Updated: 6/15/2021

Equinovalgus Foot

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  • summary
    • Equinovalgus Foot is an acquired foot deformity commonly seen in pediatric patients with cerebral palsy, spina bifida, or idiopathic flatfoot, that present with a equinovalgus foot deformity.
    • Diagnosis is made clinically with presence of a valgus heel deformity with lateral calcaneal displacement and compensatory forefoot supination. 
    • Treatment ranges from bracing to surgical osteotomies and arthrodesis depending on the underlying etiology, severity of deformity, and rigidity of contracture.
  • Epidemiology
    • Incidence
      • common foot deformity seen with
        • idiopathic flatfoot (if the heel cord is tight)
        • cerebral palsy (spastic diplegia and quadriplegia)
        • spina bifida
        • fibular hemimelia
      • typically bilateral
  • Etiology
    • Pathophysiology
      • primary deformities
        • midfoot abduction
        • hindfoot valgus
        • equinus contracture
      • secondary deformity
        • forefoot supination
      • muscle imbalances
        • spasticity and/or overpull of
          • peroneals
          • gastoc-soleus complex
        • weakness of
          • posterior tibialis
          • anterior tibialis
      • pathomechanics
        • results in lever arm dysfunction during gait
          • due to shortened lever arm and non-rigid lever
        • patient is bearing weight on the medial border of the foot and possibly the talar head
        • external rotation of the foot creates
          • instability during push off
          • external foot progression
  • Presentation
    • Symptoms
      • pain
      • difficulty with brace and/or shoe wear
      • painful callus over talar head secondary to weightbearing
    • Physical exam
      • inspection and palpation
        • valgus heel deformity with lateral calcaneal displacement
          • seen when viewing feet from posterior
        • prominent talar head
          • appreciated in the medial hindfoot
        • midfoot break is common
        • compensatory forefoot supination
          • is common (best appreciated when hindfoot valgus is corrected manually during physical exam)
        • hallux valgus often develops over time
        • the medial and lateral malleoli are palpated -- the lateral malleolus should be distal to the medial malleolus, unless there is ankle valgus
      • motion
        • flexibility of the deformity is checked
        • the hindfoot valgus deformity is manually corrected (by inverting the hindfoot) in order to check for true ankle dorsiflexion and achilles contracture
          • a valgus heel can mask an equinus contracture by allowing for dorsiflexion through the subtalar joint
  • Imaging
    • Radiographs
      • recommended views
        • weight-bearing AP and lateral foot x-rays
        • weight-bearing AP radiographs of the ankles are obtained
          • used to rule out ankle valgus if suspected clinically (based on palpation of the malleoli, as above)
      • findings
        • "talar sag" (talus tilted inferiorly)
          • indicates collapse of the arch
        • decrease in the calcaneal pitch
          • due to heel cord tightness
  • Treatment
    • Nonoperative
      • bracing and physical therapy
        • indications
          • flexible deformities
        • technique
          • ankle foot orthosis or supramalleolar orthosis -- should be fabricated with hindfoot in subtalar neutral
      • serial casting
        • indications
          • often helpful for deformities recalcitrant to bracing, therapy and home program
    • Operative
      • calcaneal osteotomy with soft tissue procedure
        • indications
          • rigid deformities which have failed conservative treatment
        • types
          • calcaneal slide or calcaneal lengthening osteotomy
      • fusions
        • indications
          • severe rigid deformities, particularly in the presence of severe midfoot breaks in limited ambulators
        • types
          • talonavicular fusion
            • indicated if severe midfoot break in neuromuscular patients with low function
          • subtalar fusion
            • consider in severe valgus foot, though rarely needed
      • subtalar arthroeresis
        • indications
          • poor outcomes and contraindicated
  • Techniques
    • Calcaneal osteotomy with soft tissue procedure
      • soft tissue procedures
        • gastrocnemius recession or achilles tendon lengthening for equinus
        • peroneus brevis lengthening, if performing calcaneal lengtheing osteotomy
      • bony procedures
        • calcaneal osteotomy
          • medial slide osteotomy or calcaneal lengthening osteotomy
        • lateral column lengthening procedure
          • performed most commonly through calcaneus
          • trapezoidal bone graft
          • medial reefing of medial structures
          • may need to perform medial column osteotomy if fixed supination present after calcaneal osteotomy completed
        • medial calcaneal sliding osteotomy
          • calcaneus is slid 1/3 to 1/2 calcaneal diameter
        • Grice procedure
          • extra-articular subtalar arthrodesis via a lateral approach
          • place bone graft in lateral subtalar joint to block valgus
          • does not interfere with tarsal bone growth
          • uncommonly performed currently
  • Complications
    • Overcorrection (resultant varus deformity)
      • most common complication
      • more common in children with neuromuscular disease
    • Recurrence
      • more common if forefoot supination not corrected at time of primary surgery
    • Sural nerve injury
      • at risk during lateral calcaneal osteotomy approach
    • Overlengthening of lateral column
      • results in a painful lateral forefoot secondary to overload
    • Wound dehiscence
      • risk minimized by use of non-absorbable sutures
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