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Metatarsalgia occurring in individuals with pes cavus is typically associated with abnormal loading patterns in the forefoot resulting from structural alterations. Simultaneously, the frequent overstress of the plantar fascia (PF) caused by the persistence of this foot deformity may further exacerbate the chronic pain induced by metatarsal overload. We aimed to investigate and quantify the effects of PF stiffness on the internal biomechanics of pes cavus using a computational modelling approach. A patient-specific finite element model of the foot-ankle complex using the actual three-dimensional geometry of idiopathic pes cavus bones and soft tissues was reconstructed. A sensitivity study was conducted to evaluate the effects of varying elastic modulus (0-700 MPa) of the PF on the metatarsal stress distribution, and force transmission through the metatarsophalangeal (MTP) and tarsometatarsal (TMT) joints in the pes cavus. The results indicated that variations in PF stiffness led to stress redistribution in the metatarsal region. Peak stress gradually reduced with decreasing stiffness until the PF was released, eventually resulting in a reduction of 22.39% compared to the reference value of 350 MPa. Furthermore, adjusting the PF stiffness to twice the reference value (700 MPa) increased the contact forces through the TMT and MTP joints by up to 23% and 116%, respectively. The reduction of PF stiffness alleviated focal metatarsal loading, and therefore, surgical fascia release can be considered to alleviate metatarsalgia in patients with pes cavus.

Background: Flexible cavovarus deformity is prevalent and the Coleman block test is frequently used to assess the first ray plantarflexion malpositioning in the overall deformity as well as the flexibility of the hindfoot. The objective was to assess and compare the weightbearing computed tomography (WBCT) 3-dimensional (3D) changes in clinical and bone alignment in flexible cavovarus deformity patients when performing the Coleman block test when compared to normal standing position and to controls., Methods: Twenty patients (40 feet) with flexible cavovarus deformity and 20 volunteer controls (40 feet) with normal foot alignment underwent WBCT imaging of the foot and ankle. Cavovarus patients were assessed in normal orthostatic and Coleman block test positions. Foot and ankle offset (FAO), hindfoot alignment angle (HAA), talocalcaneal angle (TCA), subtalar vertical angle (SVA) and talonavicular coverage angle (TNCA) and a CT-simulated soft tissue envelope image, WBCT clinical hindfoot alignment angle (WBCT-CHAA), were evaluated by 2 readers. Measurements were compared between cavovarus nonstressed and stressed positions and to controls. P values of .05 or less were considered significant., Results: The intra- and interobserver intraclass correlation coefficient were good or excellent for all WBCT measurements. Cavovarus patients demonstrated significant correction of WBCT-CHAA (9.7 ± 0.4 degrees), FAO (2.6 ± 0.4%), and TNCA (8.8 ± 1.8 degrees) when performing the Coleman block test (all P values <.0001). However, WBCT-CHAA and FAO measurements were still residually deformed and significantly different from controls ( P values of .001 and <.0001, respectively). TNCA values corrected to values similar to healthy controls ( P  = .29). No differences were observed in cavovarus patients during Coleman block test for the coronal measures: HAA, TCA, and SVA measurements., Conclusion: In this study, we observed improvement in the overall 3D WBCT alignment (FAO), axial plane adduction deformity (TNCA), as well as CT simulated clinical hindfoot alignment (WBCT-CHAA) in flexible cavovarus deformity patients when performing a Coleman block test. However, we did not find improvement in measures of coronal alignment of the hindfoot, indicating continued varus positioning of the hindfoot in these patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: The cavovarus foot is a complex 3-dimensional deformity. Although a multitude of techniques are described for its surgical management, few of these are evidence based or guided by classification systems. Surgical management involves realignment of the hindfoot and soft tissue balancing, followed by forefoot balancing. Our aim was to analyze the pattern of residual forefoot deformities once the hindfoot is corrected, to guide forefoot correction., Methods: We included 20 cavovarus feet from 16 adult patients with Charcot-Marie-Tooth who underwent weightbearing CT (mean age 43.4 years, range: 22-78 years, 14 males). Patients included had flexible deformities, with no previous surgery. Using specialized software (Bonelogic 2.1, Disior) a 3-dimensional, virtual model was created. Using morphologic data captured from normal feet in patients without pathology as a guide, the talonavicular joint of the cavovarus foot was digitally reduced to a "normal" position to simulate the correction that would be achieved during surgical correction. Models of the corrected position were exported and geometrically analyzed using Blender 3.64 to identify anatomical trends., Results: We identified 4 types of cavovarus forefoot morphotypes. Type 0 was defined as a balanced forefoot (2 cases, 10%). Type 1 was defined as a forefoot where the first metatarsal was relatively plantarflexed to the rest of the foot, with no significant residual adduction after talonavicular joint correction (12 cases, 60%). Type 2 was defined as a forefoot where the second and first metatarsals were progressively plantarflexed, with no significant adduction (4 cases, 20%). Type 3 was defined as a forefoot where the metatarsals were adducted after talonavicular derotation (2 cases, 10%)., Conclusion: In this relatively small cohort, we identified 4 forefoot morphotypes in cavovarus feet that might help surgeons to recognize and anticipate the residual forefoot deformities after hindfoot correction. Different treatment strategies may be required for different morphotypes to achieve balanced correction., Level of Evidence: Level IV, retrospective case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Objectives: The etiology of flatfoot and cavus foot is multicausal and controversial. So far, no literature reports the relationship between the sagittal morphology of subtalar joint and the alignment of foot. The purpose of this study was to explore whether the subtalar alignment would influence the configuration of foot., Methods: From January 2017 to January 2020, we included 109 feet in the flatfoot group, 95 feet in the cavus group, and 104 feet in the control group in this retrospective comparative study. The Gissane angle and calcaneal posterior articular surface inclination angle represented the sagittal morphology of the subtalar joint. Meary's angle, calcaneal pitch angle, and talar pitch angle reflected the alignment of foot. They were measured in the weightbearing foot X-rays. The angles in different groups were compared via Mann-Whitney U test. We calculated the correlation between the sagittal alignment of subtalar joint and the alignment of foot using Spearman's correlation analysis. Interobserver and intraobserver reliability were calculated., Results: The Gissane angle, calcaneal posterior articular surface inclination angle, Meary's angle, talar pitch angle, and calcaneal pitch angle were significantly different in the three groups. The Gissane angle had an excellent correlation with the Meary's angle (r = 0.850, p < 0.0001), and the talar pitch angle (r = -0.825, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = 0.638, p < 0.0001). The calcaneal posterior articular surface inclination angle had an excellent correlation with the Meary's angle (r = -0.902, p < 0.001), and the talar pitch angle (r = 0.887, p < 0.0001), and a good correlation with the calcaneal pitch angle (r = -0.702, p < 0.0001). The interobserver and intraobserver reliability for all radiographic measurements was good to excellent., Conclusion: A subtalar joint with a larger Gissane angle and a more horizontal calcaneal posterior articular surface angle tended to have a higher foot arch and vice versa. The inspiration from this study was that the deformities of flatfoot and cavus foot may relate to the subtalar deformity., (© 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Background: The complex deformities in cavovarus feet of Charcot-Marie-Tooth (CMT) disease are difficult to evaluate. The aim of this study was to quantify the initial standing alignment correction achieved after joint-sparing CMT cavovarus reconstruction using pre- and postoperative weightbearing computed tomography (WBCT)., Methods: Twenty-nine CMT cavovarus reconstructions were retrospectively analyzed. Three-dimensional measurements were performed using semiautomated software (Bonelogic 2.1) to investigate changes in sagittal, axial, and coronal parameters. Pre- and postoperative data were compared, along with normative data. Correlation among the preoperative measurements and the amount of correction in sagittal, axial, and coronal parameters were analyzed., Results: The sagittal, axial, and coronal malalignment of the hindfoot, and the sagittal and axial malalignment of the forefoot, was significantly improved after corrective surgery ( P < .05). Sagittal Meary angle (from 14.8 to 0.1 degrees), axial talonavicular angle (TNA, from 3.6 to 19.2 degrees), and coronal hindfoot alignment (from 11.0 to -11.1 degrees) showed significant changes postoperatively ( P < .001). Hindfoot, forefoot sagittal, and forefoot axial parameters reached comparable outcomes compared with normative value ( P > .05). Regarding amount of correction, Spearman correlation demonstrated that axial Meary angle and TNA were most strongly related to improvement in sagittal Meary angle and coronal hindfoot alignment., Conclusion: Preoperative and postoperative WBCT measurements demonstrated that joint sparing CMT cavovarus reconstruction significantly improved sagittal, axial, and coronal deformities of CMT, and sagittal Meary angle was restored toward normative values. Apparent axial plane correction, the majority of which occurred at the talonavicular joint, had the strongest correlation with deformity correction in multiple planes. This suggests that soft tissue releases and correction of the talonavicular joint may be a key component of a cavovarus foot correction., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Supramalleolar osteotomy enables correction of the ankle varus deformity and is associated with improvement of pain and function in the short term and long term. Despite these beneficial results, the amount of surgical correction is challenging to titrate and the procedure remains technically demanding. Most supramalleolar osteotomies are currently planned preoperatively on 2-dimensional weight-bearing radiographs and executed peroperatively using free-hand techniques. This article encompasses 3-dimensional planning and printing techniques based on weight-bearing computed tomography images and patient-specific instruments to correct ankle varus deformities., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Cavovarus foot is a complex three-dimensional deformity, which includes a wide range of clinical conditions from subtle deformities to disabling feet. In this article, the authors discuss the role of weight-bearing computed tomography, which might enable to avoid double imaging (radiographs + tomography) in patients for which a detailed osteoarticular assessment is required, with the advantage to obtain tomographic images in standing position and a reduction of radiation exposure., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The outcome of a constant joint preserving procedure for painful plantar callosities with cavovarus foot remains unclear., Methods: Eleven patients (11 feet) who underwent lateral displacement calcaneal osteotomy (LDCO), dorsiflexion first metatarsal osteotomy (DFMO), and plantar fasciotomy (PF), simultaneously were included. The presence of painful callosities, heel alignment of standing (HA), and the Japanese Society for Surgery of the Foot ankle/hindfoot (JSSF) score were evaluated. Radiographically, the talonavicular coverage angle (TNCA), lateral talo-first metatarsal angle (LTMA), calcaneal pitch angle (CPA), and heel alignment angle (HAA) were measured., Results: Postoperatively, painful plantar callosities disappeared in 10 patients and remained in one patient. The postoperative HA and JSSF score significantly improved. The postoperative TNCA, LTMA, CPA, and HAA significantly improved., Conclusions: In patients with flexible cavovarus foot, LDCO, DFMO, and PF yielded good outcomes at mid-term follow-up with preservation of the foot and ankle joints., (Copyright © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: The complex deformities in cavovarus feet may be difficult to assess and understand. Weightbearing computed tomography (WBCT) is increasingly used in evaluating complex deformities. However, the bone axes may be difficult to calculate in the setting of severe deformity. Computer-assisted 3D axis calculation is a novel approach that may allow for more accurate assessment of foot alignment or deformity. This study aimed to assess differences in measurements done manually on 2D slices of WBCT vs 3D computer models in normal and cavus feet., Methods: We retrospectively analyzed WBCT scans from 16 normal and 16 cavus feet in patients with Charcot-Marie-Tooth disease. Six measurements were assessed: talar-first metatarsal angle (axial plane), forefoot arch angle (coronal plane), and Meary angle, calcaneal pitch, and cuneiform and navicular to floor distances (sagittal plane). 2D measurements were performed manually and 3D measurements were performed using specialized software (Bonelogic, DISIOR). Bland-Altman plots and linear regression were used to analyze differences., Results: There were no significant biases in measured variables in normal feet. In the cavovarus group, automated assessment calculated increased sagittal plane deformity (fixed bias 7.31 degrees for Meary angle, 2.39 degrees for calcaneal pitch) and less axial plane deformity (fixed bias 10.61 degrees for axial talar-first metatarsal angle). The latter also demonstrated proportional bias indicating greater discrepancy with increasing adduction., Conclusion: Measurements were comparable in normal feet suggesting automated techniques can reliably assess the alignment of bony axes. However, automated calculations show greater sagittal and less axial deformity in cavovarus feet than measured by manual techniques. This discrepancy may relate to rotational deformity seen in cavovarus feet, which may not be easily assessed manually. 3D automated measurements may therefore play a role in better assessing and classifying the cavovarus foot, which may ultimately inform treatment algorithms., Level of Evidence: Level III, retrospective comparative study.

Bony alignment is the primary goal in foot and ankle reconstruction of the cavovarus foot. This condition presents as a malalignment causing a medial overload of the ankle articular surface and lateral overload of the hindfoot, midfoot, and forefoot. A painful gait associated with articular degeneration of the numerous joints can lead to a chronic and rigid arthrosis of joints, warranting arthrodesis of the affected joints accordingly., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Direct-type cavus foot deformities are most commonly encountered and are primarily sagittal plane deformities. Direct deformities should be delineated from rarer triplane pes cavovarus deformities. The lateral weight-bearing radiograph is the cornerstone of imaging evaluation of direct pes cavus foot deformity. The apex of Meary talo-first metatarsal angle on the lateral radiograph represents the pinnacle of the cavus deformity and assists in subclassification of the deformity. With routine application, ancillary radiographic imaging techniques, such as the modified Saltzman view or the modified Coleman block test, can give valuable insight into deformity assessment and surgical planning., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The goal of this study was to characterize the abnormal joint surface interaction at the ankle, hindfoot and midfoot joints of the cavovarus foot using distance mapping on weightbearing computed tomography (WBCT) images by comparing a series of cavovarus feet to a series of normally-aligned feet., Methods: In this case-control study, ten feet (10 patients) with asymptomatic cavovarus shape (cases; N = 10) were compared to 10 matched-paired (by age, gender and body mass index) normally-aligned feet (10 patients) (controls; N = 10). Three-dimensional models were produced from the images and distance maps representing joint surface configuration were generated for the ankle, hindfoot and midfoot joints. The distance maps for each joint were then compared between the two groups and between regions in the same group., Results: In the cavovarus group there was a significant increase in surface-to-surface distance at the posterior tibiotalar joint and a reduced distance at the anterior part, together with a greater distance at the posterior half of the medial gutter. Also, a decrease in surface-to-surface distance on the anterior half of the anterior facet and an increased distance on the posterior quadrants of the posterior facet of the subtalar joint were found. At the sinus tarsi, the lateral aspect of the talonavicular joint, the naviculocuneiform and the tarsometatarsal joints there was a statistically significant increase in surface-to-surface distance in cavovarus patients as compared to controls., Conclusion: Distance mapping analysis on WBCT images identified significant differences in surface-to-surface interaction at the foot and ankle joints between cavovarus and normally-aligned feet., Level of Evidence: Level III, case-control study., (Copyright © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

For pre-operative osteoarthritis (OA) patients with varus knee, previous studies showed inconsistent results. Therefore, we conducted this study to better identify the association of Hospital for Special Surgery (HSS) score and mechanical alignment. 44 patients (51 knees) with constitutional varus knee caused by combined deformities (LDFA (lateral distal femoral angle) > 90°and MPTA (medial proximal tibial angle) < 85°)) were selected and analyzed with a mean follow-up period of 14 months after total knee arthroplasty (TKA). From January 2015 to December 2016, patients were collected consecutively after primary TKA. After filtering, fifty-one knees (44patients) were analyzed with a mean follow-up period of 14 months. All patients were divided into two groups based on post-operative hip-knee-ankle (HKA) acute angle: varus mechanical alignment (VMA) group (HKA < - 3°) and neutral mechanical axis (NMA) group (- 3° ≤ HKA ≤ 3°). 30 knees were included in the NMA group, and 21 knees in the VMA group. Comparisons of HSS between NMA group and VMA group were performed. After adjusting for age and Body Mass Index (BMI) confounders, Compared with NMA group, the HSS score in VMA group decreased by 0.81 units (95% CI, - 3.37 to 1.75) p = 0.5370). For pre-operative constitutional varus knee caused by combined deformities in chinese populations, no significant association between post-operative lower limb mechanical alignment and HSS score was found.

Background: Pes cavovarus is a foot deformity that can be idiopathic (I-PC) or acquired secondary to other pathology. Charcot-Marie-Tooth disease (CMT) is the most common adult cause for acquired pes cavovarus deformity (CMT-PC). The foot morphology of these distinct patient groups has not been previously investigated. The aim of this study was to assess if morphological differences exist between CMT-PC, I-PC and normal feet (controls) using weightbearing computed tomography (WBCT)., Methods: A retrospective analysis of WBCT scans performed between May 2013 and June 2017 was undertaken. WBCT scans from 17 CMT-PC, 17 I-PC and 17 healthy normally-aligned control feet (age-, side-, sex- and body mass index-matched) identified from a prospectively collected database, were analysed. Eight 2-dimensional (2D) and three 3-dimensional (3D) measurements were undertaken for each foot and mean values in the three groups were compared using one-way ANOVA with the Bonferroni correction., Results: Significant differences were observed between CMT-PC or I-PC and controls (p<0.05). Two-dimensional measurements were similar in CMT-PC and I-PC, except for forefoot arch angle (p=0.04). 3D measurements (foot and ankle offset, calcaneal offset and hindfoot alignment angle) demonstrated that CMT-PC exhibited more severe hindfoot varus malalignment than I-PC (p=0.03, 0.04 and 0.02 respectively)., Conclusions: CMT-related cavovarus and idiopathic cavovarus feet are morphologically different from healthy feet, and CMT feet exhibit increased forefoot supination and hindfoot malalignment compared to idiopathic forms. The use of novel three-dimensional analysis may help highlight subtle structural differences in patients with similar foot morphology but aetiologically different pathology., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2020 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

The cavovarus foot (CF) is a complex three-dimensional foot deformity. In addition to primary forms, secondary forms can be distinguished. The diagnosis of CF is made clinically; however, anamnestic information, a targeted examination including neurological status and at least radiological imaging using the hindfoot-centered imaging technique are required to determine the treatment. Conservative treatment for CF consists of the provision of insoles up to the adaptation of an orthopedic custom-made shoe, depending on the severity of the deformity. The indications for a surgical procedure are present in the case of increasing complaints, although the timing should be extensively discussed with the patient in order to be able to achieve the best functional results. Surgical treatment is generally complex but a combination of soft tissue interventions and osteotomy/arthrodesis can usually be used to achieve a plantigrade foot position and thereby enable the patient to walk with a functionally improved gait.

Background: Subtle cavus foot (SCF) is an entity characterized by mild cavus. However, few studies have examined whether a SCF may be a risk factor for chronic ankle instability (CAI)., Methods: This study included 116 patients who underwent lateral ankle ligament repair (modified Broström operation) for CAI and 105 controls. We used the standing lateral radiograph, so compared calcaneal pitch angle, Meary's angle, heights of the first and fifth metatarsal bases, and fibular positions between groups. Additionally, two observers subjectively rated the standing lateral radiographs for the presence of SCF., Results: There were no significant intergroup differences in any of the radiographic angles. The prevalence of SCF was 20.7% in the CAI group and 18.1% in the control group according to observer 1 versus 21.6% and 28.6% (CAI group and control group, respectively) according to observer 2. There were no significant intergroup differences in the proportion of SCF between the two observers (p=0.105 and 0.211, respectively)., Conclusion: SCF was not a significant risk factor for CAI when judging by standing lateral radiograph, and the detection of SCF seems to require considerable experience. Thus, care should be taken when determining whether to perform corrective osteotomies when treating CAI patients with SCF., Level of Evidence: III, case control., (Copyright © 2019 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Cavovarus deformity is considered an anatomical risk factor for chronic lateral ankle instability (CLAI). However, subtle deformity can be difficult to detect, and its correction is controversial. The current study aimed to evaluate clinical and radiographic outcomes of a modified Broström procedure (MBP) with additional procedures for CLAI with subtle cavovarus deformity and a positive peek-a-boo heel sign. We reviewed the records of 15 patients who underwent MBP with additional procedures for CLAI with a positive peek-a-boo heel sign between August 2009 and April 2015. Consecutive physical and radiographic examinations were performed. The visual analog scale (VAS) for pain, the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and the Karlsson-Peterson (KP) ankle score were applied to assess clinical outcomes. Weight bearing radiographs, hindfoot alignment view, and ankle stress radiographs were also examined. The mean follow-up period was 58.5 months. Calcaneal lateral closing wedge osteotomy was performed in seven patients to correct fixed hindfoot varus, and first metatarsal dorsiflexion osteotomy was performed in 11 patients to correct plantarflexion of the first ray. Three patients underwent both procedures. Mean VAS, AOFAS, and KP ankle scores improved significantly ( p =0.001), and instability did not recur. Radiographically, all stress parameters improved significantly ( p =0.007). Simultaneous correction of a positive peek-a-boo heel sign and cavovarus deformity with MBP for CLAI improves clinical outcomes and prevents recurrent instability. A comprehensive evaluation and cautious approach for subtle cavovarus deformity should be followed when treating patients with CLAI. This trial is registered on Clinical Research Information Service (CRiS, KCT0003287)., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2020.)

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.

Background: Cavus foot is a deformity represented by an increased and rigid medial longitudinal arch, and it is often associated with persistent pain and gait disturbances. None of the conservative conventional treatments for cavus foot have shown conclusive evidence of effectiveness, and so further is research needed to understand how to manage this condition better. This study aimed to assess the immediate and short-term radiological changes after combining static stretching and transcutaneous electrical stimulation of the plantar fascia in adults with idiopathic cavus foot., Methods: A randomized, single-blinded clinical trial was conducted. Sixty-eight participants with idiopathic cavus foot, as determined by an internal Moreau-Costa-Bertani angle (MCBA) less than 125° in a lateral weight-bearing foot radiograph, were equally distributed into a neuromuscular stretching group (NSG) or a control group (no intervention). The NSG underwent a single session, combining transcutaneous electrical nerve stimulation with static stretching of the plantar fascia. Primary measurements of 3 angles were taken using a lateral weight-bearing foot radiograph: the internal MCBA; the calcaneal pitch angle (CPA); and the first metatarsal declination angle (FMDA). Outcomes were collected at baseline, immediately postintervention, and 1 week after intervention., Results: Analysis of variance revealed a significant group effect for all angles (all, P < .05). NSG participants showed a significant increase in the internal MCBA (P = .03), and a significant decrease in the CPA (P = .01) and FMDA (P = .04) from baseline to immediately postintervention. These changes remained statistically significant 1 week after the intervention (all, P < .05)., Conclusion: The combination of static stretching and transcutaneous electrical stimulation of the plantar fascia, compared with no treatment, achieved immediate and short-term changes in the internal MCBA, the CPA, and the FMDA, which resulted in flattening the medial longitudinal plantar arch in adults with idiopathic cavus foot.

The purpose of the clinical examination is to detect subtle cavus or cavovarus deformity, assess the severity and type of deformity, differentiate between idiopathic versus secondary etiologies of cavus foot deformity, and evaluate for other associated abnormalities. The clinical examination should begin with a gait analysis. The neurologic examination reveals peripheral neuropathy or central nervous system etiology for the foot deformity. On plain radiographs, forefoot-driven deformity can be assessed using the Meary angle, and hindfoot-driven deformity can be measured by the calcaneal pitch. Computed tomography and MRI scans can assess for tarsal coalitions and soft tissue pathologies, respectively., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cole osteotomy is performed in patients having a cavus deformity with the apex of the deformity in the midfoot. Correction of the deformity at this midfoot level improves foot and ankle stability by creating a plantigrade foot. We retrospectively reviewed the clinical and radiographic results of six feet (five patients) that underwent Cole midfoot osteotomy (2011-2015)., Methods: The patients had different etiologies (spastic cerebral palsy, burn sequelae, spina bifida, and Charcot-Marie-Tooth disease). Dorsal and slightly laterally based transverse wedge osteotomy through the navicular bone medially and the cuboid bone laterally was performed. Patients were under routine clinical follow-up. We evaluated clinical and radiographic results., Results: Mean clinical follow-up was 15.7 months (range, 6-36 months). The mean preoperative and postoperative talo-first metatarsal angles on lateral radiographs were 29.9° and 8.7°, respectively ( P < .05) and on anteroposterior radiographs were 30.3° and 8.6° ( P < .05). The mean preoperative talocalcaneal angle on anteroposterior radiographs increased from 19.2° to 29.8° postoperatively ( P < .05). The mean postoperative calcaneal pitch angle change was 10.8° on the lateral radiograph ( P < .05). At final follow-up, all five patients were independently active, had plantigrade feet, and were able to wear conventional shoes. The mean American Orthopaedic Foot and Ankle Society questionnaire score was 38.8 preoperatively and 79.5 postoperatively ( P < .05). Only one patient did not have full bony union. Achilles tightness was seen in one patient., Conclusions: Cole midfoot osteotomy is a laboring procedure to correct adult pes cavus deformity with the apex in midfoot, although having some complication risks.

Background: The aim was to calculate the Achilles tendon moment arm in different degrees of plantarflexion for pes planus, pes cavus and normal arched feet., Methods: 99 patients (99 radiographs; 40 males, 59 females; mean age 49 years, SD 15) with a healthy ankle joint and a preoperative weightbearing lateral radiograph of the foot were included. Three groups (pes planus, pes cavus and normal-arched feet) with equal sample sizes (n=33) were formed. On radiographs, the angle formed between a horizontal line and the line connecting the insertion of the Achilles tendon with the center of rotation of the ankle, was measured. The interrater reliabilities (ICC) of the angle alpha were compared on radiographs and on MRIs. Using the angle alpha, the Achilles tendon moment arm was calculated in different plantarflexion positions., Results: The ICC of alpha was higher on radiographs (0.84, [0.73-0.91]) than on MRIs (0.61, [0.27-0.81]). The average alpha was statistically significantly different (normal arched foot 31 degrees (°), pes planus 24°, pes cavus 36°, p=0.021), resulting in a significant shorter Achilles tendon moment arm for pes cavus than for pes planus (p<0.0001) and normal arched feet (p=0.006) in neutral position., Conclusion: The data suggests that it is feasible to use radiographs to measure the Achilles tendon moment arm. The maximum Achilles tendon moment arm is reached at different angles of ankle flexion for pes cavus, pes planus and normal-arched feet. This has to be taken into consideration when planning surgeries., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Tibialis posterior transfer (TPT) is the treatment most widely used to palliate foot drop due to dorsiflexor palsy. TPT has been extensively studied in patients with peripheral neurological causes of foot drop. In contrast, data are scarce on central foot drop, in which TPT is often blamed for causing flattening of the arches. The primary objective of this study was to assess the impact on foot alignment of TPT in patients with central foot drop. The secondary objective was to determine whether TPT combined with other surgical procedures improved gait., Hypothesis: TTP can induce flattening of the medial arch of the foot., Patients and Methods: We retrospectively identified 13 patients managed with TPT (1 foot per patient). Mean follow-up was 65 months (range, 12-108 months). The causes were stroke (n=5), head injury (n=3), spinal cord injury (n=2), cervical spondylotic myelopathy (n=1), cerebral palsy (n=1), and a brain tumour (n=1). The clinical assessment focused chiefly on forefoot alignment and footprint parameters. The following variables were collected from weight-bearing radiographs: Djian-Annonier angle, Méary-Toméno angle, lateral arch angle, and calcaneal pitch angle in the sagittal plane; talo-metatarsal angle in the transverse plane; and rearfoot valgus angle in the coronal plane., Results: Of the 13 feet, 6 had normal footprint parameters and 7 pes cavus. There were no cases of flatfoot. Pronation deformities and supination deformities were each found in 2 patients. Comparing the radiographic parameters between the two feet in each patient identified differences only for the lateral arch angle and calcaneal pitch angle, which indicated pes cavus on the operated side (operated side: 142.7° [range, 136°-156°], p=0.041; and 24° [range, 14°-33°], p=0.028, respectively)., Discussion: In contrast to the working hypothesis, we found no evidence of progression to valgus flatfoot after TPT transfer performed to treat central foot drop., Level of Evidence: IV, retrospective study with no control group., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: The primary aim of this study was to determine the prevalence of asymptomatic pes planus and cavovarus foot deformities using the tripod index (TI)., Methods: A retrospective study was conducted on 122 adult subjects over the age of 18 from January 2010 to December 2016 with symptomatic pes planus (n=78) or cavovarus (n=44) foot deformities. We subdivided both groups into subjects who presented with unilateral symptomatic deformities (pes planus unilateral symptomatic; cavovarus unilateral symptomatic) and bilateral symptomatic foot deformities (pes planus bilateral symptomatic feet and cavovarus bilateral symptomatic feet). The severity of TI was compared between sides., Results: The prevalence of asymptomatic pes planus and cavovarus foot deformities was 52% and 67.6%, respectively. Subjects with unilateral symptomatic foot deformities had significantly more severe TI values for the symptomatic cavovarus foot -98.96% (-288.89 to 0%) compared to asymptomatic cavovarus -67.41% (-270.59 to 14.71%) (p=0.015). Subjects with unilateral symptomatic pes planus deformity also had more severe TI on the symptomatic foot 57.49 (-9.38 to 141.67%) compared to the asymptomatic foot 30.43 (-51.52 to 119.23%) (p<0.01). Subjects with bilateral symptomatic foot deformities had no significant difference in severity of Tripod Index between feet., Conclusion: Although half of subjects with unilateral symptomatic deformities had a foot deformity on the contralateral side, the severity of deformity between symptomatic and asymptomatic feet was significantly different for both pes planus and cavovarus feet. Further studies should prospectively follow postoperative radiographs to determine whether a correction in foot alignment directly improves symptoms. Level of evidence: III ., Competing Interests: Disclosures: Phinit Phisitkul is a paid consultant for Arthrex and Restor 3D, receives royalties from Arthrex; and has stock/stock options in First Ray and Mortise Medical., (Copyright © The Iowa Orthopaedic Journal 2019.)

Background: Few authors have directly compared multiple types of lateralizing calcaneal osteotomies (LCOs) in terms of their ability to achieve deformity correction. The aim of this research was to use a digital model of a varus hindfoot to compare 4 different LCOs in terms of deformity correction and amount of tuberosity lateralization required. The authors hypothesis was that osteotomies involving a wedge resection would achieve greater correction with less lateralization., Methods: A weightbearing computed tomographic scan of a patient with a varus hindfoot deformity was used to construct a 3-dimensional digital model of the hindfoot, preserving weightbearing alignment. Four different LCOs were modeled: a standard oblique osteotomy, a Dwyer osteotomy, a modified Dwyer osteotomy involving lateralization in addition to wedge resection, and a Malerba Z-type osteotomy with wedge resection and lateralization. Incremental corrections were performed with each osteotomy type, and amount of correction was assessed with a vertical hindfoot angle and measurement of the lateral translation of the most inferior aspect of the calcaneus. Calcaneal length and osteotomy contact surface area were also measured., Results: The modified Dwyer osteotomy led to the greatest improvements in the vertical hindfoot angle and lateral translation, followed by the Malerba osteotomy. The standard and Malerba osteotomies allowed the most preservation of calcaneal length; the Malerba and Dwyer osteotomies had the greatest contact surface area., Conclusion: LCOs that involve wedge resection as well as lateralization were able to achieve the greatest correction of hindfoot varus., Clinical Relevance: For the surgical treatment of cavovarus foot deformities, osteotomies with wedge resection in addition to lateralization enable more powerful correction.

History A 99-year-old Chinese-Indonesian woman with a longstanding history of diabetes mellitus was admitted for chest infection and was incidentally found to have bilateral deformed feet. She was otherwise asymptomatic and could ambulate independently. Photographs and radiographs of the feet were obtained.

Cavus foot deformity is an often overlooked source of pathology. In the cavus foot, the fibula is often noted to be posterior on lateral radiographs. The objective of the study was to determine with three-dimensional imaging if the fibula is truly posterior or just artifact. Using physical examination, patients with cavus were selected and compared to controls. An established technique to determine fibular position on computed tomography and magnetic resonance imaging was used to compare the study group to controls. Thirty-six cavus feet were compared to 36 controls. The average cavus fibula was noted to be 72% more posterior than the fibula of control patients and the difference in axial malleolar index was significant between the groups. This study shows that the cavus fibula is truly more posterior in patients with high arches. (Journal of Surgical Orthopaedic Advances 27(4):255-260, 2018).

Cavovarus deformities in children and adolescents require sound considerations concerning the timing for corrective surgery. Progression can be recognized best by repeated pedographic examination with evaluation of the typical features of cavovarus deformity. Surgical correction consists of a combination of soft tissue release, bony realignment, and restoration of muscle balance. In most cases plantar or medioplantar soft tissue release should be considered, whereas calf muscle lengthening is rarely indicated. Typical joint-sparing bone procedures are elevating osteotomies at the medial tarsometatarsal ray and realigning calcaneal osteotomies. Advanced cases require navicular-cuneiforme arthrodesis for correction of severe cavus component, hindfoot fusion at the Chopart line, or Lambrinudi triple fusion. Supramalleolar rotational osteotomy should be considered in severe cases. Peroneal dysfunction is addressed by peroneus longus to brevis transfer, posterior tibial tendon transfer compensates for severe extensor weakness to a certain degree, claw toes can be rebalanced by flexor or extensor tendon transfer, often in combination with proximal interphalangeal joint fusion. Surgical treatment should take into account the components of deformity, muscular function, progression and the underlying disease of the individual case. Further deterioration can be prevented by adequate surgery in the young patient. However, repeated surgical interventions may be necessary later in this patient group.

Objective: The aim is to correct the underlying cavovarus deformity and to achieve a pain-free and stable hindfoot., Indications: Rigid neurologic, posttraumatic, congenital, and idiopathic cavovarus deformities., Contraindications: General surgical or anesthesiological risks, infections, critical soft tissue conditions, neurovascular impairment of the lower extremity, noncompliance, patients with severely reduced bone quality, insulin-dependent diabetes mellitus, smoking., Surgical Technique: The talonavicular and subtalar joints are exposed using a single medial approach. Joint cartilage is carefully debrided. Hindfoot reposition with complete correction of cavovarus deformity in all three planes. Joints are stabilized using cannulated screws, followed by wound closure., Postoperative Management: A soft wound dressing is used. Thromboprophylaxis is recommended. Patient mobilization starts on postoperative day 1 using a stabilizing walking boot or cast for 6 weeks with 15 kg partial weight bearing. Clinical and radiographic follow-up 6 weeks postoperatively to assess osseous consolidation at the arthrodesis site. Following clinical and radiographic follow-up at 6 weeks, full weight bearing is gradually initiated., Results: Between January 2012 and July 2014, triple arthrodesis was performed in 11 patients with a mean age of 62 ± 14 years due to cavovarus deformity. The mean follow-up was 34 ± 8 months (range 24-48 months). In all patients, the cavovarus deformity was substantially corrected. Significant pain relief from 7.1 ± 2.2 (range 5-10) to 1.8 ± 1.5 (range 0-4) on the visual analogue scale was observed.

Background: Lisfranc (tarsometatarsal joint) injuries are relatively rare, accounting for less than 1% of all fractures, and as many as 20% of subtle Lisfranc injuries are missed at the initial patient presentation. An undiagnosed Lisfranc injury can have devastating consequences to the patient. Therefore, any factor that can raise a clinician's index of suspicion to make this diagnosis is potentially important. The cavus foot has been associated with various maladies of the lower extremity, but to our knowledge, it has not been reported to be associated with Lisfranc injury., Questions/purposes: Do patients who experience a low-energy Lisfranc injury have greater talar head coverage and a greater talo-first metatarsal angle than control subjects?, Methods: A retrospective, case-control study was conducted from September 2011 to December 2014 to identify patients diagnosed and treated for a low-energy Lisfranc injury. Twenty-three adult patients with an average age of 42.6 years (SD, 16.3 years) were identified and compared with 61 adult control subjects with an average age of 49.4 years (SD, 14.1 years). Control subjects came from the practice of a fellowship-trained foot and ankle orthopaedic surgeon. Control subjects underwent a history and physical, clinical examination, and diagnostic imaging to confirm that they had no prior foot disorder, no prior foot surgeries, were within 3 years of age of a patient with a Lisfranc injury, and were independent ambulators. Two authors (DSD and JDP) measured the talonavicular and talo-first metatarsal angles on weightbearing AP and lateral radiographs of the foot. The intrarater reliability and interrater reliability for the talo-first metatarsal angle and the talonavicular angle showed high agreement. The intrarater intraclass correlation coefficients (ICC) of the talo-first metatarsal angle were 0.94 (95% CI, 0.91-0.96) and 0.93 (95% CI, 0.9-0.96). For the talonavicular angle the ICCs were 0.83 (95% CI, 0.75-0.89) and 0.88 (95% CI, 0.81-0.92) for Raters 1 and 2 respectively. The interrater ICCs were 0.91 (95% CI, 0.69-0.96) for the talo-first metatarsal angle and 0.9 (95% CI, 0.85-0.94) for the talonavicular angle. The patients and controls were compared to determine if the patients who sustained a Lisfranc injury were more likely to have a pes cavus foot alignment. We performed a mixed modeling analysis to control for potential cofounding variables and determine if there was an association of Lisfranc injury with the talo-first metatarsal angle and the talonavicular angle., Results: After controlling for confounding variables such as the effect of the measurement round effect and the effect of the rater, our repeated measures analysis via mixed model showed patients were associated with a higher talo-first metatarsal angle than control subjects (adjusted least square mean for patients = 3.05; for controls = -2.65; mean difference, 5.7; p = 0.001). Repeated measures analysis via mixed model showed that patients also were associated with a more positive talonavicular angle than control subjects (adjusted least square mean for patients = -4.83, for controls = -11; mean difference, 6.17; p = 0.002). Patients with Lisfranc injuries had a higher mean talo-first metatarsal angle than did control subjects (1.9° ± 7.9° versus -2.2° ± 7.3°; mean difference, 4.1°; 95% CI, -7.7° to -0.5°; p = 0.028), and less talar uncovering (-4.2° ± 9.7° versus -11° ± 8°; mean difference, 6.7°; 95% CI, -6.7° to -10.8°; p = 0.001)., Conclusions: We found that cavus midfoot alignment was more prevalent among patients with Lisfranc injuries than among individuals with no foot injury or disorder. Although this does not suggest that cavus alignment causes or predisposes patients to this injury, we believe the finding is important because this provides a radiographic parameter that clinicians can use to raise their index of suspicion for a Lisfranc injury and aggressively pursue this diagnosis. Future studies would benefit from obtaining contralateral foot imaging at the time of injury in all patients with Lisfranc injury or prospectively following patients with foot imaging and recording the incidence of future foot injury., Level of Evidence: Level III, prognostic study.

Posterior tibial tendon transfer has been described to reduce and balance the cavovarus deformity in those patients who receive a total ankle replacement for end-stage arthritis. In this article, we discuss the indications and provide a detailed description of the technique for this powerful procedure. Case examples that demonstrate the utility of the procedure are provided., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)