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Flat foot


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Flat foot

  1. 1. Presenter Dr. Sushil Paudel
  2. 2.  Also known as pes planus Medial border of the foot is abnormally in contact withthe floor during weight bearing Low or absent medial longitudinal arch When associated with deformities of the hind, midand fore foot – pes plano valgus
  3. 3.  ANKLE – plantarflexion and dorsiflexion SUBTALAR (TALOCALCANEAL) – inversion andeversion MIDTARSAL – adduction and abduction, flexion andextension, supination and pronation
  4. 4.  Forefoot - abduction and supination (relative to hind foot) Talar head - displaced medially, anteriorly and downwards Calcaneum everts, dorsiflexes - hindfoot is in valgus Navicular- subluxates dorso-laterally, uncovering the talarhead The medial column of the foot appears to be longer thanthe lateral column
  5. 5.  Navicular, cuneiform, cuboid become wedge-shaped, with apex directed dorso-laterally Plantar, spring and deltoid ligaments are stretched Anterior, posterior tibial tendons and plantarmuscles are stretched whereas the achilles tendonand peronei become adaptively shortened Calluses develop over the medial bonyprominences
  6. 6.  Meary’s angle - between long axis of talus and long axis of firstmetatarsal on a standing lateral Xray0 degrees – normal0 – 15 degrees – mild15 – 30 degrees – moderate> 30 degrees – severe The location of the sag, talo-navicular, naviculo-cuneiform orboth can also be determined
  7. 7.  Calcaneal pitch - angle between the plantar surface of thecalcaneum and horizontal on a lateral x-ray Normal 15 degrees , in flat foot is decreased May be 0 or negative in case of tightened TA The talocalcaneal angle on an AP view is a marker of hind footvalgus Talus much more vertical than normal
  8. 8.  Exact incidence not known One of the most common orthopedic deformities Affects 15 - 20% of adults, mostly asymptomatic Of this 2/3rdhave flexible flatfoot , 1/4thhave a contracted tendo-achilles associated with a flexible flatfoot and the remainderhave rigid flatfoot the most common cause being tarsal coalition
  9. 9.  The medial longitudinal arch normally develops during the firstdecade of life Therefore flatfeet are usual in infants, common in children andrare in adultsFOOTNOTE - Flatfoot in an infant is actually a ‘fat foot’ as theexcessive amount of fat obscures the arches
  10. 10. An arched foot is a distinctive feature of manA) Two longitudinal arches◦ Medial longitudinal arch◦ Lateral longitudinal archB) Transverse arch
  11. 11.  Supports body weight in upright posture Acts as a lever to propel the body forwards in walking,running and jumping Acts as a shock absorber Concavity of the arches protects the soft tissues of the soleagainst pressure
  12. 12. Ends :Anterior : 1-3 MT headsPosterior : Medial tubercle of calcaneumSummit: Superior articular surface of body of talusPillars :Anterior: Talus, navicular, 3 cuneiforms, 1-3 MTPosterior: Medial half of calcaneum
  13. 13.  Shape of bones: wedge shaped with apex pointing downwards.The talus acts as a key-stone Intersegmental ties: ligaments and musclesSpring ligamentDorsal ligaments - interosseus talocalcanealligamentTendinous extensions of tibialis posterior
  14. 14.  Tie beams or bow strings : connect two ends of an archMedial part of plantar aponeurosisMedial part of the flexor digitorum brevisAbductor hallucis, flexor hallucis longus, flexorhallucis brevisMedial part of flexor digitorum longus.
  15. 15. Slings : suspend the arch from aboveTibialis posterior, Flexor digitorum longus,Tibialis anterior and peroneus longusFlexor hallucis longus - bulkiest and strongestmuscles supporting med arch
  16. 16. FLEXIBLEDepending on mobility of tarsaljointsRIGID
  17. 17.  PHYSIOLOGIC – due to ligamentous laxity in 1stdecade HYPERMOBILE FLATFOOT – excessive ligamentous laxity –familial, Down’s, Marfan’s, Ehlers-Danlos, OsteogenesisImperfecta BONY ABNORMALITIES – hypoplasia of sustentaculum tali,hypoplastic calcaneum OCCUPATIONAL OBESITY
  18. 18.  MOTOR WEAKNESS – posterior tibial tendon dysfunction,accessory navicular, muscular dystrophy, peripheral nervelesions, cerebral palsy, spinal cord conditions like polio,myelodysplasia, Werdnig – Hoffman disease, spina- bifida SECONDARY TO ANATOMIC DEFECTS ELSEWHERE :Ext. rotation of the limbGenu valgumEquinus deformity of the ankle (tighttendo- achilles)Varus deformity of the foot
  19. 19. CongenitalTarsal coalitionCongenital verticaltalusAcquired
  20. 20.  Inflammatory arthrosis, Traumatic arthrosis Charcot foot Residua of clubfoot Contractures of peronei or TA - Rheumatoid arthritis, Gout,Degenerative arthritis, Infection, Acute sprain, Osteochondralfracture, Foot tumors especially osteoid osteoma
  21. 21. Hereditary conditionMarked ligamentous laxityDeformity disappears when feet are freed of weight bearingWeight bearing axis - shifted medial to normal positionProlonged weight bearing in the everted foot - Heel cordcontractures ( flexible flatfoot associated with tight heel cord)
  22. 22.  No broad consensus Unstable architecture of tarsal bones Congenitally short tendo achilles Weakened muscle power Ligamentous laxity
  23. 23.  Age of presentation: adolescence Usually bilateral and asymptomatic Family history of flatfeet and joint hyper mobility Pain, discomfort, burning sensations and fatigue onactivity and prolonged standing, cramping at night Felt around the navicular, talocalcaneal joint, below themedial malleolus or at the ant. or post. extremities of theplantar ligaments
  24. 24.  Flatfoot only on weight bearing Deformity correctable on passive manipulation by placing the foot inequinus and inverting the heel Deformity correctable on tip toe standing Deformity correctable by voluntarily contracting the tibialis and long toeflexors Jack’s (great toe extension) test - the arch can be restored by simplydorsiflexing the great toe – suggests that sag is at thenaviculocuneiform level
  25. 25.  Examine the tendo-achilles for tightness (TA contracture tends makeSflexible flatfoot symptomatic) Short tendo-achilles: limited dorsiflexion(not able to walk on heels) Harris and Beath documented that presence or absence of thelongitudinal arch did not corelate with the disability and a flatfoot wascompatible with normal function unless associated with a tight tendo-achilles Examine ROM of ankle,subtalar, midtarsal joints Examine the gait Generalized ligamentous laxity Hypermobility of the subtalar and mid-tarsal joints: the forefoot can bebent outwards and upwards to an unusual degree
  26. 26.  Spine, hips and knees should be examined General examination for neuromuscular abnormalities Don’t forget to examine the shoesshoes show excessive wear along the medial borderPedobarography A record of pressures can be obtained by making the patient tostand and walk on a force plate. Mainly used to compare preand post operative function
  27. 27. Non weight bearing radiographs are essentially normal
  28. 28.  Physiological flexible flatfoot with full ROM isasymptomatic It does not cause pain or disability Xrays are not indicated and treatment is not required Child should be left alone If symptomatic always look for associated causesmost commonly tight heel cord
  29. 29. Mainstay of treatment as This is what is required in majority Condition is essentially benign Only symptomatic treatment possible No change in ultimate shape of the footFOOTNOTE – it is the parents and grand parentswho need treatment and not the child
  30. 30. Conservative treatment should always betried first Arch supports, rubber inserts, Plastizote Whitman valgus brace UCBL (University of CaliforniaBiomechanics Laboratory) heel inserts Shoe modifications –Thomas heel or a 14inch wedge on the inner border Custom molded orthotics
  31. 31.  Do not alter underlying structural fault Do not encourage redevelopment of the arch Running sports shoes have been found to be as effective astraditional orthoses and are more socially acceptableFOOTNOTE - They reduce shoe wear and are said to be moreeffective in treating shoes rather than feet
  32. 32.  Toe-walking and multiple toe-ups If tendo-achilles is contracted, stretching it actively andpassively is an important form of management Grasping marbles with toes Heel to toe walking Playing in sand Ballet dancing Walking on a supination boardFOOTNOTE - There is no scientific study evaluating theeffectiveness (or lack of it) of these exercises
  33. 33.  Reserved for patients with intractable symptomsunresponsive to shoe or orthotic modifications andwho are unable to modify pain producing activity Limitation of daily activities is an indication forsurgeryFOOTNOTE - Surgery for flexible flatfoot should notbe performed for cosmetic reasons
  34. 34.  Soft tissue procedures – achilles tendon lengthening Arthroeresis of the subtalar joint Osteotomy - lateral collumn lengthening (DILLWYN EVANS,PHILIPS, MOSCA, ANDERSON AND FOWLER), posterior calcanealosteotomy (GLEICH, KOUTSOGIANNIS), transverse calcanealosteotomy to raise the floor of the sinus-tarsi (CHAMBERS,MILLER), osteotomies of medial cuneiform and cuboid Arthrodesis – limited medial collumn arthrodesis (HOKE, DURHAM,CALDWELL, COLEMAN), subtalar arthrodesis (these procedureshould be condemned as subtalar motion is lost and arthritic changesinvariably develop in the other tarsal joints), triple arthrodesis(indicated as a salvage procedure when other procedures havefailed)
  35. 35.  Arthrodesing procedures should be delayed until 10and preferably 15 years Before 10 years arthrodesis is difficult because ofexcessive cartilaginous component of tarsal bones Subsequent bony growth is retarded Patient must be prepared to accept permanent loss ofinversion-eversion motion
  36. 36. Achilles tendon lengthening is included if the ankle lacks atleast 10 degrees of dorsiflexion with the knee extendedIf patient has severe enough symptoms to warrant surgery,then heel cord lengthening should be part of acomprehensive procedure to reconstruct the archTECHNIQUE 3 small insicions( 2 medial, 1 lateral) along the length of thetendon Tendon is cut from midline outwards Tendon sheath is repaired to prevent scarring Closure is done with knee extended and ankle dorsiflexed Long leg cast with ankle in neutral is given for 6 weeks
  37. 37.  A silicone or silastic implant (Smith –STA peg) is placed intothe sub talar joint The plantar flexed posture of the talus and valgus at thesubtalar joint is limited by the interposition peg Generally performed in young children Potential complications (such as synovitis, peroneal spasticflatfoot, stiffness of the sub talar joint and foreign bodyreaction) are many 95% success has been claimed but this procedure requiresfurther investigation
  38. 38. TECHNIQUE Elevation of tibialis posterior tendon Elevation of osteoperiosteal flap from proximal to distal Naviculocuneiform arthrodesis Advancement of osteoperiosteal flap Advancement of tibialis posterior
  39. 39.  Displacement of the posterior half of the calcaneusmedially Reestablishes the weight bearing line Indicated in cases with excessive heel valgus
  40. 40. Koutsogiannis calcaneal osteotomy
  41. 41.  Osteotomy is fashioned in a coronal plane 1.5 cmposterior to the calcaneocuboid joint between theanterior and middle facets This is not a simple opening wedge osteotomy, butrather a lengthening distraction wedge osteotomy,and it requires a trapezoid graft Tricortical iliac crest graft is inserted between theanterior and middle facets of the calcaneus Additional internal fixation is required
  42. 42.  Nonunion of calcaneal graft Displacement of the graft requiring revision Diplacement of the calcaneocuboid joint Recurrence of deformity or pain
  43. 43.  Indicated for correction of residual deformities in flat foot Forefoot supination is corrected by a plantar medial closingwedge osteotomy of first cuneiform
  44. 44.  Tarsal coalition (peroneal spastic flatfoot,congenital rigid flatfoot) [most common cause] Heel cord tightening Accessory navicular Vertical talus
  45. 45.  Cannot be passively manipulated without causingpain Feet are flat - regardless of weight bearing / position Pain is usually a prominent symptom.
  46. 46.  Thin or thick bar composed of bone (synostosis), cartilage(synchondrosis) or fibrous tissue (syndesmosis) connects tarsalbones Failure of embryonic segmentation Calcaneum is held in eversion An irritative focus is produced which causes painful spasm of theperonei Impossible for the patient to walk on the lateral border of thefoot due to limited inversion Mechanics of the tarsus is impaired and abnormal stresses resultcasing sec. degenerative arthritis
  47. 47.  Symptoms : do not develop until ossification of the fibroussyndesmosis or the cartilagious synchondrosis Syndesmosis and synchondrosis are usually more troublesomethan synostosis Symptoms – vague foot pain, difficulty in walking on unevensurfaces, foot fatigue, painful limp Tenderness is present along the bar The condition is known to run in families Auto. dominant inheritance with variable penetrance 50% bilateral Incidence - 0.4-6%
  48. 48.  Talipes cavo varus Talipes equino varus Fibular hemimelia PFFD Neivergelt-pearlman syndrome- massive tarsal and carpalcoalitions Apert’s syndrome-synostosis of tarsal bones
  49. 49.  Symptomatic at 8 – 12 yrs Varying loss of subtalar motion Best seen on a 45 degree lat oblique projection Beaking of dorsal articular margin of talus is uncommon CT is usually not required
  50. 50.  Middle facet talocalcaneal coalition is most common Symptomatic at 12 – 16 yrs of age Marked reduction or absence of subtalar motion Best seen on a Harris view – posterosuperior oblique projection Talar beaking is commonly seen – traction spur and not a sign ofdegenerative arthritis CT is usually needed for diagnosis
  51. 51. Most patients respond to conservative treatment – Rest Shoe inserts (arch supports) Orthotics (AFO, Plastizote, UCBL insert) Shoe modifications (high top shoes, Thomas heel, Whitman plate) 4-6 weeks of immobilization in a short leg walking cast with the footplantigrade may provide lasting relief of symptoms Splintage with an outside iron and inside T-strap
  52. 52.  Resection of the bar and interposition of muscle, fator gelfoam – should be performed before secondarydegenerative changes have set in Calcaneal osteotomy can be combined to to correcthind foot valgus Subtalar arthrodesis Triple arthrodesis
  53. 53.  Extensive talocalcaneal coalition Multiple coalition Development of sec. degenerative arthritis Ball and socket ankle joint When the coalition involves more than 50% articular surfaceof talocalcaneal joint or more than 50% of the posterior facet
  54. 54.  First described by Bauhin in 1605 Also called prehallux, accessory scaphoid, os tibiale externum,os naviculare secondarium and navicular secundum Separate ossification center for the tuberosity of the navicular Prevalance 5-10%
  55. 55. Cause and effect relationship with flatfoot has not been shown3 types Round sesamoid bone within TP tendon - rarely symptomatic 8-12 mm ossicle connected to the navicular by a synchondrosis. Thisis the type that is usually symptomatic as the synchondrosis is at risk ofdisruption from traction injury / shear forcesNavicular beak / Cornuate navicular -fusion of acc. navicular with theprimary navicular.
  56. 56.  Usually asymptomatic, noticed incidentally Presentation - adolescence Pain over an enlarged area at the medial aspect ofthe navicular just at the insertion of the tibialisposterior tendon Pain aggravated by wearing tight-fitting shoes
  57. 57.  Accessory navicular is best seen on the external oblique view Accessory navicular ossifies even later than a normal navicularwhich is the last tarsal bone to ossify CT can identify an accessory navicular Bone scan can identify a hot accessory navicular
  58. 58.  Soft pads, avoid wearing tight fitting shoes Special shoes, valgus correcting shoe inserts( UCBLdevise) Steroid and analgesic injections Strenghening of tibialis tendon and treatment oftendonitis Immobilization in a short leg cast
  59. 59.  Simple excision of the accessory navicular shelling it out of thepost. tibial tendon Navicular is resected until it is slightly depressed relative to thetalus and cuneiform Bone wax is applied to the to prevent regrowthGood or excellent result in 93% cases
  60. 60.  Involves excision of the accessory navicular with re-routing ofthe central slip of the tibialis posterior laterally onto the plantarsurface of the navicular, where it is sutured under tension to thesurrounding ligaments Gives no added advantage in short term and long term follow upand therefore the simpler procedure is preferred
  61. 61. Kidner’s procedure
  62. 62.  Congenital rigid flat foot, rocker bottom foot, convexpes valgus or teratologic dorsolateral dislocation ofthe talo-naviculo-cuneiform joint First description by Henken in 1914 Characteristic features described by Lamy andWeissman
  63. 63.  Congenital dislocation of talonavicular joint such that the talus isdisposed vertically with its head forming the most prominent part of thesole The navicular is displaced dorsolaterally firmly lodged on to the neckof the talus, preventing reduction. The navicular abuts the ant. surfaceof the tibia The calcaneum is displaced posterolaterally in relation to the talus, isrigidly locked into equinus and in contact with the distal fibula The angle between the long axis of the talus and calcaneum ismarkedly increased The forefoot is deviated outwards and dorsally and hence the solehas a convex contour
  64. 64.  Dorsolateral dislocation or extreme subluxation ofcalcaneocuboid joint might occur Abnormal relationship of tarsal bones remain constantwhether the foot is plantar flexed or dorsiflexed, this is incontrast to congenital flexible flatfoot Achilles tendon is contracted, ant. tibial and peroneal tendonsare taught The subtalar joint is abnormal with the anterior facet absentand the middle facet hypoplastic
  65. 65.  Adaptive changes occur in the tarsal bones with weight bearing The talus becomes shaped like an hour glass, with itslongitudinal axis almost same as the tibia Only the posterior 1/3rdof the superior articulating surface of thetibia articulates with the tibia Anterior part of the plantar surface of the calcaneus becomesrounded Callosities develop beneath the anterior end of the calcaneusand along the medial border of the foot superficial to the head ofthe talus
  66. 66.  Muscle imbalance Intra-uterine compression Arthrogryposis Autosomal dominant transmission Arrest of fetal development of the foot between 7thand 12thweeks of gestation
  67. 67.  Spina bifida AMC Trisomy of Ch-13, 14, 15, 18 Microcephaly Prune belly syndrome Spinal muscular atrophy Neurofibromatosis Congenital dislocation of hip CNS abnormality can produce this deformity by muscleimbalance( weak posterior tibial and strong peroneals)
  68. 68.  Usually bilateral Sole is characteristically convex at birth, so that it resemblesthe bottom of a rocking chair and hence the name Dorsolateral fold is deep and situated at the mid-tarsal area Talar head is prominent over the medial and plantar aspects Deformity from the outset is rigid Deformity may be so severe that heel might not touch theground at all Gait is awkward and resembles a waddle Shoes are rapidly worn out over the inner sides Pain - at adolescence or soon thereafter
  69. 69.  Idiopathic flatfoot Paralytic flatfoot Spurious correction of clubfoot Talipes calcaneovalgus (benign condition easily amenable tocorrection) Tarsal coalition
  70. 70.  Calcaneus is held in eversion by contracted interosseousligament, bifurcated ligament and calcaneofibular ligament Calcaneus is fixed in equinus by contracted posteriorcapsule and achilles tendon Dorsal capsules of talonavicular, calcaneocuboid joints andtibio-navicular portion of the deltoid ligament are markedlycontracted and prevent reduction Tibialis anterior, long toe extensors, peroneus brevis andtriceps surae are contracted Posterior tibial and peroneal tendons may be displacedanteriorly so that they act as dorsiflexors rather than plantarflexors
  71. 71.  Forefoot dorsiflexors are contracted Calcaneonavicular ligament is elongated and attenuated Posterior tibial tendon becomes attenuated as it passes over thedisplaced head of talus If deformity persists into late childhood, alterations in the bonyshape develop that encourage redisplacement even aftersurgery Talus assumes hour-glass constriction, calcaneus becomescurved dorsally at its anterior end becoming beak shaped andnavicular becomes wedge shaped
  72. 72.  Difficult to treat tends to recur Manipulation and cast application are rarely successfuland if reducible by closed means a diagnosis of obliquetalus is made But manipulation and serial casting keeps the skin andsoft tissues stretched Open reduction is generally required
  73. 73.  1 - 4 years : soft tissue release and open reduction(KUMAR, COWELL, RAMSEY) 4 - 8 years : soft tissue release and open reduction withGrice-Green subtalar extra-articular arthrodesis >12 years, failure of above procedures : triplearthrodesisChildren > 3 yrs with severe deformity generally requirenavicular excision at the time of open reduction
  74. 74.  Should be done before 2 yrs Best done as a single stage release at 1 yrSTEPS Dorso-lateral soft tissue release Medial soft tissue release Reduction of talonavicular and calcaneocuboid jts Posterior soft tissue release Internal fixation
  75. 75.  Results are satisfactory if surgery is done before 27months All feet have some residual midfoot sag and forefootabduction and some have decreased motion Commonest reason for surgical failure is inadequatereduction of the navicular
  76. 76.  Aseptic necrosis of the navicular Aseptic necrosis of the talusThese can be averted by limited amount of dissection
  77. 77.  Most common cause of adult onset acquired flat footTREATMENT NSAIDS Intrasynovial injection of corticosteroids Splintage with outside iron and inside T strap
  78. 78.  Unilateral deformity that develops rapidly History of trauma Young patient- tendon transfer using flexor digitorum longus Elderly- splintage If this fails and symptoms are marked triple arthrodesis