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Management of Flatfoot The Best Foot Forward
Dr. Shah Alam KhanMS,DNB,MRCS(Ed),FRCS, M.Ch.Orth (Liverpool)
Associate ProfessorDepartment of Orthopedics
All India Institute of Medical ScienceNew Delhi, INDIA
Issues
• Define Flat-foot• Clinical Features• Investigations• Treatment Indications• Treatment Options
Definition
• No Universally accepted Radiological or Clinical definition
• Lateral Talus–First metatarsal angle (Meary's angle)
Grading
Denis Grading- Objective Evaluation
Denis A. Pied plat valgus statique. Encyclopedie Medico-Chirurgicale AppareilLocomoteur. Paris, France: Editions Techniques; 1974
Clinical Features
• Depressed longitudinal arch in 23% of the adult population (Harris R, Beath T: Army Foot Survey: An Investigation of Foot Ailments in Canadian soldiers, Ottawa: National Research Council of Canada; 1947:1)
• Prevalence of flat feet in Children 4-13 yrs was 2.7% (Rodriguez et al, Paediatrics, 1999)
• Only 5 to 10% of Adult & Pediatric flatfoot need Active treatment (Smith MA. Flat feet in children. Br Med J. 1990;301:1331)
Clinical Features
• Cosmesis (in about 40% children)
• Pain (25-30%)• Early Fatigue (15-25)• Awkward Gait (5%)• Frequent Falls (3%)• Quick Shoe Wearing
off (2-5%)
Flexibility
Passive Extension of Great Toe should have two effects for a POSITIVE test:1.Elevation of
Longitudinal Arch2.Lateral Tibial
Rotation
Great Toe Extension Test
Rose et al . The diagnosis of flat foot in a child. JBJS Br. Vol. 67-B. No. I. Jan 1985
Examination
• Particular attention to TA
• Check Dorsiflexion of Ankle
• Evaluate the torsional Profile of the limbs
• Foot Callosities
Examination
Complete Neurological Assessment:
• Weakness (poliomyelitis, peripheral neuropathy)
• Weakness with Achilles tendon contracture (Duchenne's muscular dystrophy)
• Spasticity with equinus (cerebral palsy)
Examination
• Stiff Hindfoot• Rule out a Tarsal
Coalition• Rigid Rocker Bottom
Deformity (Congenital Vertical
Talus)
Investigations
Rationale:• No need to investigate
EVERY child• Rule out SINISTER causes• To look for a TREATABLE
cause
Radiography• Foot (AP, 45 deg Int Obl) • Ankle (AP, Lateral)• Rule out Tarsal
Coalition/CVT• Evaluate the Meary’s Angle
Bohne WH. Tarsal coalition. Curr Opin Pediatr. 2001 Feb;13(1):29-35
CT Scan
• Best to evaluate a bony coalition
• Weight Bearing CT in Flexible flat-feet (Fore foot Arch Angle)
Ferri et al. Weightbearing CT scan of severe flexible pes planus deformities. Foot Ankle Int. 2008 Feb;29(2):199-204
Podography
• Static & Dynamic Foot prints
• Pressure Mat (conventional)
• Computerised
Podography
• Shape of the Heel and its relation to the other toes
• Areas of High pressure under great toe, Ist MT and Medial side of Heel
Is it Rigid or Flexible Flat foot?
Are there any other causes of
this condition?
Risk Factors in Flexible Flat foot
• Obesity• Ligamentous Laxity• Rotational Deformities of Knee• Tibia vara• Tarsal Coalition• Short Tendo Achilles
Napolitano et al. Risk factors that may adversely modify the natural history of the pediatric pronated foot. Clin Podiatr Med Surg. 2000 Jul;17(3):397-417
Treatment
AbstentionistsInterventionists
Vs
Treatment Protocols
• No treatment in 95-97%• Some treatment in 3-5%• Surgery in around 2% children (Sullivan. Pediatric flatfoot: evaluation and management J Am Acad Orthop Surg.1999; 7: 44-53 )
• Treat symptomatic pediatric flatfoot• Monitor (or with discretion simply treat) asymptomatic non-
developmental pediatric flatfoot• Identify asymptomatic developmental pediatric flatfoot
Angela Margaret Evans. The Flat footed child-to treat or not to treat. J Am Podiatric Med Assoc.2008: Vol98; 7: 386-89)
Conservative Treatment
• Observant Neglect (children with risk factors)
• Counseling the Parents• ?Foot Exercises• ??Orthosis• Pain Management
Intrinsic Foot Exercises
• Passive stretching of Great toe & TA
• No conclusive evidence that Intrinsic foot exercises help
• Build up of muscles useful in Maintaining an arch
Insoles
Insoles
• Known to cause stimulation of foot muscles (Tib Post)
• Supports the Medial Ligamentous complex
• Helpful before 3yrs of age• Volumes of Literature
available
Bordelon RL. Hypermobile flatfoot in children. Comprehension, evaluation, and treatment. Clin Orthop Relat Res. 1983 Dec;(181):7-14
Modified UCBL shoe insert significantly
reduced the degree and duration of
abnormal pronation during the stance
phase and thus had the potential for
decreasing strain in the plantar
ligaments
(Leung AK et al. Biomedical gait evaluation of the immediate effect of
orthotic treatment for flexible flat foot. Prosthet Orthot Int. 1998
Apr;22(1):25-34)
We concluded that wearing
corrective shoes or inserts
for three years does not
influence the course of
flexible flatfoot in children.
(Wenger et al. Corrective shoes and inserts as treatment for flexible
flatfoot in infants and children. J Bone Joint Surg Am. 1989
Jul;71(6):800-10)
Arch alignment improved
significantly but to a limited
degree (<2%) in cadaveric feet
with the use of orthoses. Hindfoot
valgus malalignment did not
consistently improve by the use
of shoe inserts.(Kitaoka et al. Effects of foot orthosis on 3D Kinematics of flatfoot- A
cadaveric study. Arch Phys Med Rehabil 2002 Jun;83(6):876-9)
Indications for Surgery
• Failure of Conservative Methods & Pt Symptomatic
• NEVER for Cosmetic Reason• Symptomatic Flat foot interfering
with daily ADL• Flat foot with a cause (Accessory
Navicular, CP, Tarsal Coalition)
Principles of Surgery in Flat foot
Crego and Ford1. Any procedure for flatfoot correction should be done for
disabling pain2. Not be done for cosmetic reasons only3. Surgeon, Patient & the parents must be able to accept some
loss of inversion and eversion of the foot in exchange for pain relief
4. Arthrodesis for relieving painful flatfoot has been most successful when the subtalar joint is included
5. Triple arthrodesis is recommended for the skeletally mature flatfoot
Surgical Procedures in Flat foot
Surgical procedures can be classified as follows :• Medial soft tissue + bony procedure• Calcaneal procedures• Arthrodesis• Arthroereisis
MEDIAL PROCEDURES
• Raising of osteoperiosteal flap based at the sustentaculum tali
• Arthrodesis of the first metatarsal- medial cuneiform and first cuneiform- navicular joint
• Advancement of osteoperiosteal flap beneath insertion of tibialis anterior tendon
Surgically Correctible Flatfoot
Equino-valgus foot ofCerebral Palsy
Surgically Correctible Flatfoot
Surgically Correctible Flatfoot
Painful Rigid Flatfoot:• Subtalar Fusion (before mid
foot breaks)• Grice Green Procedure (less
than 10 years)• Triple Arthrodesis (Age> 10 yrs)
Surgically Correctible Flatfoot
Painful Flexible Flatfoot:• Determine the anatomic
cause of the pain• Lateral Column Lengthening• Calcaneal Osteotomy• Lengthening of a short TA• Distraction calcaneo-cuboid
arthrodesis
Calcaneo-valgus deformity. D. Evans. JBJS. Vol 57-B. 1975. p 270-278
Surgically Correctible Flatfoot
Excision of Calcaneo-navicular Bar
Take Home Message
• Evaluation of Flat foot in Children requires Skill & Care
• Great Toe Extension test determines the Flexibility of Flatfoot
• Flexible Flat feet in almost all children require Conservative treatment
• Role of Insoles is doubtful
Take Home Message
• Before adventing on Surgical intervention remember to rule out other causes
• Surgical Treatment is limited for few
BIO LOGICAL Treatment of Flat foot