Paving the Way for Success in Cavus Foot Procedure Selection

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The Western Wisconsin Foot and Ankle Symposium hosted a dynamic discussion from Andrea Cifaldi, DPM, AACFAS, on pes cavus and surgical procedure selection. Podiatry Today touched down with her to learn more about her experience and observations on this complex topic.

What information is the most important to consider when selecting a procedure for a patient with pes cavus?

Dr. Cifaldi said that a comprehensive understanding of the patient’s symptoms, deformity, and any underlying neuromuscular etiology will allow for optimal procedure selection in these cases.

“Surgeons should identify the apex(es) of deformity and assess for reducibility, soft tissue contractures, and muscular imbalance,” she explained. “Additionally, the presence of lateral ankle instability, peroneal tendon pathology and digital contractures should all be considered in surgical planning.”

She added that no one test or study in isolation should guide procedure selection, however, in her experience, a comprehensive workup will include weight-bearing foot and ankle radiographs, a Coleman block test or similar maneuver, and if indicated, electromyography/nerve conduction velocity (EMG/NCV) testing and/or advanced imaging.

What one thing can DPMs do today in their practices to optimize their procedure selection process for pes cavus?

Recognizing the role of muscle imbalance in pes cavus deformity and performing a thorough physical exam including muscle strength testing to evaluate the dynamic deforming forces is key, she noted. Common patterns of muscle imbalance she shared include:

• weakness of peroneus brevis with unopposed pull of tibialis posterior leading to hindfoot varus;
• weakness of tibialis anterior with unopposed pull of peroneus longus leading to plantarflexion of the first metatarsal; and
• imbalance of intrinsic and extrinsic muscles leading to digital contractures.

“Understanding these imbalances and utilizing tendon transfers to achieve a well-balanced foot will be crucial to long-term success in cavus reconstruction,” said Dr. Cifaldi.

Are there any resources that you recommend DPMs be aware of when it comes to cavus foot procedure selection?

Dr. Cifaldi recalled numerous comprehensive review articles on the topic of cavus foot reconstruction that specifically address considerations for procedure selection.

“Kaplan et al. provided a valuable treatment algorithm for surgical correction of the cavus foot¹ while other authors have addressed specific aspects such as indications for osteotomy and arthrodesis^2-4, the role of tendon transfers⁵, and management of forefoot deformities in the cavus foot.⁶"

Dr. Cifaldi is a fellowship-trained foot and ankle surgeon currently practicing at OakLeaf Clinics, a private multi-specialty group in Eau Claire, WI. She is an Associate of the American College of Foot and Ankle Surgeons.

References
1.     Kaplan JRM, Aiyer A, Cerrato RA, Jeng CL, Campbell JT. Operative treatment of the cavovarus foot. Foot Ankle Int. 2018;39(11):1370-1382.
2.     Myerson MS, Myerson CL. Cavus foot: Deciding between osteotomy and arthrodesis. Foot Ankle Clin. 2019;24(2):347-360.
3.     DeVries JG, McAlister JE. Corrective osteotomies used in cavus reconstruction. Clin Podiatr Med Surg. 2015;32(3):375-387.
4.     Zide JR, Myerson MS. Arthrodesis for the cavus foot: when, where, and how? Foot Ankle Clin. 2013;18(4):755-767.
5.     Randt TQ, Wolfe J, Keeter E, Visser HJ. Tendon transfers and their role in cavus foot deformity. Clin Podiatr Med Surg. 2021;38(3):427-443.
6.     DiDomenico LA, Rizkalla J, Cartman J, Abdelfattah S. Hallux and lesser digits deformities associated with cavus foot. Clin Podiatr Med Surg. 2021;38(3):343-360.

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