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This article provides a historical review of osteotomies in the management of rigid cavus foot.
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Positives and negatives of the various historical osteotomies are outlined.
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Akron dome midfoot osteotomy is performed at the apex of deformity.
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Akron dome midfoot osteotomy is capable of complete multidirectional correction of deformity.
Management of the Rigid Cavus Foot in Children and Adolescents
Section snippets
Key points
Although the complexity of the rigid cavus foot has been appreciated for roughly 100 years, a myriad of surgical options have failed to yield consensus on the
Metatarsal osteotomies
A substantial number of metatarsal osteotomies designed for correction of the rigid cavus have been described throughout the literature.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 The disadvantage of performing the correction at this level is that, although it provides for correction in the forefoot, the apex of the deformity lies within the midfoot region. In nearly all cases, the apex of the rigid cavus is located at the level of the medial cuneiform.9, 10, 11, 26 Correction of the
Proximal midtarsal and midfoot biplanar osteotomies
Surgical correction of the rigid cavus deformity dates back to Steindler,1, 2, 3 who reported on an approach to the rigid cavus foot via a dorsal-based wedge osteotomy through the talar neck passing plantar-wise through the distal promontory of the calcaneus and the proximal cuboid (Fig. 2). This osteotomy was typically combined with a plantar stripping (recession of the plantar fascia and short flexors) to diminish their bowstring effect on the cavus, and Steindler subsequently received
Medial-lateral midfoot biplanar osteotomies
When viewed in the frontal plate, the midfoot and forefoot region can be perceived as consisting of medial and lateral columns. These 2 columns can be architecturally balanced to provide biplanar correction. Various combinations of medial opening and lateral closing wedge osteotomies have been described in this regard (Fig. 4). Redirecting the wedges in a slightly plantar or dorsal direction may provide additional correction of midfoot cavus. Adopting this combined approach has led to several
Multiplanar correction with external fixation
Several small pin external fixators have been used to correct residual rigid cavus deformities. These adaptable devices offer a distinct advantage for deformity correction of all types because of their ability to achieve correction in multiple planes. The use of these fixators has been described in numerous small case series. Several methods have been used to correct the deformities through distraction histogenesis without osteotomy49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and distraction with
Multiplanar osteotomies
The deformity in a rigid cavus foot is typically a multiplanar 3-dimensional rigid bone deformity. Japas8 in 1968 described the first extensive multiplanar V-shaped osteotomy of the tarsals that provided correction in all planes (Fig. 5). The osteotomy is approached through a longitudinal dorsal incision. A second, small medial incision is used for a plantar fascia release. The apex of the osteotomy is centered dorsally at the apex of the deformity and has 2 limbs. One extends distally and
Akron dome midfoot osteotomy
The Akron dome midfoot osteotomy was designed to correct all types of cavus deformities regardless of origin (Fig. 6).9, 10, 11 The indications for the procedure were any cavus deformity with less than 50% of the foot plantigrade (subjective observation) with or without symptomatic abnormal weight-bearing pressure areas. The goal of surgical treatment is to obtain a plantigrade painless foot. It was never anticipated in any regard that existing hindfoot deformities (equinus, varus or valgus, or
Discussion
One must keep in mind that all of these operations are primarily salvage surgeries performed in complex cases with fixed bony rigidity. The Akron dome osteotomy addresses the center of the deformity and provides full multidirectional correction. At the conclusion of the operative procedure, the versatility of the procedure allows for the distal foot to be rotated or manipulated into any desirable position of correction. In 2008, the authors reported that failures of the procedure seemed to be
Summary
In light of the historical evaluation of surgical approaches to the rigid cavus feet, attempts at extensive multiplanar corrections centered at the apex of the deformity seem to have provided the best options for maximum correction.
Although a multitude of surgical options exist for the management of rigid cavus deformity in children and adolescents, the Akron dome midfoot osteotomy seems to offer the best current option for multiplanar correction, regardless of origin.
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No direct or indirect commercial financial incentive was associated with this publication. The authors declare no conflict of interest.