Pediatric flatfoot - Treatment Options


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Pediatric flatfoot is a pathologic deformity that should not be ignored.

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Pediatric flatfoot - Treatment Options

  1. 1. Pediatric Flatfoot: to treat or not to treat, you be the judge. Michael E. Graham, DPM, FACFAS
  2. 2. There is an on-going debate as to what to do with a mis-aligned child’s foot.
  3. 3. The general consensus has been:
  4. 4. The general consensus has been:if it’s a flexible deformity – let it be
  5. 5. The general consensus has been: if it’s a flexible deformity – let it be orif it’s a rigid deformity – off to surgery.
  6. 6. The overall opinion is to do:
  7. 7. NOTHING!
  8. 8. Traditional reconstructiveprocedures are rather invasive and have their fair share of potential complications.
  9. 9. So the perception is that the“cure is worse than the disease.”
  10. 10. Why initiate a treatment thatcould lead to symptoms or pain?
  11. 11. Most people don’t realize that those misaligned feet lead to a chain reaction of destruction.
  12. 12. Here’s why -
  13. 13. Walking isthe 2ndmost commonconscious function of our body.
  14. 14. One of the human physiognomies isour ability to stand, walk and run – on our two feet.
  15. 15. Feet are the foundation to our body.
  16. 16. Aligned feet = Aligned body.
  17. 17. Mis-aligned feet = Mis-aligned body!
  18. 18. So whether or not there are painful foot symptoms, there could be symptoms to other parts of the body.
  19. 19. Let’s explore misaligned feet a little more.
  20. 20. What is the difference between analigned versus mis-aligned foot? That is a very important question.
  21. 21. The answer begins with the hindfoot
  22. 22. the most complex and arguablyone of the most important joints of the skeletal system.
  23. 23. This joint mechanism involves 3 bones Navicular Talus Calcaneus
  24. 24. The Talus, Calcaneus and Navicular form:the TaloTarsal joint
  25. 25. with 4 articular joint contact areas.
  26. 26. There are two specific functions of the talotarsal joint.
  27. 27. First is the efficient handling of thevertical forces from the body above,converting those forces horizontally into the foot.
  28. 28. Those forces should be distributed in such a way that the majority of forces should pass posteriolateralthrough the back of the calcaneus.
  29. 29. The second function is the“locking” and “unlocking”of the bones of the mid-foot.
  30. 30. The two complex triplane motionsof supination and pronation occur between the talus on the tarsal bones.
  31. 31. There should be a total of 2/3rds supination and 1/3rd pronation
  32. 32. Why is this ratio important?
  33. 33. Talotarsal supination locks the footbones, creating a stable framework.
  34. 34. Talotarsal pronation unlocks thebones of the foot in order to adapt to an uneven ground surface.
  35. 35. There are specific times during the walking/gait cycle when thetalotarsal joint should be in one of three positions.
  36. 36. Supination Neutral Pronation Neutral position is when the talotarsal joint is neither supinating nor pronating.
  37. 37. Back to pediatric flatfoot
  38. 38. The most important contributingfactor that leads to a mis-aligned foot is? Anyone? Anyone?
  39. 39. The alignment of the talotarsal joint!
  40. 40. The difference between these twofeet is an aligned versus malaligned talotarsal joint.
  41. 41. How does misalignment of the talotarsal joint occur?
  42. 42. It occurs as a result of a partialdislocation of the talus on the calcaneus and/or navicular.
  43. 43. Recurrent talotarsal dislocation occurs in a flexible deformity.
  44. 44. Some call this peri-talar instability or subluxation, either way it is a complex partial joint dislocation.
  45. 45. So what?
  46. 46. This represents a major flaw within the musculoskeletal system.
  47. 47. The forces that should be passing through the back of the heel arenow passing through the inner-front of the foot.
  48. 48. These excessive forces create a path of destruction adversely affecting the bones, ligaments and tendonsto the inner aspect of the foot while standing, walking and running.
  49. 49. Furthermore, thereis yet another path of destruction up the musculoskeletal chain.
  50. 50. The foundation to the body is now pathologically altered.
  51. 51. Every step leads to an “earth-quake” effect to theknees, hips, back and possibly even the neck and shoulders.
  52. 52. Flexible recurrent talotarsal dislocation is more destructive than an inflexible rigid deformity.
  53. 53. That’s due to the potential pathologic forces that are created as the supinatory motion reloadsthe joint forces that are repeatedlystressing and straining the tissues.
  54. 54. A rigid inflexible talotarsal joint stays in the locked position anddoes not have the same “reloading” of force.
  55. 55. The role of “locking” and“unlocking” of the talotarsal joint must also be taken into consideration.
  56. 56. Partial talotarsal dislocation leads toa pathologic duration of pronation – called over-pronation/excessive pronation/hyperpronation.
  57. 57. Instead of the bones of the foot in a stable locked position, they are in an unstable unlocked position.
  58. 58. This leads to increased stress and strain on the bones, ligaments andtendons which leads to the majorityof secondary deformities within the foot and ankle.
  59. 59. We now see that a flexible mis- aligned foot is a very dangerousdeformity that could be responsible for many of the musculoskeletal disorders throughout the body.
  60. 60. What’s the fix?
  61. 61. Depends if it’s a recurrent partial talotarsal dislocation or rigiddeformity and also if there are other pathologic osseous alignment issues.
  62. 62. There are 2 Treatment Categories External Internal
  63. 63. Problem with External Options• Cannot stabilize the talus on the tarsal mechanism.• Gives a false sense of correction.• Not corrective, just supportive.• Compliance issues – patient must wear them for them to be effective.
  64. 64. Internal options: depends on thedegree and location of deformities.
  65. 65. A Recurrent Talotarsal Dislocation: Neutral Position Relaxed Stance Position Internal EOTTS Can possibly be internally stabilized via an internal, extra-osseous, extra-articular talotarsal joint stabilizing stent.
  66. 66. Extra-osseous Talotarsal Stabilization (EOTTS) • Stent is made of titanium. • Talus glides over a Type II EOTTS device. • Instantly the joint forces are normalized. • Talotarsal joint is now internally stabilized.
  67. 67. Many times this procedure alone isenough to stabilize the deformity.
  68. 68. Need to evaluate the whole footThis image exhibits a talotarsal joint This image shows a talotarsal jointdislocation with a normal calcaneal dislocation in addition to a lower thaninclination angle. normal calcaneal inclination angle.
  69. 69. Lower than normal Calcaneal Inclination Angle This patient could benefit from the EOTTS device but also requires either a lengthening of the Achilles tendon complex and/or calcaneal osteotomy.
  70. 70. Instability in the Medial Column • If there is significant instability to the mid- foot then additional surgery will be required here. • Many times, this procedure is not performed until the child is older.
  71. 71. Rearfoot reconstructive surgeryis reserved until there is so muchdestruction that there is no other option.
  72. 72. Don’t blow off those misaligned feet as normal!
  73. 73. Children do not out-grow this pathologic deformity.
  74. 74. Where is the evidence that arecurrent talotarsal joint dislocation will heal on its own? There isn’t any, they just get worse!
  75. 75. Not only does this deformity lead to destruction within the foot and ankle,
  76. 76. it leads to a path of destruction up the body.
  77. 77. Benefits of Treatment• Internal option – does not rely on patient compliance• Reversible• Time tested• Scientifically based• Just makes sense
  78. 78. Risks of No TreatmentNot only will this lead to problems within the foot and ankle, it leads to problems in the knees, hips, pelvis, back and neck.
  79. 79. Risks of TreatmentPossible need to remove the stent (EOTTS) Revision Resize – under/over-correction Failure to achieve the desired result There are no complication free procedures
  80. 80. For more information on EOTTS please visit: