Cavovarus Foot


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Cavovarus Foot


Sebastián Drago Perez MD1,2 and Cristian Ortiz Mateluna MD3


1Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile


2Faculty of Medicine, Universidad de los Andes, Santiago, Chile


3Foot and Ankle Center, Orthopedic Department, Clínica Universidad de los Andes, Santiago, Chile


Clinical scenario



  • A 35‐year‐old man presents with ankle instability and overload of the lateral border of his foot.
  • This has worsened over the last few years. He is otherwise fit and well. His father had a similar problem, with a similar foot shape.
  • On examination he has bilateral high arches and varus heels with callosities under the lateral borders of his feet. He has some clawing of the toes.

Top three questions



  1. In patients with cavovarus foot and Charcot‐Marie‐Tooth (CMT), does physiotherapy result in better functional scores compared to no physiotherapy?
  2. In patients undergoing peroneus longus (PL) to peroneus brevis (PB) tendon transfer, does running locked suture result in improved construct strength compared to vertical mattress sutures?
  3. In patients undergoing lateralizing calcaneal osteotomy, does prophylactic tarsal tunnel release result in less neurologic deficit compared to no tarsal tunnel release?

Question 1: In patients with cavovarus foot and Charcot‐Marie‐Tooth (CMT), does physiotherapy result in better functional scores compared to no physiotherapy?


Rationale


Lateral ligament instability, foot drop, and/or Achilles tendon tightness can be manifestations of CMT disorders which conventionally are referred for physiotherapy.


Clinical comment


Physiotherapy is a simple intervention that may be useful to improve the function of CMT patients.


Available literature and quality of evidence



  • Two randomized controlled trials (RCTs) and two cohort studies exist to answer this question.

Findings


Lindeman et al. found in their RCT that a strengthening program directed to proximal musculature improves strength and functional performance in patients with CMT.1,2 This study completed 24 weeks of follow‐up (level I).


Rose et al., also in an RCT, reported an improvement of dorsiflexion range with serial night casting over four weeks.3 Following those four weeks, the patients performed gentle stretching exercises and maintained the dorsiflexion range obtained. This study was conducted in CMT patients (level I).


El Mhandi et al., in a cohort study, showed that a 24‐week interval‐training stationary bike program performed three times per week was well tolerated by all patients.4 In addition, it was significantly beneficial to their subjective perception of pain/fatigue; improved the functional capacity of these CMT patients; and although there was no reduced fatigability when tested in isometric mode, all patients increased their dynamic strength and physiological capacities (level II).


Chetlin et al., in a retrospective analysis of an RCT, found that a progressive resistance training program improved strength and activities of daily living in patients with CMT.5 This study is important because it shows that patients with CMT can improve significantly with a simple, cost‐effective, and home‐based program (level II).


Resolution of the clinical scenario



  • Periodic rehabilitation exercises directed to strength1,2 (level I), stretching3 (level I), and aerobic capacity5 (level II) improve strength and activities of daily living.
  • Physiotherapy is a mainstay in CMT treatment (level I).6
  • A period of physiotherapy or home exercises supervised by physiotherapist is recommended (level I). They may be directed to proximal musculature strengthening, stretching, and aerobic capacity.

Question 2: In patients undergoing peroneus longus (PL) to peroneus brevis (PB) tendon transfer, does running locked suture result in improved construct strength compared to vertical mattress sutures?


Rationale


Most authors recommend using PL to PB tendon transfer in the surgical treatment of cavovarus foot to correct forefoot pronation, reduce the first ray plantarflexion and reinforce the weak eversion of the hindfoot.7,8 The PL to PB transfer usually requires side‐to‐side tenorrhaphy, as this is stronger than Pulvertaft weave technique.9

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Cavovarus Foot

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