Updated: 4/19/2018

Equinovalgus Foot

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Introduction
  • 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
  • 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 displacment
        • 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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