description and treatment of flexible flatfoot

1. Flexible Flatfoot
CAMPBELL’S OPRATIVE
ORTHOPAEDICS 2013
By: Dr Hamid Hejrati
Resident of Orthopedic Surgery
Iran, Mashhad university of medical science

2. Definition
 Exact incidence in children  unknown
 One of the most common “deformities”
evaluated by pediatric orthopaedists.
 “usual in infants, common in children, and
within the normal range in adults” in
assessing and documenting the spontaneous
development of the longitudinal arch.

3.  The heel  excessive eversion during weight
bearing
 Forefoot  usually abducted,  midfoot sag with
lowering of the longitudinal arch  the talar head
and navicular tuberosity appear to be in contact
with the floor and to participate excessively in
weight bearing.
 The medial column of the foot appears longer than
the lateral column.

4. Severe flexible flatfoot in an 8-year-old girl. A, Posterior view.
Shortening of the Achilles tendon valgus eversion of the heels.
The talar heads are prominent. B, Medial view, (left). Weight
bearing on the entire arch, particularly on the talonavicular area,
is a source of symptoms. C, Medial breakdown of the left shoe.

5.  The entire foot is often described as pronated,
although this description is misleading because
the forefoot is actually supinated in relation to
the hindfoot, a fact that is most appreciated
when the hindfoot is corrected operatively or
stabilized manually during physical examination.

6.  A standing lateral radiograph
allows measurement of the
lateral talus–first metatarsal
angle, or Meary angle. This angle
is normally 0 degrees (a straight
line).
 In a flexible flatfoot an apex-plantarward angle will be
present. The normal range of this angle also varies with
age, with spontaneous improvement in plantar sag seen
until age 8 years.

7.  The location of the sag—talonavicular or
naviculocuneiform joint—can be determined and may
suggest the cause of an abnormal measurement (i.e.,
a tight heel cord producing a plantar flexed talus and
talonavicular sag).

8.  The degree of plantar flexion of the talus—
the angle formed by the longitudinal axis of
the talus and the horizontal—can also be
measured (normal, 26.5 ± 5.3 degrees) as
can the calcaneal pitch angle, which is
formed by the axis of the calcaneus and the
horizontal.

9.  Reason to obtain radiographs  to rule out causes of
the “deformity” other than idiopathy.
 The differential diagnosis includes:
1. tarsal coalition,
2. congenital vertical talus (convex pes valgus),
3. persistent talipes calcaneovalgus,
4. an accessory navicular,
5. various arthritic and inflammatory conditions.

10.  Most of these conditions are diagnosed primarily
from the history and physical examination findings,
and in such situations radiographs should be used to
confirm a suspected diagnosis.
 radiographs obtained to appease parents—to “prove”
that the flexible flatfoot is indeed just that.
 In otherwise typical cases it is unnecessary for
diagnosis

11.  In the typical flexible flatfoot, the longitudinal
arch reconstitutes when the foot is in a non–
weight-bearing position.
 Inversion of the heels and arch reconstitution
during toe standing are requisite examination
findings for a diagnosis of flexible flatfoot.

13.  The general neurologic assessment—observation
of gait, coordination, and reflexes—will uncover
neurologic or myopathic conditions associated
with flatfeet in which the foot position may be
due to weakness poliomyelitis, peripheral
neuropathy, weakness with Achilles tendon
contracture Duchenne muscular dystrophy, or
spasticity with equinus cerebral palsy.

14.  Particular attention to the Achilles tendon is
important because a contracture tends to
make hypermobile flatfeet symptomatic.
 Should be asked to walk on the heels, which
will be difficult. Passive dorsiflexion of the
foot, with the heel locked in varus
(inverted), will demonstrate contracture.
They have had progressive arch pain
medially, sometimes with callus
development and medial shoe breakdown.

15. Natural History
 The arch is usually obscured in an infant’s foot
because of subcutaneous fat, and spontaneous
resolution of fat foot can be anticipated as the
young child matures and such fat atrophies.
 Improvement in the sag of the medial ray of the foot
would suggest that ligamentous laxity in a toddler
spontaneously resolves as the ligaments become
more taut.
 Development of the arch is independent of the use
of such external orthoses or the wearing of
corrective shoes.

16.  Studies shows presence or absence of a
longitudinal arch did not correlate with disability
and that a flatfoot was compatible with normal
function unless an Achilles tendon contracture
was present.
 More significant is the tendency for children
wearing closed-toe or “fashionable” shoes to have
arch development inhibited by placing a valgus
stress on the first MTP joint.

17. Treatment
Conservative Treatment
 No treatment is indicated in an asymptomatic
pediatric patient. Education and reassurance
are the mainstays.
 With the lack of objective studies
demonstrating a lasting change in the
radiographic anatomy of the foot with the use
of corrective devices, there is no medical
indication for the treatment of asymptomatic
flatfeet.

18.  Exercises to treat flatfoot. A,
Manual stretching with the knee
extended and the hindfoot inverted.
Multiple daily repetitions are
prescribed. B, Passive stretching of
the triceps surae in an older child.
Note that the feet are inverted, the
knees are extended, and the heels
remain on the floor.

19.  In symptomatic patients  medial arch pain,
fatigue and cramping at night  arch supports
and orthoses may be of benefit.
 We have found that the footwear sold in sporting
goods stores, especially that running shoes
designed for a “hyperpronated” foot have
significant heel and arch support built into the
shoe itself, thus making prescription of
additional orthoses superfluous.

20.  Because running shoes usually support the
relaxed portion of the arch or hindfoot, the
suggestion to use such footwear may be all
that is necessary to resolve the problem.

21.  In more recalcitrant cases  UCBL insert can
be attempted  can acutely change the
talonaviculocuneiform axis and improve
calcaneal pitch. it has been reported to
alleviate symptoms and improve shoe wear in
symptomatic patients. Acceptance of this more
rigid may be problematic in that the rigid
orthosis can be somewhat uncomfortable.

22.  A and B, The University of
California Biomechanics
Laboratory (UCBL) orthosis
used for the treatment of
flatfoot.
 C, Standing lateral
radiograph showing
naviculocuneiform sag.
 D, Standing lateral
radiograph with the UCBL
orthosis. The
naviculocuneiform sag and
calcaneal dorsiflexion
(“pitch”) are improved.
A B
C D

23. Treatment
Surgical Treatment
Indications  intractable symptoms
unresponsive to shoe or orthotic
modifications and who is unable to modify
the activities that produce pain. Thus
patients with talonavicular calluses and
medial arch “strain” whose daily activities
are limited by foot pain are the only true
candidates for surgical management.

24.  surgical correction of flatfoot must
emphasize joint-sparing procedures, usually
combining extraarticular osteotomy with
soft tissue imbrication.

25. Arthroereisis. Arthroereisis of the subtalar
joint, using a silicone or Silastic implant, has
been reported as an alternative to more
complex joint reconstruction. The rationale of
the procedure is to limit the amount of valgus
motion in the subtalar joint by using an
interposition peg.

26.  Intraoperative view
of a subtalar
arthroereisis implant
(STA-peg) (arrow),
which was removed
because of
unrelenting subtalar
pain. Note the
synovitis associated
with the device.

27. Heel Cord Lengthening. An Achilles
tendon contracture should always be
considered and treated during any surgery
for flatfoot. Heel cord lengthening should
be part of a comprehensive procedure to
reconstruct the longitudinal arch.

28. Subtalar Fusion. Subtalar fusion as a
primary procedure for hypermobile flatfoot
should probably be condemned. While there
is no question that excessive heel valgus and
restoration of the longitudinal arch can be
achieved through this procedure, the
sacrifice of subtalar motion for this purpose
is too great a cost.

29. Lateral Column Lengthening. Lateral
column lengthening by insertion of a bone
graft into an osteotomy of the calcaneal
neck is currently the most attractive
procedure to correct a flatfoot deformity
and not sacrifice joint motion.

30.  Dorsal view (A) and lateral
view (B) of lateral column
lengthening to treat
flatfoot. K-wire fixation
can be useful to prevent
displacement of both the
graft and the distal
osteotomy fragment.
 Post OP short-leg cast
immobilization is maintained
for 8 to 12 weeks to ensure
healing of the osteotomy.

31.  Results of calcaneal lengthening
1. relief of medial arch pain
2. resolution of calluses
3. correction of heel valgus
4. improvement in the appearance of the arch
5. radiographic restoration of the Meary angle and the lateral
talocalcaneal angle
6. maintenance of subtalar motion.

32. Imbrication of Talonaviculocuneiform
Complex. Imbrication of the
talonaviculocuneiform complex medially can
be performed in combination with calcaneal
lengthening.
 It is not recommended as a single procedure

33.  Medial imbrication
of the talonavicular-
cuneiform joints in
the surgical
treatment of
flatfoot.
 A, The tibialis
posterior is divided
(for later
imbrication). The
osteoperiosteal flap
is raised in a
proximal-to-distal
direction.

34.  B, After reduction of
the talonavicular
displacement by
translating the
navicular medially and
plantarward, the
osteoperiosteal flap is
advanced proximally.
Internal fixation is
recommended.

35.  C, The tibialis
posterior is
shortened/imbricated
after proximal
reattachment of the
osteoperiosteal flap.

36.  Our technique involves initial detachment
and later imbrication of the tibialis
posterior tendon and raising of an
osteoperiosteal flap of the cuneiform-
navicular capsules by sharply dissecting a
tongue of the medial capsules from
proximal talonavicular to distal and leaving
the flap attached at the cuneiform.

37.  The osteoperiosteal flap is advanced proximally
and plantarward, and is reattached to the talar
neck with heavy suture. The tibialis posterior
should be shortened and advanced to restore
appropriate tension after “shortening” of the
medial column by soft tissue imbrication.
 Although excellent results have been reported
with this medial reconstruction alone, we continue
to use it only in conjunction with a calcaneal
osteotomy.

38.  Medial imbrication can also be combined with
a sliding calcaneal osteotomy to reestablish
the weight-bearing line in the center of the
ankle-subtalar coronal plane, merely creates
a compensatory varusization for
talocalcaneal valgus, the effect of such a
shift seems to be helpful in supporting the
plantar flexed talus and decreasing overall
eversion and midfoot abduction.

39.  Significant improvement in both pain
measures and radiographic parameters has
been reported in adolescents undergoing
this combined correction.

40.  Complications of the combined procedure:
1. Nonunion of the calcaneal graft
2. Displacement of the graft requiring revision
3. Displacement of the calcaneocuboid joint,
4. Recurrence of the deformity
5. Pain that develops with time or prolonged weight
bearing.