Flatfoot Deformity in Children and Adolescents

Question 1

EPIDEMIOLOGY

Answer 1

• incidence flatfoot in adults ~ 20%
• most infants born without medial longitudinal arch, arch develops naturally by age 5
• boys 2x likely to have flexible flatfoot, obese 3x, blacks
• history – birth hx, medical hx, family hx, onset, location pain, triggers/relievers, difficulty shoe wear, skin problems, functional disability, results of attempted treatment
• physical – torsional/angular variations lower extremity gait pattern, ligamentous laxity, signs related to other medical conditions (Marfans, Downs, etc), hip if infant, shape foot sitting/standing, heel raise, jack toe raise, Silfverskiold test, ROM subtalar, wear on shoes
• xrays for those with painful or rigid flatfeet – WB ap/lat foot, AP ankle, oblique foot +/- Harris axial hindfoot (if concerned for tarsal coalition)

Question 2

Management

Answer 2

• child with flexible or rigid flatfoot with pain/difficulty shoe wear à treat
• flexible flatfoot + short Achilles à stretching program
• Surgical rarely indicated in pediatric flatfoot
• flexible flatfoot – if failed prolonged non-op attempts and pain medial midfoot +/- sinus tarsi interfering with normal activities
• osteotomies have become mainstay management flexible flatfoot
• calcaneal lengthening osteotomy and calcaneo-cuboid-cuneiform osteotomy both produce good clinical and radiographic outcomes
• Silfverskiold test to determine if need to lengthen gastrocs vs achilles
• complications involve subluxation of CC joint – avoid with proper stabilization
• calcaneovalgus deformity – hyperdorsiflexion ankle + mild valgus alignment ankle and subtalar joints
• due to intrauterine positioning
• resolves spontaneously and does not lead to flatfoot deformity of disability
• congenital vertical talus (CVT) present at birth as rigid flatfoot
• dorsiflexion through midfoot, rocker-bottom deformity, hindfoot equinovalgus +/- toe extensors contracted
• deformity cannot be passively corrected
• requires casting and surgery
• frequently found in myelomeningocele and arthrogryposis
• tarsal coalition – abnormal fusion 2 or more bones midfoot/hindfoot
• TC and CN most common types
• up to 75% asymptomatic, pain if present worse with activity and forced inversion
• treatment initially conservatively if fails surgery considered (resection and interposition fat/muscle/wax
• outcomes better with CN resection vs TC
• if >50% joint involved à fuse
• skewfoot – z-shaped deformity with significant hindfoot valgus and metatarsus adductus
• callosities and difficult shoe wear
• coincident tight Achilles tendon
• treatment involves modified shoe wear, orthotics, surgery for recalcitrant cases (calcaneal lengthening osteotomy + medial cuneiform opening wedge osteotomy + Achilles tendon lengthening)

Question 3

Abstract

Answer 3

Most children with flatfeet are asymptomatic and will never require
treatment. In general, flatfoot deformity is flexible and will not cause pain
or disability; it is a normal variant of foot shape. Thus, it is essential to
reassure and educate patients and parents. A flatfoot with a contracture
of the Achilles tendon may be painful. In these cases, a stretching
program may help relieve pain. Scant convincing evidence exists to
support the use of inserts or shoe modifications for effective relief of
symptoms, and there is no evidence that those devices change the
shape of the foot. The surgeon must be vigilant to identify the rare rigid
flatfoot. Indications for flatfoot surgery are strict: failure of prolonged
nonsurgical attempts to relieve pain that interferes with normal activities
and occurs under themedial midfoot and/or in the sinus tarsi. In nearly all
cases, an associated contracture of the heel cord is present.
Osteotomies with supplemental soft-tissue procedures are the best
proven approach for management of rigid flatfoot.
Although flatfoot