Disoders like Flat foot, pes cavus, Hallux valgus discussed

1. Dr. Aman Shah
PG Orthopaedics
Ngmc (KU)

2.  BRIEF ANATOMY OF FOOT AND ANKLE
 ARCHES OF FOOT
 DEFORMITIES
 PES PLANUS
 PES CAVUS
 HALLUX VALGUS
OUR FEET ARE NO MORE
ALIKE THAN OUR FACES

4.  LONGITUDINAL ARCHES
 Medial Longitudinal Arches
 Lateral longitudinal arches
 Transverse Arches
 Anterior
 posterior
 FACTORS RESPONSIBLE OF
MAINTENANCE OF ARCHES
 Bony Factor
 Intersegmental Ties
 Tie beams
 Slings
STRUCTURE OF ARCHES
• PILLARS
• Ends
• Summit
• Main joint

6. PES PLANUS
 Loss of Longitudinal arch
 Congenital or Acquired
Flexible
Rigid
 Tarsal coalition
 Inflammatory joint disorder
 Neurological disorder
Compensatory
 Bilateral in 50 percentage

7.  Stage 1: tibialis posterior tendon is inflamed but intact
 Stage 2: tendon becomes dysfunctional and arch collapses
 Stage 3: deformity becomes fixed and Subtalar arthritis occur
 Stage 4: Ankle joint with Arthritic changes

8.  Head of Talus Lies significantly forward downward and Medial,
 Calcanuem in Valgus
 Anterior extremity medial
 Posterior extremity lateral
 Forefoot is in Abduction, Slight supination(though the entire foot appears
pronated)
 Navicular, cuneiforms, cuboid become wedge shaped
 Spring Ligament, Deltoid ligament Stretched
 Lateral Ligaments Contracted
 Tibialis muscles Elongated and weakened
 Pernonei muscles Adaptively Shortened
Medial Column is longer
than Lateral column

9.  Aymptomatic in infants(noticed by family members)
 Fatigue on walking and being indulged in sports
 Flat foot only on weight beating
 JACK TEST(suggests naviculo-calcaneal sag)
 Foot is rotated externally in relation to leg,
 Heel in valgus
 Too Many toes sign

10.  MEARY ANGLE

11.  Meary angle
 First metatarsal- talus angle
 Calcaneal pitch
 A short tongue like sustentaculum that doesnot support head
 Divergence of lonf axis of talus from that of the calcaneus

12. Normal range is 17 to 32 degrees
Angle decreased in pes planus

13. AP weight beaing view
Line drawn though midaxis of talus
should pass through the base of first
metatarsal
Angled slightly lateral to the first
metatarsal’s long axis

14. Pes planus

15.  Aim is to relieve ligamentous tension
 Arch Supports and shoes
UCBL orthosis
Whitman Arch Support
Thomas Heel

16.  Toes are made to planter flex and curl over washcloth until patient is able to pick
up ubject with his toes
 Passive manipulation of toes into flexion
 Weight bearing on toes
 NOT TO OVER EXERT and STRAIN contracting muscles

17.  For patients with intractable symptoms
 Acquired grade 2-4 flat foot
 SOFT TISSUE IMBRICATION
 ARTHERIOSIS
 LATERAL COLUMN LENGTHING
 SLIDING CALCANEAL OSTEOTOMY
 DURHAM PLASTY
 ARTHRODESIS

18.  FDL and FHL tendon transfers into navicular to reconstruct Posterior tibial
tendon
 Tendoachilles lengthening

19.  Detachment of Tibialis posterior
 Raising osteo-periosteal flap
 Talonaviculocuneiform alignment is corrected
(but after lateral column lengthening)
 Tibialis posterios is shortened
 To maintain tension after imbrication

20.  Most preferred technique
 Can be used in combination with imbrication of talo-naviculo-cuneiform complex
 Trapezoidal shaped tricortical iliac crest
allograft used
 Stabilize Calcaneocuboidal articulation
percutaneously
 Lenghetning of peroneus brevis

21. A. Elevation of posterior tibial tendon
B. Elevation of osteo-periosteal flap from
C. Proximal to distal
D. Arthrodesis of navicular-first cuneiform
E. Extend of arthrodesis resection through mid foot
F. Internal fixation of navicular-first cuneiform

22.  Reduces the over all eversion and hind foot
Abduction
 Usually done in combination with medial
Imbrication
 High risk of non union

23.  Opening wedge medial cuneiform
osteotomy
 Obtain desired plantarflexion of first ray
to thelevel of 5th ray
 Maintain tripod configuration

24.  Limit the amount of valgus motion in subtalar join
 Long term outcome nondocumented
 Complication like synovitis necessisates removal

25.  Triple arthrodesis in stage 3
 Tibiotalar calcaneal fusion in Stage 4

27.  Arch is higher than normal
 Clawing of the toes
 Always look for some neuromuscular disorders
 POLIOMYELITIS
 MUSCULAR DYSTROPHIES
 CEREBRAL DISORDERS
 USUALLY BILATERAL

28.  Dropping of forefoot
 Forefood everted / pronated
 Contracture of plantar fascia
 Varus of heel
 Inititally apparent only on weight bearing
 Clawing of toe
 Distal and middle phalynx are flexed
 Proximal phalynx and MTP hyper extended

30.  Pain over metarsal heads and toes
 High longitudinal arch
 Heel later goes in to varus
 Callosities present
 PEEK-A-BOO Sign
 COLEMAN BLOCK TEST
 in flexible type calcaneal goes to normal
with dropping of first ray

32. DECREASED Hibbs angle
Normal range > 150
Meary angle is normally zero
Raised in pes cavus

33.  Role of conservative management is limited
 Surgical managements
 Soft tissues surgerys
 Osteotomies
 Hindfoot fusion
PES CAVUS IS NEVER REGARDED IDIOPATHIC UNLESS AN EXHAUSTIVE SEARCH FAILS
TO DISCLOSE A CAUSE

34. 10 FACTORS DESCRIBED BY
TACHDJIAN
1. The apex of the deformity,
2. The type of pes cavus (i.e., cavovarus versus calcaneocavus),
3. The position of the hindfoot,
4. The presence of a claw-toe deformity,
5. The presence of skin changes on the sole of the foot,
6. Abnormal shoe wear,
7. The rigidity of the deformity,
8. The strength of the muscles,
9. The stability of the neurologic disease
10. The age of the patient and skeletal maturity of the foot

35.  Almost always performed with other procedures
 In STEINDLER TECHNIQUE
 PF, FDB, Abductor digiti quinti, Abductor hallucis is extraperiosteally released from its
origin
 Occasionaly Achilles Tendon lengthening is done if there is equinus deformity
 Should not be done concomitantly

36.  PL depresses first Metarsal
 PB (Attached TO 5TH MT) causes hind foot eversion
 Augmenting Peroneus Brevis provides for dynamic hind foot varus correction

37.  EHL is divided 1 inch proximal to interphalangeal joint
 Distal stump is fixed to proximal phalanx
 In the proximal stump 2 inches of sheath is excised
to avoid distal growth
 The severed stump is attached to metatarsal
 Metatarsal is held in dorsiflexion

38.  for rigid type
DWYER PROCEDURE
 Osteotomy made posterior to posterior facet
of sub talar joint
 Extended distally to plantar surface
 Lateral wedge closing osteotomy
 Or sliding inferior fragment laterally

39.  Mitchell described another calcaneal osteotomy for calcaneocavus deformity
 Distal fragment is slided superiorly and posteriorly

40.  V-osteotomy
 Medial limb emerges proximal to
first cuneiform
 Lateral limb emerges through
cuboid to fifth metatarsal
 Apex at highest point of cavus
usually navicular
 Steintman pin from metarsal toward rear
of foot

42.  Talonavicular and calcaneocuboid joints are untouched
 Vertical osteotomy made near center of tha navicular and cuboid
 Second osteotomy anterior to first
 Join at undersurface of first vertical osteotomy
 Removal of wedge

44.  Very common deformity
ETIOLOGY
 Splaying of fore foot with varus angulation of first metatarsal
 Metarsal adductus
 Narrow foot ware
 Family history
 Increased first metarsal length

45.  CONTRACTURE OF ADDUCTOR hallucis, FHB, lateral capsule
 Sesamoid enlarged and displaced laterally
 Varus of first ray with elnargment of metarasal head and neck( FORMS BUNION)
 Great toe
 Displaced laterally
 Rotated on its axis
 Nail bed may face medially
 There can be wedging of first cuneiform
 Occasionally hammer toe

46.  Wt bearing lateral and anteroposterior view of foot

47. Less than 15 degree

48. Less than 9 degrees

49. Less than10 degrees

50. Less than 10 degress

51.  Type1:
 congruent]
 MTP normally centered
 Type 2:
 Noncongruent
 Type 3:
 Noncongruent
 Slightly subluxated

52. CONSERVATIVE
 MILD DEFORMITIES
 CONTRAINDICATION FOR SURGERIES
 Toe spreaders at night
 Trainers shoes
 Bunions pad
 Assurance

54.  Simple exostectomy
 Medial eminence of first metatarsal is resected
 This step is a component of various other operations to correct hallux valgus

55.  Releasing ADDUCTOR TENDON from proximal phalynx and transferring it to
neck of first metarsal
 Combined with silver procedure
 May include excision of lateral sesamoids

56.  In physiologically old age patient 70 years age
 High rate of recurrence
 Medial eminence removal
 Excision of proximal end of phalynx
 Soft tissue resection

57.  Removal of medial eminence
 Osteotomy of distal portion of first metatarsal shaft
 Lateral displacement and angulation of capital fragment
 Medial capsulorrhaphy

58.  V SHAPED OSTEOTOMY in Sagittal plane through metarsal
 Lateral displacement of Capital fragment
 Removal of resulting projection of first metarsal
 Fixation by Kirschnner wire or cortical screw
 Medial capsulorrhaphy
Recommended for age < 50
HVI<40
IMA<20

60.  Z SHAPED OSTEOTOMY
 LATERAL SHIFTING OF PLANTAR
DISTAL FRAGMENT
 REMOVAL OF EXPOSED MEDIAL
EMINENCE AND DORSOMEDIAL
FRAGMENT

61.  TROUGHING IS A COMMON COMPLICATION

62.  Intermetarsal angle less than 13 degree
 Patient older than 55 yrs old
 Corrects 8 degree valgus for each 2.5 mm to 3 mm wedge removal
 Contraindications
 open physis
 RA
 OA of MTP

63.  Originally used for correction of primus valgus

64.  IMA> 20
 HVA> 45
 SEVERE PRONATION OF HALLUX
 RA
 RECURRENT HALLUS VALGUS

65.  Arthrodesis of first metatarsocuneiform articulation
 Three incisions
 Removal of medial eminence
 Release fo adductors
 Screws from dorsal to plantar and proximally to distally

67.  Always rule out some neuro muscular cause before management of pescavus
 Cosmetic appeal is not an indication for pesplanus and hallux valgus
 Orthosis are helpful to relieve symptoms
 Orthosis do not correct the deformity
 No single procedure is gold standard; Combination of various procedure can be
done based on severity

68. THANK YOU
STAY SAFE