s i u m

po
y m n kl e
l e S d A
A n k t a n
a n d F o o
Surgicalo o t treatment of the the
r d F s o f e n t
3 Cavovarus foot
r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia
Martin Weber
L G R
B A
IN I K
I K L 0 1 1
UN 9 t h , 2
b e r
p t e m
S e
 Cavovarus foot - etiology
s i u m
po
y m n kl e
l e S d A
A n k t a n
> Muscle imbalance:
a n d F o o
o o t
— forefoot cavus:
th e
r d F s o f e n t
3 r
– Tibialis anterior-
weakness
r d e g e m
– Strong s
D i o a n a
M
peroneus
i ti c
r– Plantarflexion
longus
n d
A r t h i s a
n o s 1st
S T
g I
Dia – Supination
ray

L G R
A
of
entire foot
I K B
L I N
– Hindfoot varus
K 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavovarus foot - test
s i u m
y mpo n kl e
l e S d A
A n k t a n
ray t and
> Plantarflexion of 1st
F o o
o o th e
r d F s o f e n t
r
— Forefoot driven
3 hindfoot varus
r d e g e m
i sino a n a
i ti c
— Reversible
D block d M
r t hr„Coleman
s a n test“
A os i T
g n I S
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
Coleman and Chesnut, CORR 1977, 123:60-2

e p t e
S
 Cavovarus foot - „surgical“ problems
s i u m
ypo
m n kl e
l e S d A
A n k t a n
> Clawtoes
a n d F o o
o o t
> Metatarsalgia
th e
r d FHindfoot instability s of e n t
3 > Ankle arthrosisrder
>
g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavovarus foot – treatment „instruments“
s i u m
y po
m n kl e
l e S d A
A n k t a n
o
> Operative treatment

a n d F o
o o t t h e
r d F Dorsiflexion osteotomysofometatarsals
— Osteotomies
f e n t
3 e ofrcalcaneus em
–
–
s o
Valgus osteotomy
Valgusiosteotomy
d
r of distalntibiaagand fibula
i
–
c D M a
hr i t a n d
Art nLateralization
— Soft
o s i
tissue sprocedures
T
g I S
Dia Peroneus longus toA R
– of tibialis anterior tendon insertion
–
L G
brevis tendon transfer

I K B
–

K L I N
Lateral ankle ligament reconstruction
1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 „when“ use „which“ instrument
s i u m
y po
m n kl e
l e S d A
A n k t a n
> Metatarsalgia
a n d metatarsal (+toe alignment) F o o
o o t
— df osteotomy
th e
r d F s o f e n t
3 > Instability, forefoot r de r
cavus
g e m
D
— df osteotomy i s o a a
metatarsal 1n(+2, +3)
i ti c longusdtoM
r n
Arth nosis a
— Peroneus brevis tendon transfer

g fixed hindfoot varus IST

ia Valgus osteotomy calcaneus
> Instability,
D— L G R
B A (or smot)

I
— Ankle ligament
N I Kreconstruction
I K Ltibial tendon transfer if weakness
0 11 of peroneal muscles
UN 2
— Anterior

9 t h ,
b e r
p t e m
S e
 „when“ use „which“ instrument
s i u m
ypom n kl e
l e S d A
> Ankle arthrosisA +n k t a n
a nd (or smot, or both) e Fo
— OTt calcaneus
or - instability
o
o o
F— OT MT1 f th t
r d
3 — Tendon transfers: r s o en
m longus to brevis
o r d e a g e
s n
anterior tibial, peroneus

c D i M a
h i ti
rNo ligament a n d
A r t
—
s i s reconstruction

g n o I S T
Dia A L G R
I K B
K L IN 11
UN I , 2 0
r 9 t h
m b e
e p t e
S
 „instruments“ NOT to use
s i u m
y m po n kl e
l e S d A
A n k t a n
an d F o o
o
— Tendont
o– results in weakness f t
lengthening (better:
h e
transfer, preserve muscle power)

r d F s o e n t
3 r d e r g e m
o a
– Achilles: may increase pain from anterior ankle impingement

D i s M a n
i ti c
— rArthrodeses n d
h
Art – nInsufficient
i s a(better: osteotomy, preserve mobility)
o s correction
S T
ia g R I
Gon adjacent joints
D – Stiffness increasesAload
Lose shock absorption capability of „stiff“ joints
L
–

I K B
L I N
– In neuropathy:

K 1
risk of adjacent ulceration
1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 „instruments“ not to use
s i u m
ypom n kl e
l e S d A
A n k t a n
> No arthrodeses
a n d F o o
o o t th e
r d F s o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
po
y m n kl e
l e S d A
A n k t a n
o
> Osteotomies

a n d of F o
t metatarsals e
– Dorsiflexion

F o o osteotomy
f th t
3 r d r s o m e n
o r de a g e
D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
po
y m n kl e
l e S d A
A n k t a n
o
> Osteotomies

a n d of F o
t metatarsals e
– Dorsiflexion

F o o osteotomy
f th t
3 r d r s o m e n
o r de a g e
D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
po
y m n kl e
l e S d A
A k
n of calcaneus t a n
o
> Osteotomies
Valgusd o
–
t a n osteotomy
e F
F o o f th t
3 r d r s o m e n
o r de a g e
D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Approaches - incisions
s i u m
ypom n kl e
> Release insertion anterior
l e S d A
A n k t a n
o
tibial tendon
a n d above ankle F o
o
> Rerouting
o t ATT
th e
r d F(+cheilectomy)
s o f e n t
3 > Bone tunnel lateral r de r g e m
cuneiform iso a n a
i ti c D d M
r t h r
> Osteotomy
s a n
calcaneal
A tuberosity os i T
g n I S
Dia
> Peroneal tenodesis
A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Valgus osteotomy of the calcaneal
tuberosity ium o s
y m p n kl e
> Lateral incision S
le L-shaped d A
A k
— Straight, curvedn(Dwyer), t a n
a n dosteotomy F o o
o
> Transverse
o t th e
r d F o f e n t
rs resection
— Aiming K-wire
3 > Lateral translationrd+ewedge g e m
— CAVE D i s o
traction injuryM a na
r i ti c n dscrew
LPN
h
> rtFixation
A — 1-3nscrews i s a
s
with axial
g o I S T
Dia A L G R
I K B
K L I N 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Valgus osteotomy of the calcaneal
ium
tuberosity – injury to plantar nerves
o s
y m p n kl e
l e S d A
A n k t a n
a n d F o o
o o t th e
r d F s o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
po
y m n kl e
l e S d A
> Osteotomies
A k
n of distal tibia and fibula ot a n
Valgusd o
–
t a n osteotomy
e F
F o o f th t
3 r d r s o m e n
o r de a g e
D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lateral closing wedge OT: technique

s i u m
Guide wire parallel to joint ym po kl e
kl e S
n d An
d A n o t a
t a n e F o
F o o f th t
3 r d r s o m e n
o r de a g e
D i s M a n
r i ti c n d
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lateral closing wedge OT: technique

s i u m
y po
mof medial cortex kl e
Resect wedge of n k
S
Osteotomy - stop 5 mm short
le length n d An
A planned
o t a
Weaken a
t nd cortex if needed Fo
medial
e
o o f th
3 rdF e r s o m e n t
o r d a g e
D i s M a n
r i ti c n d
Ar t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lateral closing wedge OT: technique

s i u m
o
„bend“ medial cortex to close osteotomy
m p kl e
e S y A n
n kl a n d
n d A o o t
o t a h e F
F o o f t n t
3 r d e r s m e
o r d a g e
D i s M a n
r i ti c n d
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lateral closing wedge OT: technique

s i u m
po
fixation
y m n kl e
l e S d A
A n k t a n
a n d F o o
o o t th e
r d F s o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lateral closing wedge osteotomy
in medial ankle arthrosis
s i u m
9 patients, f-up 56m (16-88) m
y po kl e
Supramalleolar lateral
kl e S
approach
n d An
d A n o t a
Lateral closing
t an wedge OT
e F o
o o
No arthroscopy th
r NoFosteophytectomy rs of
d e n t
3 Correction to neutral r de g e m
D i s o (+ /
a
-
na
3°)
i ti c
r later
All improved
n
(AOFAS d Mscore 4874)
r t h a
A2
n o
patients sis progression (1 fused)
ST
g I
Dia AL GR
B
Harstall, Weber; Foot and Ankle International 2007, 28(5): 542-8

Lit:
IN I K
-Weber BG:Unfallheilkunde 80:191,1977

IK L
-Takakura JBJS 77B:50, 1995

0 11
UN , 2
-Stamatis FAI 24:754, 2003

r 9t h
be
e p t em
S
 Cavus foot - treatment
s i u m
po
y m n kl e
l e S d A
>Soft tissue procedures
A n k t a n
a n d of tibialis F o o
t tendon insertion the
–Lateralization

o o
F –Peroneus longus to brevis
anterior
f t
r d s o e n
3 tendon transferrder g e m
D i s o a n a
r i ti c
–Lateral ankle
d M
ligament
n
A r t h a
reconstruction
i s
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Approaches - incisions
s i u m
ypom n kl e
> Release insertion anterior
l e S d A
A n k t a n
o
tibial tendon
a n d above ankle F o
o
> Rerouting
o t ATT
th e
r d F(+cheilectomy)
s o f e n t
3 > Bone tunnel lateral r de r g e m
cuneiform iso a n a
i ti c D d M
r t h r
> Osteotomy
s a n
calcaneal
A tuberosity os i T
g n I S
Dia
> Peroneal tenodesis
A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Approaches - incisions
s i u m
ypom n kl e
> Release insertion anterior
l e S d A
A n k t a n
o
tibial tendon
a n d above ankle F o
o
> Rerouting
o t ATT
th e
r d F(+cheilectomy)
s o f e n t
3 > Bone tunnel lateral r de r g e m
cuneiform iso a n a
i ti c D d M
r t h r
> Osteotomy
s a n
calcaneal
A tuberosity os i T
g n I S
Dia
> Peroneal tenodesis
A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Approaches - incisions
s i u m
ypom n kl e
> Release insertion anterior
l e S d A
A n k t a n
o
tibial tendon
a n d above ankle F o
o
> Rerouting
o t ATT
th e
r d F(+cheilectomy)
s o f e n t
3 > Bone tunnel lateral r de r g e m
cuneiform iso a
to medial
D M a n
r i ti c n d
r t h
> Osteotomy
A tuberosity i s a
calcaneal
n os S T
g I
Dia
> Peroneal tenodesis
A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Tendon transfer - ATT
s i u m
ypom n kl e
l e S d A
A n k t a n
65 y
a n d F o o
o
Resection
o t peroneal muscles
th e
r d Fbecause of synovial ssarcoma o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Tendon transfer - ATT
s i u m
ypom n kl e
l e S d A
A n k t a n
65 y
a n d F o o
o
Resection
o t peroneal muscles
th e
r d Fbecause of synovial ssarcoma o f e n t
3 r de r g e m
i s o a n a
preop ic D M
t hr i t a n d
A r s i s
g n o I S T
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Tendon transfer - ATT
s i u m
y po
m n kl e
l e S d A
A n k t a n
65 y
a n d F o o
o
Resection
o t peroneal muscles
th e
r d Fbecause of synovial ssarcoma o f e n t
3 r de r g e m
D i s o a n a
i
Transfer
ti c ATT
r from C1 d M
insertion
n
A r t h i s a
n os to C3
S T
i a g G R I
D A L
4 m postop
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Tendon transfer - ATT
s i u m
po
y m n kl e
l e S d A
A n k t a n
65 y
a n d instability F o o
o t
Ankle arthrosis,
o th e
r d F ATT insertion of e n t
3 Transfer
from C1otord e r s e m
i s C3
n a g
i c D M a
t h i t
mr postop a n d
A r
24
s i s
g n o I S T
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
y po
m n kl e
l e S d A
A n k t a n
d of tibialis anterior tendon
> Soft tissue procedures
a n F o o
o o t
– Lateralization
th e insertion

d F o f transfert
e n
3r s
Peroneus longus to brevis tendon
r
–

r de g e m
o a
– Lateral ankle ligament reconstruction

D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L I N 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Approaches - incisions
s i u m
ypom n kl e
> Release insertion anterior
l e S d A
A n k t a n
o
tibial tendon
a n d above ankle F o
o
> Rerouting
o t ATT
th e
r d F(+cheilectomy)
s o f e n t
3 > Bone tunnel lateral r de r g e m
cuneiform iso a n a
i ti c D d M
r t h r
> Osteotomy
s a n
calcaneal
A tuberosity os i T
g n I S
Dia
> Peroneal tenodesis
A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Tendon transfer – Peroneus longus to
brevis ium o s
y m p n kl e
> Tendons intact:
e
los S d A
— Distal tenotomyn(at
A k t a n
a n d of longus, F o o
t weave into brevis the
peroneum)
F o o f t
o n
Pulvertaft
3 r d e r s m e
o r d a g e
D
> Longus ruptured: i s M a n
i t
— rSidei c n d
Arth proximal a
to side-tenodesis in
s i s
o in distal rupture
rupture of longus
T
—g n I S
Dia G R
Weave

B A L
I N I K
KL + distal tenodesis of 2011
> Brevis ruptured:
— N I
ULongus to Brevis to bypass ,
h
Proximal
r 9 t
ruptured zone ofbbrevis
m e
e p t e
S
 Tendon transfer – Peroneus longus to
brevis ium o s
y m p n kl e
> Tendons intact:
e
los S d A
— Distal tenotomyn(at
A k t a n
a n d of longus, F o o
t weave into brevis the
peroneum)
F o o f t
o n
Pulvertaft
3 r d e r s m e
o r d a g e
D
> Longus ruptured: i s M a n
i t
— rSidei c n d
Arth proximal a
to side-tenodesis in
s i s
o in distal rupture
rupture of longus
T
—g n I S
Dia G R
Weave

B A L
I N I K
KL + distal tenodesis of 2011
> Brevis ruptured:
— N I
ULongus to Brevis to bypass ,
h
Proximal
r 9 t
ruptured zone ofbbrevis
m e
e p t e
S
 Tendon transfer – Peroneus longus to
brevis ium o s
y m p n kl e
> Tendons intact:
e
los S d A
— Distal tenotomyn(at
A k t a n
a n d of longus, F o o
t weave into brevis the
peroneum)
F o o f t
o n
Pulvertaft
3 r d e r s m e
o r d a g e
D
> Longus ruptured: i s M a n
i t
— rSidei c n d
Arth proximal a
to side-tenodesis in
s i s
o in distal rupture
rupture of longus
T
—g n I S
Dia G R
Weave

B A L
I N I K
KL + distal tenodesis 2011
> Brevis ruptured:
— N I
Uof Longus to Brevis to 9th,
Proximal

bypass rupturedbzone e r of
brevis ptem
Se
 Anterior ankle cheilectomy
s i u m
ypom n kl e
l e S d A
A n k t a n
a n d F o o
o o t th e
r d F s o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavus foot - treatment
s i u m
y po
m n kl e
l e S d A
A n k t a n
d of tibialis anterior tendon
> Soft tissue procedures
a n F o o
o o t
– Lateralization
th e insertion

d F o f transfert
e n
3r s
Peroneus longus to brevis tendon
r
–

r de g e m
o a
– Lateral ankle ligament reconstruction

D i s M a n
r i ti c n d
A r t h i s a
n o s S T
g I
Dia A L G R
I K B
K L I N 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Cavovarus foot – surgical treatment
s i u m
y po
m n kl e
l e S d A
> Combination ofAstatic n k t a n
a n d o o
and dynamic realignment
F
> Extentt of procedure tailored to individual
o o th e deformity
r d F s o f MT1 nt
e
3 — Tendon transfer:
—
r de r
OT supramalleolar, calcaneus,
g e m
D i s o n a
ATT, PL to PB
a
r i ti c
> Avoid tendon
d M
lengthening
n
(increases weakness)
h
A t nosis
> rAvoid fusions a
(insufficient correction, new problems)
g I S T
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S
 Lisfranc joint instability
s i u m
ypom n kl e
> Thank you
l e S d A
A n k t a n
a n d F o o
o o t th e
r d F s o f e n t
3 r de r g e m
D i s o a n a
r i ti c n d M
A r t h i s a
n os S T
g I
Dia A L G R
I K B
K L IN 1 1
UN I , 2 0
r 9 t h
m b e
e p t e
S