Management of Flatfoot education health care

flat foot

1. Management of Flatfoot The Best Foot Forward Dr. Shah Alam Khan MS,DNB,MRCS(Ed),FRCS, M.Ch.Orth (Liverpool) Associate Professor Department of Orthopedics All India Institute of Medical Science New Delhi, INDIA

2. Why a CME on Foot & Ankle ?

3. Issues Define Flat-foot Clinical Features Investigations Treatment Indications Treatment Options

4. Definition No Universally accepted Radiological or Clinical definition Lateral Talus–First metatarsal angle ( Meary's angle )

5. Grading Denis Grading- Objective Evaluation Denis A. Pied plat valgus statique . Encyclopedie Medico- Chirurgicale Appareil Locomoteur. Paris, France: Editions Techniques; 1974

6. 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)

7. 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%)

8. Flexibility

9. Passive Extension of Great Toe should have two effects for a POSITIVE test: Elevation of Longitudinal Arch 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

10. Examination Particular attention to TA Check Dorsiflexion of Ankle Evaluate the torsional Profile of the limbs Foot Callosities

11. Examination Complete Neurological Assessment: Weakness (poliomyelitis, peripheral neuropathy) Weakness with Achilles tendon contracture ( Duchenne's muscular dystrophy) S pasticity with equinus (cerebral palsy)

12. Examination Stiff Hindfoot Rule out a Tarsal Coalition Rigid Rocker Bottom Deformity (Congenital Vertical Talus)

13. Investigations Rationale: No need to investigate EVERY child Rule out SINISTER causes To look for a TREATABLE cause

14. 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

15. 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

16. Podography Static & Dynamic Foot prints Pressure Mat (conventional) Computerised

17. 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

18. Is it Rigid or Flexible Flat foot? Are there any other causes of this condition?

19. 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

20. Treatment Abstentionists Interventionists Vs

21. 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)

22. Conservative Treatment Observant Neglect (children with risk factors) Counseling the Parents ?Foot Exercises ?? Orthosis Pain Management

23. 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

24. Insoles

25. 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

26. 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)

27. 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)

28. 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)

29. 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)

30. Principles of Surgery in Flat foot Crego and Ford 1. Any procedure for flatfoot correction should be done for disabling pain 2. Not be done for cosmetic reasons only 3. 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

31. Surgical Procedures in Flat foot Surgical procedures can be classified as follows : Medial soft tissue + bony procedure Calcaneal procedures Arthrodesis Arthroereisis

32. 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

33. Surgically Correctible Flatfoot Equino-valgus foot of Cerebral Palsy

34. Surgically Correctible Flatfoot

35. Surgically Correctible Flatfoot Painful Rigid Flatfoot: Subtalar Fusion (before mid foot breaks) Grice Green Procedure (less than 10 years) Triple Arthrodesis (Age> 10 yrs)

36. 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

37. Surgically Correctible Flatfoot Excision of Calcaneo-navicular Bar

38. 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

39. 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