procedures:
a. Tendo Achilles lengthening: is indicated in almost all of the above flatfoot
procedures

9. Rearfoot Arthrodesis: Is usually used with severe DJD, severe triplane

deformity with pain, paralytic deformity, or for long-standing rupture of the
tibialis posterior, with collapse of the foot.
a. Subtalar arthrodesis: Restores the appropriate T-C relationship while
preserving midtarsal motion
i. The procedure involves resection of the sinus tarsi with packing with
autologous bone chips, and screw fixation.
ii. Objections to this procedure include:
 Fusion of one portion of the STJ results in DJD of the other joints
 No correction occurs in the forefoot which is usually in varus
 Potential for fatigue failure of the screw
 Long term loss of the correction

b. Triple arthrodesis: Because this is a long-standing and reliable

procedure, it will be discussed in great detail.
i. Definition: fusion of the T-C, C-C, and T-N joints
ii. History: originally used for paralytic deformities, modified by Ryerson in
1923 with a two incision approach/internal fixation/above knee casting.
iii. Indications: pain, instability, structural deformity (rigidity)
iv. Specific etiological conditions:
 Valgus foot deformity
 Collapsing pes valgus deformity
 Ruptured posterior tibialis tendon
 Tarsal coalitions
 Tarsal arthritis
 Cavus foot
 Talipes equinovarus
vi. Preoperative considerations:
 Procedure must be delayed until the patient reaches skeletal maturity
 Patient must have adequate ankle dorsiflexion available
 Due to the amount of dissection prophylactic antibiotics should be
considered
 Hemostasis necessary during the procedure
v. Surgery:
 The dissection is started laterally passing between the sural and the
intermediate dorsal cutaneous nerves. The contents of the sinus tarsi are
vacated, the extensor digitorum brevis muscle is reflected distally, and
the peroneals are mobilized and protected from the lateral surface of the
calcaneus. This gives exposure to the posterior facet, the C-C joint, and
the lateral aspect of the T-N joint. The medial incision is dissected down to
the dorsomedial aspect of the T-N joint. The periosteum and posterior
tibial tendon are dissected inferiorly off the navicular, and the periosteum
is reflected off the dorsal surface of the navicular and the head and neck
of the talus until it connects with the lateral incision. If a subtalar wedge is
to be taken, the medial incision dissection is carried posteriorly, reflecting
the periosteum and the deltoid ligament of the sustentaculum tali,
exposing the anterior and middle facets.
 A minimal amount of bone is resected off all joint surfaces. The MTJ -is
resected first, which relaxes tissues and makes it easier to manipulate the
foot. Any wedging of the MTJ should be done after the STJ is resected and
temporarily fixed. In any wedging of the STJ, the most bone should come
off the calcaneus.
 The rearfoot and forefoot must be fixed in slight valgus, because a valgus
foot can be accommodated to be comfortable and a varus foot can rarely
be made comfortable. If inadequate dorsiflexion is available at the ankle
then jamming of the anterior ankle will occur causing development of
chronic synovitis and degenerative destruction of the foot. Too much
resection posterior to the STJ will cause dorsiflexion of the ankle joint and
jamming. Anterior displacement of the talus on the calcaneus will
plantarflex the forefoot, while posterior displacement of the talus will
dorsiflex the forefoot. Plantarflexion of the forefoot will cause more ankle
joint dorsiflexion and jamming of the ankle. The forefoot can be rotated on
the rearfoot to accommodate frontal plane problems.
 Temporary fixation is achieved with K-wires or Steinmann pins. The STJ is
fixated first. Rigid compression fixation gives more constant joint fusion. A
6.5mm cancellous or cannulated screw is used to fixate the STJ. Using
screws in the MTJ is difficult due to the angulation, and so staples may be
used for fixation of the T-N and C-C joints. Fluoroscopy or intraoperative x-
rays must be taken to assure proper position.
vi. Postoperative management:
 Jones compression cast for 2-3 days
 Drain pulled at 48-72 hours
 A B-K NWB cast is applied for 8 weeks
 Change cast and suture removal at 2-3 weeks
 Change cast every 2-3 weeks thereafter
 Take serial x-rays to evaluate healing every 4 weeks
 A B-K WB cast is then used for 4 weeks
 Physical therapy continued for 3 months
 Goal is a return to normal function 6 months postoperatively
vii. Complications:
 Fracture
 Wound dehiscence
 Peroneal tendonitis
 Entrapment neuropathy
 Nonunion
viii. Postoperative gait pattern:
 Abducted gait
 Shorter stride
 Difficulty in going down stairs

Subtalar Joint Blocking Procedures (Arthroereisis

and Arthrodesis) for Flatfoot
There are 2 major categories: extra-articular arthrodesis which actually fuses
the joint by means of a bone graft eliminating all motion, and arthroereisis
which limits excessive valgus motion of the STJ and retains the varus range
of motion.

1. Arthrodesis:
a. Grice Green (EASTA: extra-articular subtalar joint arthrodesis): This
procedure allows you to fuse the STJ without disturbing growth.
i. Indications
 Paralytic instability and equinovalgus
 Peroneal spastic flatfoot
 Unresectable tarsal coalitions
 Age bracket 3-14 years old
ii. Contraindications
 Ankle valgus flatfoot
iii. Procedure
 Use corticocancellous graft placed at 900 to the STJ axis
2. Arthroereisis:
a. Indications
i. To see if a patient needs an arthroereisis: have the patient stand on the
toes, the heel must supinate
ii. Age is 4-8 years
iii. Cavovalgus foot
iv. A foot that has been unresponsive to treatment for 2 years
v. Eversion of the heel at least 8°
vi. Predominant frontal plane deformity
vii. Flexible forefoot varus deformity above 10°
b. Contraindications
i. Rigid flatfoot
ii. Significant arthritis/trackbound tarsal joints
iii. Ankle valgus
iv Equinus (must be released)
v. Skewfoot
vi. Torsional problems
vii. Frontal plane knee deformity
c. 3 types
i. Self-locking wedge
 Viladot
 Valenti
 Addante
 Valgus stop
ii. Axis altering (not for adults): elevates a low STJ axis
 STA-peg
iii. Direct impact (can be used for all ages)
 Sgarlato
 Pisani
d. Anatomical placement
i. Sinus tarsi
 Valgus stop
 STA-peg
 Sgarlato
ii. Canalis tarsi
 Valenti
 Viladot
e. Postoperative care
i. Cast for 2 weeks
ii. Orthoses and high top sneakers for 1 year
f. Complications
i. Extrusion of the implant
ii. Fracture of the implant
iii. Fracture of the calcaneus
iv. Improper placement of the implant
v. Over/undercorrection
vi. Infection
vii. Erosion of the bone-implant interface
Flatfoot Surgery (rigid): Convex Pes Planovalgus
1. Etiology of Rigid Flatfoot:
a. Vertical talus
b. Congenital T-N dislocation
c. Arthrogryphosis
d. Tarsal coalition/peroneal spastic flatfoot
e. Tarsal arthrosis caused by trauma
f. Cerebral palsy
g. Spina bifida
h. Improper correction of clubfoot
i. Post-traumatic
j. Neurotrophic (late stages)
2. Clinical Presentation of Convex Pes Planovalgus (vertical Talus):
(see pediatrics)
a. Rocker-bottom deformity with prominent talar head bulge on the medial
and plantar aspect of the foot.
b. The forefoot may actually touch the anterior surface of the tibia
c. Valgus rearfoot that is in equinus

3. Radiographic Presentation of Convex Pes Planovalgus:

a. Definitive diagnosis when it is evident that the tarsal navicular is dorsally
dislocated on the neck of the talus even when the foot is maintained in a
stress plantarflexed attitude (forced plantarflexion and inversion will not
reduce the dislocation of the T-N joint in a true convex pes piano valgus
deformity).
b. Talus is vertical, lying parallel to the longitudinal axis of the tibia
c. Calcaneus is in an equinus position
d. T-C angle is abnormally increased on the D-P view
4. Pathology of Convex Pes Planovalgus:
a. Severe dislocation of the T-N joint (navicular is articulating with the dorsal
aspect of the talus
b. Neck of the talus is hypoplastic
c. Talar head is flattened
d. Calcaneus is displaced posteriolaterally
e. Calcaneus is convex on its plantar surface
f. The tibialis posterior and peroneals are located anterior to their normal
position and are contracted
g. The tibialis anterior, EHL, EDL, and the triceps surae are contracted
h. The tibionavicular ligament and dorsal talonavicular ligament are
contracted (the problem in the repair of this foot type)

Surgery of the Convex Pes Planovalgus Foot: Surgery is dependent

upon patient's age, clinical and radiographic features, type and degree of
previous treatment, and experience of the surgeon. The common objective of
all procedures is release of all soft tissue contractures, establishment of a
rectus forefoot to rearfoot relationship, and the production of equal medial
and lateral foot columns.
a. Talar procedures: resect the head and neck of the talus
b. Navicular procedures: naviculectomy
c. Tendon transfers: transfer of the tibialis anterior/posterior and peroneals
d. Open surgical reduction: T-N joint reduction along with a peritalar release,
heel cord lengthening, extensor and peroneal tendon lengthening, STJ and
ankle joint capsulotomy, calcaneocuboid joint reduction, and transfer of the
tibialis anterior into the navicular (K-wires removed at 6 weeks and A-K cast
removed at 3 months)

Metatarsus Adductus
1. Indications
a. Failure to respond to conservative treatment
b. Residual deformity after treatment of talipes equinovarus
c. Newly diagnosed metatarsus adductus deformity

2. Considerations: (see section Pediatrics)

a. Age of patient
b. Osseous development
c. Severity of deformity
d. Presence of concomitant deformities
e. Extent of malfunction and disability

3. Soft Tissue Surgery:

a. Heyman, Herndon, and Strong:
i. Indications:
 For flexible met. adductus which is reducible on manipulation (stress x-
ray)
 Usually children less than 5 years old
 Deformity present at Lisfranc's joint, without significant bowing present in
the proximal portion of the metatarsal bones themselves ii. Procedure:
 2 or 3 longitudinal dorsal incisions, or a transverse incision
 Release of the dorsal, interossei, and plantar ligaments of the
tarsometatarsal joints and intermetatarsal joints
 Preserve the plantar-lateral ligaments, especially 5th metatarsocuboid
articulation and the peroneus brevis tendon
 Manipulate the foot into abduction
 K-wire fixation of the first met-cuneiform joint and 5th met-cuboid joint
 Release of the naviculocuneiform and intercuneiform joints is rarely
needed
 Consider abductor hallucis release or tenotomy in conjunction with HH&S
iii. Precautions
 Avoid damage to the 1st metatarsal epiphyseal growth plate (do not
confuse this with the met-cuneiform joint)
 Be careful not to introduce latrogenic dorsal dislocations at the met-
cuneiform joints
iv. Postop care
 Cast for 6-12 weeks
 Manipulate the foot and recast every 3-4 weeks depending upon the
severity
 Monitor the foot carefully for the development of a flatfoot deformity
v. Complications
 Dorsal dislocation
 Degenerative arthritis
 Damage to the growth plates

b. Thompson procedure (modified):

i. Indications
 Congenital hallux varus primarily
 Flexible met. adductus secondarily
 Hyperactivity of the abductor hallucis ms.
ii. Procedure
 Medial longitudinal 1st m.p.j. skin incision approach
 Dissection to level of deep fascia over the abductor hallucis muscle
 Transection of the abductor hallucis tendon with resection of a segment of
the tendon and portion of the distal muscle
 Consider lesser m.p.j. release medially if lesser digits are also adducted
 Release of the medial head of the flexor hallucis brevis if adduction of the
hallux is still present
iii. Precautions
 Do not reduce varus of the hallux without insuring correction of any
adduction deformity of the first metatarsal
 Place the medial incision over the 1st m.p.j. strategically; if too superior or
inferior, may damage the medial neurovascular bundle
 Avoid the procedure as a primary mode of correction for met. adductus
unless clinical findings and x-rays strongly support hyperactivity of the
abductor hallucis as the primary etiology
iv. Postoperative care
 Weightbearing in a surgical shoe for 3-6 weeks
 Splinting of the hallux and the first ray
v. Complications
 Hallux abductovalgus
 Hallux hammertoe (hallux malleus)

c. Johnson osteochondrotomy: cartilaginous procedure

i. Indications
 Met. adductus deformity in children between the ages of 5-8 years (can be
younger)
ii. Procedure
 3 dorsal longitudinal incisions
 Closing abductory base wedge osteotomy of the 1st metatarsal
 Wedge resection of cartilage and bone from the bases of the lesser
metatarsals, distal to the proximal articular surface (base is lateral with
the apex medial)
 Fixation of the osteotomies with stainless steel wire, k-wires, or staples
iii. Precautions
 Avoid damage to the epiphyseal growth plate of the 1st metatarsal
 Overcorrection/undercorrection of individual ray segments
iv. Postoperative care
 Non-weightbearing with cast immobilization for 6-8 weeks
 Serial x-rays to assess healing

4. Osseous Surgery:
a. Modified Berman-Gartland procedure:
i. Indications
 Met. adductus in the child older than 6-8 years old
 Residual deformity following treatment of talipes equinovarus
ii. Procedure
 3 dorsal longitudinal incisions
 Transverse or oblique-type closing abductory wedge osteotomy of the 1st
metatarsal
 Similar type of osteotomies of the lesser metatarsals with the cortical
hinge medially
 Fixation of osteotomies with SS wire, K-wires, staples, AO screws or
combinations
iii. Precautions
 Avoid damage to growth plate of 1st metatarsal
 Meticulous subperiosteal dissection is critical to avoid heavy callus
formation and undesirable synostosis between adjacent metatarsals
 Preservation of the medial cortical hinge is important to insure stability
 Careful planning to avoid over/undercorrection
iv. Postoperative care
 Non-weightbearing cast immobilization 6-8 weeks
 Convert the cast to posterior splint and start PT
 Orthotics when patient resumes weightbearing
 Serial x-rays to assess bone healing at 6 weeks, 12 weeks, 24 weeks and 1
year
v. Complications
 Over/undercorrection
 Delayed union/nonunion/pseudoarthrosis
 Fracture of cortical hinge
 Damage to growth plate
 Elevatus of metatarsals
 latrogenically induced flatfoot deformity
b. Lepird procedure:
i. Indications
 Met. adductus in the child greater than 6-8 years old
 Residual talipes equinovarus deformity
ii. Procedure
 3 dorsal longitudinal incisions
 Oblique closing-abductory wedge osteotomy (Juvara type) of the
1st metatarsal with AO/ASIF screw fixation
 Rotational osteotomy of each lesser metatarsal with AO/ASIF
screw fixation (2.7 mm cortical used mostly) perpendicular to the
plane of the osteotomy
 An oblique closing wedge osteotomy may be used on the 5th
metatarsal in place of the rotational type (if preferred)
 Rotational osteotomies are performed from dorsal-distal to plantar-
proximal with temporary preservation of the cortical hinge (facilitates
fixation). The osteotomy is approximately 45° from the weightbearing
surface. The precise angle will depend on the declination of the metatarsal
segment. As the declination of the metatarsal increases, the osteotomy
will be more parallel to the weightbearing surface of the foot
 Area of the cortical hinge preserved is most commonly proximal/plantar
 The screws are then removed and the osteotomy is completed
 The screws are reinserted, the distal fragments are rotated laterally, and
the screws are tightened
 The alignment of the foot is assessed; if realignment is necessary the
screw(s) can be loosened and the bone adjusted
iii. Postoperative care
 Same as Berman-Gartland
iv. Complications
 Same as Berman-Gartland
 if the osteotomy is performed too vertically the rotation of the osteotomy
will be around the longitudinal axis of the metatarsal bone itself, resulting
in inversion/eversion of the bone itself
v. Advantages
 This procedure is amenable to rigid internal fixation and primary
bone healing
 Over/undercorrection can be corrected during surgery
 Biplanar correction can be achieved
 Eliminates pin tract infections

5. Ancillary Procedures:
a. Equinus Deformity
i. TAL
ii. Gastrocnemius recession
b. Flatfoot Deformity:
i. STJ arthroereisis
ii. Evans calcaneal osteotomy
iii. Modified Young's tenosuspension/ Modified Kidner procedure
iv. T-N joint arthrodesis/ N-C arthrodesis

Cavus Foot Type

1. Description: Pes cavus is primarily a sagittal plane deformity and can
best be described by the area of involvement.
a. Anterior pes cavus: Types
i. Metatarsus cavus (at Lisfranc's joint)
ii. Lesser tarsal cavus (lesser tarsus)
iii. Forefoot cavus (Chopart's joint)
iv. Combined anterior cavus (occurring at 2 or more of the aforementioned
areas)
b. Rearfoot cavus: may not truly be a separate cavus deformity. It may be a
compensation for anterior cavus. It etiology is:
i. Pseudoequinus: reverse buckling of the ankle joint
ii. Muscle weakness/spasticity
iii. Congenital
c. Combined: both rearfoot and forefoot

Note* The apex of the deformity should be located on a lateral x-ray

2. Etiology:
a. Neuromuscular: 66%

Note* Because there is such a high correlation between neuromuscular

disease and pes cavus, and because the cavus foot is often an early i.
manifestation of such disease, a neurology consult is mandatory prior
to any surgical intervention
Muscle lesion: muscular dystrophy
ii. Peripheral nerve lesion: Charcot-Marie-Tooth, polyneuritis, traumatic
lesion
iii. Spinocerebellar tract: Friedreichs ataxia
iv. Anterior horn cell: poliomyelitis, cord tumors
v. Pyramidal/extrapyramidal: cerebral palsy
vi. Cerebral cortex: hysteria
b. Congenital
i. Pes arcuatus (rare)
ii. Spina bifida
iii. Myelomeningocele
iv. Clubfoot
v. Congenital syphilis
c. Idiopathic: 33%
i. Trauma
ii. Infection
iii. Ledderhose's disease
iv. Spinal cord tumors

3. Classification:
a. Flexible deformity (mild): Non-weight bearing, contracted digits, high arch
and varus deformity of the heel may be noticed. With loading, digits appear
normal, arch is flattened and heel may go into valgus. Minimal clinical
symptoms at this point
b. Semi-rigid deformity (moderate): Weight-bearing does not completely
reduce the contracture of the digits, arch appears higher and heel is in more
varus attitude. Soft tissue contractures and bony adaptation begin to take
place. Symptoms are more prominent.
c. Rigid deformity (severe): Joint motion is limited. The foot is similar in
appearance both weight/non-weight bearing. Digits are contracted dorsally
and painful keratomas are present. Difficult to fit shoes.
d. Progression of deformity: Often progresses from flexible to rigid as the
patient gets older.

4. Compensation for Anterior Cavus:

a. Retraction of the toes at the m-p joints (due to extensor substitution)
b. Reverse bucking of the m-p joints
c. Forefoot reduction of the "flexible" anterior cavus
d. Ankle joint dorsiflexion

5. Associated Conditions:
a. Forefoot varus
b. Forefoot valgus
c. Plantarflexed 1st ray
d. Metatarsus adductus
e. Rearfoot pseudoequinus
f. Rearfoot varus

6. Principles of Surgical Judgement:

a. The presence of neurological disease will dictate what types of procedures
you can and cannot do. You must determine whether the disease is
progressive
b. For idiopathic pes cavus the following flow chart from McGlamry ED (ed)
Comprehensive Textbook of Foot Surgery , 2 ed, Williams & Wilkins, (with
permission) illustrates the surgical decision making plan best.
c. You must determine whether the deformity is flexible or rigid and follow
the preceding flow chart
d. You must consider the age of the patient (soft tissue procedures are best
in the child)

7. Preoperative Evaluation:
a. Neurology consult
b. Spinal x-rays
c. EMG's and nerve conduction studies
d. X-rays of the foot (lateral)
i. Calcaneal inclination angle > 30°
ii. Talar-1st metatarsal angle > 6° (Meary's angle)
iii. Increased pitch of the 5th metatarsal
iv. Note apex of the deformity
v. Cyma line broken posteriorly (can be normal)
vi. Sinus tarsi is clear and accentuated
vii. Coalition views should be used to assess the subtalar joint
viii. An axial view of the calcaneal angle should be taken to rule out a
structural varus
8. Pathogenesis:
a. With weak tibialis anterior the long extensors substitute for ankle
dorsiflexion, causing hyperextension of the MPJ's and retrograde pressure on
the metatarsal heads (extensor substitution)
b. Weak peroneus brevis and strong posterior tibial ms. will create a varus
heel
c. Paralysis of intrinsics causes the development of clawtoes
d. Weak gastrocnemius causes flexor substitution which causes clawtoes.
9. Surgery: Soft tissue
a. Plantar release
i. Subcutaneous fasciotomy
ii. Steindler stripping: through a medial incision the abductor hallucis,
-flexor digitorum brevis, and the abductor digiti quinti are stripped from the
periosteum of the calcaneus. The plantar fascia is released and the long
plantar ligament is released.
iii. Tachdjian: describes a plantar medial approach used with a fixed anterior
cavus. Includes releasing the long/short plantar ligaments, spring ligament
(calcaneonavicular), the calcaneonavicular portion of the bifurcate ligament,
and the plantar fascia. Lengthening of the long flexors and the tibialis
posterior is performed if on intraoperative reduction of the cavus foot bow-
stringing of these tendons is noted
iv. Complications:
 Plantar fasciitis
 Forefoot may become splayed

(Note * These procedures are followed by serial casting

b. Tendon transfers (give best results when the patient is > 10 years old)
i. Jones suspension: transfer of the extensor digitorum longus to the
neck of the 1st metatarsal with i.p.j. fusion
Complications:
 Transfer lesion to the 2nd metatarsal if 1st ray is raised too high
 Hallux limitus
 Tendon may not hold the correction
 Failure of the fusion site
ii. Heyman procedure: transfer of all five extensor tendons to their
respective metatarsal heads.
Complications:
 Clawtoes may result
 Tendonitis of the EDL
 Tendons may not hold the correction
 Same as Jones complications
iii. Hibbs procedure (modified): transfer of the long extensors to the
second and third cuneiform, a Jones transfer of the EHL, anastomosis of
the distal stumps of the long extensors to the EDB tendons. This procedure
helps load the midtarsal joint in dorsiflexion.

Note* Although the Hibbs procedure is a classic procedure described for the
correction of anterior cavus, it should not be performed for pes cavus,
because it fails to provide the dynamic force necessary to elevate the
metatarsal heads

iv. Split tibialis anterior tendon transfer (STATT): the lateral half of the
tibialis anterior tendon is sectioned and anastomosed to the peroneus tertius
tendon near its insertion into the base of the 5th metatarsal.
v. Peroneus longus tendon transfer
vi. Tibialis posterior tendon transfer

Note* The above procedures are utilized with flexible deformities

10. Surgery: Osseous

a. Cole procedure: dorsal wedge tarsal osteotomy to reduce a fixed anterior

cavus, which extends from the cuboid laterally through the
naviculocuneiform joints medially. The width of the wedge is determined by
the severity of the deformity.

Note* The disadvantage of the Cole procedure is that it can result in a

shorter, wider, and thicker foot b.
Japas procedure: a midtarsal V-osteotomy (apex of the V is proximal and at
the highest point of the cavus). The lateral limb of the V extends through the
cuboid, and the medial limb of the V extends through the cuneiform

Note* Difficult to control the amount of correction

Note* The primary difference in indications between the Cole and Japas is
that the Cole is for more severe deformities and is only performed in the
skeletally mature foot

c. 1st ray Dorsal Wedge Flexory Osteotomy

d. DWFO all metatarsals
Complications:
i. If 1st metatarsal is done alone, may get transfer lesion to 2nd
ii. May decrease ROM of 1st MPJ
iii. May get a metatarsal on different planes
e. Truncated tarsometatarsal wedge osteotomies: first described by
Jahass, excision of a truncated wedge of bone. across the tarsometatarsal
articulations. This procedure is contraindicated in subtalar joint
abnormalities, moderate-severe rearfoot varus, or muscular imbalance
secondary to Charcot-Marie-Tooth disease
f. McElvenny-Caldwell procedure: elevation of the first metatarsal by
fusing the 1st met-cuneiform joint. If the deformity is too severe then fusion
of the N-C joint is added.
g. Calcaneal osteotomies (Dwyer: opening or closing and biplane):

Note* The biplane osteotomy permits reduction of the calcaneal inclination

angle or sagittal plane deformity, as well as frontal plane varus

h. Triple arthrodesis: previously described under Section: Flatfoot

Deformity
i. Hoke procedure: a combination of subtalar arthrodesis with a
resection/reshaping/reimplantation of the head and neck of the talus
j. Dunn procedure: a tarsal arthrodesis that obtained posterior
displacement of the foot by excising the navicular and part of the head and
neck of the talus

Note* The Dunn and Hoke procedures are useful when posterior Talipes
displacement of the calcaneus beneath the talus is needed
Equinovarus (clubfoot)
The reason to treat a clubfoot is to obtain a pliable, plantargrade,
cosmetically acceptable foot in a short treatment time with minimal risk. The
indications for operative treatment are incomplete correction of the varus
and equinus components, and you may see the bony pathology progressing if
continued conservative treatment is followed. When surgery is done early
there is less deformity to the talus
1. Types:
a. Rigid
b. Non-rigid
c. Neural component foot with joint problems

Idiopathic: only the foot is deformed, the musculoskeletal system is otherwise

normal. In this foot type you will probably go on to surgical intervention
before a non-idiopathic foot since the disorder should be known and the
progression of the disease should be known. You should wait to treat this foot
till the full deformity has developed as the treatment is more effective

Non-idiopathic: the deformity is a local manifestation of a systemic skeletal

syndrome. The foot deformity and associated skeletal anomalies are due to
the same etiologic factors that caused the failure of normal musculoskeletal
development. Can be caused by:
a. Congenital diseases: congenital constricting band syndrome (Streeter
disease), hereditary onycho-osteodysplasia (nail-patella syndrome),
arthrogryphosis multiplex congenita
b. Neurologic diseases: meningomyelocele, spina bifida, hydrocephalus, CP
c. Myopathy: muscular dystrophy

2. Etiology:
a. Unknown- but many theories (see Chapter: Pediatrics)

3. Anatomical Presentation:
a. The talus is supinated over the top of the distal calcaneus so that the
calcaneus is plantarflexed and inverted
b. Master Knot of Henry is the deforming force on the medial side of the foot.
It is the fibrous junction of the FHL/FDL sheaths to the navicular and fascia of
the FHB. It must be severed to allow the navicular to re-establish itself
laterally with the calcaneus
c. The talus is usually deformed: the head and neck are medially displaced
and downward (this is consistent in rigid clubfoot)
d. The T-N joint is subluxed with the navicular medially
e. Posterior medial structures are tight along with the STJ tissues
f. Cuboid is displaced inwardly along with the navicular at the M-T joint and
the anterior calcaneus following to go down and under the talar head
g. The anterior surface of the calcaneus faces more medially, so the lateral
column must be corrected to give a rectus foot
h. Two accessory joints are regularly found
i. The navicular rests on the anterior portion of the medial malleolus
ii. The posterior-lateral calcaneus rests on the posterior fibular malleolus
i. The tendo achilles is slightly medial on the calcaneus
j. The most consistent bony deformity is at the talar neck. It is short and
medially deviated
k. Arteriography:
i. PT artery is most prominent (so must protect during surgery)
ii. Deep plantar arch is supplied primarily by the PT not the DP (as in the
normal foot)
iii. A majority of the TEV feet develop without the DP artery
l. The calcaneofibular and posterior talofibular ligaments are tight due to the
equinus position
m. The medial submalleolar skin is contracted and heals poorly

4. Pre-operative Evaluation:
a. Angle of Kite (normal= 20-40°) approaches 00
b. A-P view shows talar bisection lateral to 1 st metatarsal
c. If foot has marked forefoot adductus, corrective surgery is indicated for
this
d. Flat-top talus may be present due to aggressive conservative treatment,
which may later produce osteochondral fracture and later arthritis
e. Preoperative vascular assessment is important to determine the amount of
correction able to be done: the limiting factor to any correction is the stress
placed on the medial soft tissue and the neurovascular bundle
f. Make sure the preoperative x-ray is taken with the knee/leg/foot vertical
and not abducted
g. A lateral stress dorsiflexion view is the most accurate judge of a clubfoot
correction
h. The long axis of the talus is directed downward toward the 3rd met instead
of medial to the 1st metatarsal as in the normal foot
i. Should consider a plantar release in children older than 6 due to cavus
deformity that progresses from accommodation contractures of the plantar
fascia, abductor hallucis, intrinsic toe flexors, and abductor digiti minimi
j. Talus is too far forward in the mortise, therefore, increased equinus and
decreased dorsiflexion
k. Tibia shows increased lateral torsion
l. Ossification centers usually appear later in the clubfoot
m. Parallel talus and calcaneus
n. No overlap of the anterior ends of the talus and calcaneus
o. In the normal foot the T-C angle increases with dorsiflexion, but with the
clubfoot this angle does not change
p. If surgery is delayed till after the age of 10, many adaptive changes will
have taken place, and a triple arthrodesis may be the procedure of choice

5. General Symptoms:
a. Lateral callosities
b. Tiring easily
c. Thin calf ms. on the affected side
d. Smaller foot
e. Small 1st metatarsal with larger 4th and 5th metatarsals
f. Limb length difference with adaptive scoliosis
g. Hyperextended knees
h. Metatarsus adductus
i. No wrinkles over the achilles insertion (this helps diagnosis idiopathic from
non-idiopathic as so if wrinkles are present the foot did have
plantar/dorsiflexion at one time indicating a non-idiopathic clubfoot)
j. Genu valgum
k. External rotation of the leg

6. General Order of Surgical Corrections:

a. Posterior release
b. Posterior medial release
c. Plantar release
d. Subtalar release
e. Metatarsus adductus procedure
f. Tendon transfers
g. Calcaneal osteotomies
h. Triple arthrodesis with soft tissue release
i. Amputation (if all else fails)
7. Surgical Treatment (soft tissue): Performed after 3 months of failed
conservative care- the next step.
a. Posterior Medial Subtalar Release (TURCO procedure)
i. Skin incision is classically a hockey stick incision from the base of the 1st
metatarsal continuing under the medial malleolus and partially up the medial
aspect of the leg. Due to severe skin necrosis from this, a linear incision is
now used
ii. Isolate the posterior tibial ms., FHL, FDL, neurovascular bundle, and medial
achilles
iii. Loosen the abductor hallucis from the medial calcaneal tuberosity
iv. Release the Master Knot of Henry (this obstructs a good view of the
medial side of the foot)
v. Posterior release is done first to allow good visualization of anatomical
structures

 Inferior/posterior achilles release with sagittal plane Z TAL

 Release FHL sheath and retract with the neurovascular bundle medial and
anterior
 Apply dorsiflexory pressure and transect ankle and STJ capsule
 Resect calcaneofibular and posterior talofibular ligaments
 Resect posterior superficial part of the deltoid ligament (talotibial)
 Lengthen the FDL to prevent clawtoe deformity

vi. Medial release now tries to reposition medially displaced navicular

laterally onto the talar head

 Posterior tibial ms. is sectioned retaining good control of the distal

segment to help isolate the T-N joint and medial structures
 Resect the calcaneofibular ligament (spring)
 Resect the superficial part of the deltoid leaving the deep tibiotalar intact
anteriorly

vii. Plantar release

 incise the plantar fascia

 incise the first layer of intrinsics
 incise the long plantar ligament

viii. Subtalar release allows the anterior calcaneus to move lateral-dorsal so

the talus may reposition to a more appropriate pronated position
 Evert the heel and intersect the interosseous talocalcaneal ligament
 May need to sever the bifurcate ligament to help reposition the talus and
calcaneus
ix. After all soft tissue releases and the foot is corrected, the T-N and T-C
joints should be stabilized with K-wires
x. Resected tendons should now be repaired except the posterior tibial
xi. Skin closure: may need skin graft in the severely deformed foot or overly
corrected foot
xii. If metatarsus adductus present now do HHS procedure

Note* Turco states that best results are obtained when:

a. the child is 1-2 years old
b. Good results decrease with age
c. Good results if the child is walking due to Wolfs Law to help bone remodel
d. Previous surgery is a hindrance

b. Tendon transfers: usually done as an adjunctive procedure, and not

primary ones. Transfers are only useful to help hold the correction of the
flexible foot
i. Stewart TAL
ii. STATT
iii. Anterior tibial transfer
iv Posterior tibial transfer

8. Surgical Treatment (osseous): Usually done after the child is 4 or if soft

tissue surgery has failed
a. Evans calcaneal osteotomy (corrects the anterior medial position of the
anterior calcaneal surface-an adaptive change)
b. Dwyer calcaneal osteotomy (tries to establish a perpendicular heel and a
weight bearing center of gravity)
c. Triple arthrodesis is the procedure of choice when all else fails
d. Talectomy is a possibility in the severely deformed foot
e. Amputation can be a viable alternative when most other procedures fail.
With the aid of bracing, many times the extremity is more functional with a
good device as compared to a very deformed and painful foot

9. Postoperative Evaluation:
a. Calcaneus is rotated out of plantarflexion to dorsiflexion
b. Posterior tubercle moves down when the anterior process moves up and
laterally away from under the talus
c. T-C angle now approx. 400 (lateral x-ray) and 250 on A-P view
d. Intraoperative lateral should shoe dorsiflexion of the calcaneus, overlap of
the talus on the anterior calcaneus if correction achieved

Note* Failure of the calcaneus to dorsiflex is evidence of incomplete subtalar

correction regardless of what the A-P x-ray and clinical exam reveal

10. Postoperative Care:

a. Cast in neutral
b. Prophylactic antibiotics given
c. Change cast every month, first cast change at 3 weeks-remove sutures
d. At second cast change, remove K-wires
e. Weight bearing allowed when wires removed
f. Straight last shoes used for 1 year
g. Physical therapy

11. Complications:
a. Rocker bottom foot if conservative treatment of equinus is corrected
before the varus component or if the internal fixation is removed too soon
b. Flap/skin necrosis
c. Inability to close the skin after reduction
d. Damage to growth plates
e. Relapse of the deformity
f. Loss of the longitudinal arch
g. Stiffness
h. Hammertoe deformities
i. Skewfoot can develop secondary to a valgus correction of the forefoot

12. General Facts:

a. Treatment must be related to the type of clubfoot and age
b. The first step in the correction of clubfoot should be the replacement of the
navicular on the talus
c. Soft tissue procedures will fail if secondary bony changes are present
d. In the older child an adaptive contracture can produce a cavus foot. This is
different from the average cavus foot because the calcaneus is plantarflexed
in clubfoot-cavus and usually dorsiflexes in idiopathic or neuromuscular
cavus. This is due to plantar contracture of the aponeurosis, abductor
hallucis, intrinsics, and deep plantar ligaments