Orthopedic surgery is required to correct severe pes cavus deformities, scoliosis, and other joint deformities. Treatment is determined by the age of the patient and the cause and severity of the deformity.
Surgical procedures consist of the following 3 types:
Soft tissue (plantar fascia release, tendon release or transfer)
Osteotomy (metatarsal, midfoot, calcaneal)
Joint stabilizing (triple arthrodesis)
Surgical procedures are usually staged. The initial procedure is a radical plantar or plantar-medial release, with a dorsal closing-wedge osteotomy of the first metatarsal base if necessary. Tendo calcaneus lengthening should not be performed as part of the initial procedure because the force used to dorsiflex the forefoot causes the calcaneus to dorsiflex into an unacceptable position. If the hindfoot is flexible and a posterior release is not necessary, posterior tibial tendon transfer can be done as part of the initial procedure for severe anterior tibial weakness.
When the hindfoot is flexible, early aggressive treatment with soft-tissue releases can delay the need for more extensive reconstructive procedures. The Jones procedure includes transfer of the extensor hallucis longus and arthrodesis of the interphalangeal joint of the great toe.
The Coleman Block Test is sometimes used to help decide what type of surgery is best. In cases of cavovarus deformity, this test evaluates hindfoot flexibility. The Coleman Block test is performed by placing the patient's foot on a wood block that is 2.5-4 cm thick, with the heel and lateral border of foot on the block and bearing full weight while the first, second, and third metatarsals are allowed to hang freely into plantar flexion and pronation. If heel varus corrects while the patient is standing on the block, the hindfoot is considered flexible.
If the subtalar joint is supple and corrects with the block test, then surgical procedures may be directed to correcting forefoot pronation, which is usually due to plantar flexion of the first metatarsal. If the hindfoot is rigid, then surgical correction of both the forefoot and hindfoot are required.
Triple arthrodesis serves as a salvage procedure for patients in whom other procedures were unsuccessful or in patients with untreated fixed deformities.
Children younger than 8 years with supple hindfeet usually respond to plantar releases and appropriate tendon transfers. A first metatarsal osteotomy may be needed in some cases.
Children younger than 12 years with rigid hindfoot deformities may need radical plantar-medial release, first metatarsal osteotomy, and Dwyer lateral closing-wedge osteotomy of the calcaneus to correct the deformities.
Generally, spinal deformities in children with CMT disease can be treated with the same techniques used for idiopathic scoliosis.
Date reviewed: 19/07/2012