Flatfoot Deformity In Children Research Articles

The Double Calcaneal Osteotomy for Pediatric Flatfoot

Category: Hindfoot Introduction/Purpose: The double calcaneal osteotomy combines a medial calcaneal sliding osteotomy and lateral column lengthening. Corrective osteotomies, as opposed to arthrodesis and arthroereises, are preferred for foot deformity correction in children and adolescents because they preserve joint mobility, shock absorption, and avoid concerns about adjacent joint degeneration. Individually, both types of osteotomies have demonstrated efficacy in achieving deformity correction and improved functional outcomes for patients. The literature regarding outcomes of this procedure in children is sparse. This retrospective study objectively analyzes outcomes of children who underwent double calcaneal osteotomies at our institution by comparing pre and postoperative radiographs and reporting postoperative complications. To our knowledge, this study contains the largest sample size of symptomatic flatfeet analyzed with regards to double calcaneal osteotomies in children. Methods: Patients who underwent a double calcaneal osteotomy over the past 5 years at our institution were analyzed. Pre and postoperative weightbearing radiographs of the foot were measured (Figure 1). Paired t tests were used to compare pre and postoperative measurements. Statistical significance was set at α < 0.05. Additional factors analyzed for each procedure include total operative time, torniquet time, hardware used for fixation, type of graft, concomitant procedures, and post-operative complications such as infection, nerve injury, nonunion, and reoperation. Results: A total of 20 patients and 26 feet were studied. Significant correction from pre to postoperative radiographic measurement was noted for the talo-first metatarsal angle, talonavicular coverage angle, calcaneal pitch, and tibiocalcaneal angle (p < 0.001). Complications were noted in 3 of the 20 patients, or 3 of 26 feet, and included infection, painful hardware, and hardware failure. Conclusion: The double calcaneal osteotomy was found to be effective in correcting the radiographic parameters associated with flatfoot deformity in children and adolescents with symptomatic flatfeet. The average postoperative radiographic measurements for the 26 feet analyzed were significantly improved from preoperative measurements. Pediatric orthopedists should strongly consider the double calcaneal osteotomy for appropriate surgical candidates.

Rare, But Existing Complications after Calcaneal lengthening osteotomy for the treatment of symptomatic planovalgus deformity in children and Adolescent

Purpose: Description and analysis of the rare, but existing complications from the application of calcaneal lengthening osteotomy for treatment of the symptomatic flatfoot deformity in children and adolescents.
 Materials and methods: The procedure of calcaneal lengthening osteotomy has been introduced at the University Orthopaedics Hospital „Prof. B. Boichev“in 1999. The study included 64 children or 92 cases, the average age being 11.61±1.90, and the youngest child being 7 years of age. The deformity is more often found in males, making up 44 or 68.75% of the cases. The females make up 20 of the cases, or more precisely 31.25%. We used angle X-ray measurements of the feet in AP and profile positioning, with a mandatory upright position of the pateints, to figure out the severity of the flatfoot deformity. When grading based on the subjective criteria, we used an instrument called Visual-Analogue-Scale Foot and Ankle (VAS FA). To grade the complications, we applied the clinically based Dindo-Clavien classification, used in orthopaedic surgery.
 Results: The average timing for an overall follow-up for all cases is 18.65± 8.29 months. A correction of the CIA appears in all cases that were operated. The average value of the angles at the time of diagnosis of the deformity, the average value was 13.07°, which has risen to 23.25° by the last follow-up session. When analyzing the changes in the MA (angle of Meary), we observed that the angle has decreased to 7.87° in the last follow-up session. The TNCA has decreased with an average of -8.272±5.27°, taking into consideration the high statistical reliability (p≤0.00). Even though we mark five cases of dorsal subluxation of the distal fragment, we have observed a complication from a degenerative process of the CC (calcaneo-cuboid) joint.

Calcaneal Lengthening For Correction of Symptomatic Flexible Flat Foot in Children

Background ; The purpose of this study was to evaluate the clinical, functional and radiological outcome of calcaneal lengthening osteotomy for the treatment of symptomatic flatfoot deformity in children. Methods; A prospective multicentre study on 29 feet of 23 patients who underwent lateral calcaneal lengthening for symptomatic flatfoot in children in the period between October 2015 and June 2017. Inclusion criteria were symptomatic flexible flatfoot in children with failed non operative treatment. During the study period, 29 feet of 23 patients with symptomatic flatfoot underwent calcaneal lengthening osteotomy. All patients met the inclusion criteria and were available for clinical and radiological follow-up. The percentage male were (62%)–female were (38%), The mean age at time of surgery was 10.4 years old (7 – 17 years old) and their mean follow up period was 26.2months.The mean functional American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score had improved from 43.45 (31-55) preoperatively to 85.52 (68-92) postoperatively at last follow up (P value < 0.001) using paired t-test as a significance test for evaluation of pre and post-operative AOFAS score Conclusions; The results of this study support the combination of lateral column lengthening and soft tissue reconstruction for treatment of Plano-valgus foot deformity, The adopted technique revealed satisfactory result both in children and adolescents.

Radiographic Analysis of Surgically Treated Flatfoot Deformity in Children with Cerebral Palsy

Category: Midfoot/Forefoot Introduction/Purpose: Pes planovalgus is the most common foot deformity in children with cerebral palsy (CP). Many of these patients become functionally limited and require surgical intervention. The objectives of this study are to apply previously validated radiographic parameters to radiographs of children with CP who have undergone surgical intervention for pes planovalgus deformity and to assess if these radiographic parameters show improvements post-operatively. Furthermore, this study aims to determine which of these parameters can most accurately be used to quantify correction post-surgery. Methods: A retrospective review was performed to identify patients aged five to 17 with a diagnosis of CP who underwent lateral calcaneal lengthening osteotomy for pes planovalgus between 2006 and 2015 at London Health Sciences Center. The previously validated radiographic measurements were applied to pre-operative and post-operative radiographs. A normality test was performed to observe whether participants were normally distributed with regard to the severity of their deformity. Paired T-test and Wilcoxon signed-rank test were used to compare changes in radiographic measurements from before and after surgery. Results: Seventeen patients met the inclusion criteria. The average age of selected patients was 13.06 years (range 9.42-16.75 years). This included 11 males and six females, all with spastic CP (12 diplegic, five hemiplegic). Of these patients, 11 underwent bilateral surgery and six underwent unilateral surgery (28 feet). These patients were followed post-operatively for a mean of 7.97 months (range 1.5-20 months). In comparing the radiographs from before and after surgery, statistically significant changes were seen in five out of the seven measurements. Talonavicular coverage angle was found to have the most significant change post-correction. Conclusion: The previously validated radiographic parameters used to assess foot and ankle deformity can be applied to the surgically treated pes planovalgus foot in patients with CP. It was found that five out of the seven measurements used to assess foot deformity changed significantly with surgical intervention. Talonavicular coverage angle was found to be the most accurate measure for post-surgical correction. This is the first study to apply these parameters to CP patients with surgically treated flatfoot deformity. Lateral calcaneal lengthening osteotomy significantly improves these radiographic measures.

Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet.

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done. We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity. The average shift achieved was 8.07mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision. In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery. MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

Lateral Calcaneal Lengthening for Correction of Symptomatic Flexible Flat Foot in Children

The purpose of this study was to evaluate the clinical, functional and radiological outcome of lateral calcaneal lengthening osteotomy and medial soft tissue plication for correction of symptomatic flatfoot deformity in children. A prospective multicenter study on 22 feet of 20 patients who underwent lateral calcaneal lengthening for symptomatic flatfoot in children by Mosca technique in the period between December 2017 and February 2019. Inclusion criteria were symptomatic flexible flatfoot in children with failed non operative treatment. During the study period, 22 feet of 20 patients with symptomatic flatfoot underwent lateral calcaneal lengthening osteotomy. All patients met the inclusion criteria and were available for clinical and radiological follow-up. The percentage female were (55%)–male were (45%), The mean age at time of surgery was 10.33 years old (7 – 17 years old) and their mean follow up period was 15months.The mean functional American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score had improved from 68.9 (58-78) preoperatively to 96.09 (86-100) postoperatively at last follow up (P value < 0.001) using paired t-test as a significance test for evaluation of pre and post-operative AOFAS score.The results of this study support the combination of lateral column lengthening and soft tissue reconstruction for treatment of PesPlano-valgus foot deformity, The adopted technique revealed satisfactory result both in children and adolescents

Postoperative CT-scan 3D reconstruction of the calcaneus following lateral calcaneal lengthening osteotomy for flatfoot deformity in children. Is the surgical procedure potentially associated with subtalar joint damage?

BackgroundSeveral anatomical studies have shown that the articular facets of the calcaneus can present with different anatomy. This study assessed the 3D anatomy of lateral calcaneal lengthening (LCL) osteotomy in relation to the anterior and middle facet of the calcaneus in a group of skeletally immature patients treated for symptomatic flatfoot deformity. MethodsDuring the study period, 14 consecutive patients (10 males, 4 females) presenting symptomatic flatfoot (20 feet) with different aetiologies underwent LCL osteotomy and CT scan with 3D reconstruction of the operated feet. Anatomy of articular factes of the calcaneus were graded according to Bunning & Barnett’s classification. In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al.’s, Mosca’s and AOFAS clinical criteria before surgery and at last follow-up visit. ResultsDespite proving difficult to assess (10 out of 20 feet), dimensions of bone and joint structures revealed significant anatomical variations. In particular, working to Bunning & Barnett’s classification, anatomy of the articular facet varied significantly among patients, and in Bunning & Barnett type-B1 or B2 the LCL osteotomy necessarily violates the articular surface of the anterior and middle facet of the calcaneus due to the fact that the two facets are fused together (single articular surface). ConclusionsThese biometric notions allow a better understanding of the impact on articular facets of the calcaneus of the osteotomy procedure suggested by Evans and Mosca. We anticipate that the findings reported here should lead to improved techniques for assessing all bone structures of the hindfoot, support logical classifications of the different pathological situations, and ultimately lead to improved treatment strategies.

Coalición calcáneo-navicular asociada a pie plano rígido infantil. A propósito de un caso

Tarsal coalition (a congenital fibrous, cartilaginous or bony connection between two bones) often leads to a flatfoot deformity in children. Usually it presents with recurrent ankle sprains or insidious onset of a painful rigid flatfoot and movement limitation of midtarsal and subtalar joints. Clinical diagnosis is confirmed by X-rays, computed axial tomography and nuclear magnetic resonance. The anteater nose sign is caused by a tubular elongation of the anterior process of the calcaneus that approaches or overlaps the tarsal scaphoid (navicular) and resembles the nose of an anteater on a lateral foot or ankle radiograph. The treatment of this union is primarily symptomatic but if the pain persists must be surgical .

Talocalcaneal coalition combined with flatfoot in children: diagnosis and treatment: a review.

Talocalcaneal coalition often leads to a flatfoot deformity in children. Previous reports have uncovered many aspects of tarsal coalition and flatfoot respectively, including the etiology, clinical presentation, and diagnostic imaging, as well as treatment. However, the optimum surgical procedure for talocalcaneal coalition combined with flatfoot has not been definitively determined. The nonconformity of treatment options is due to our incomplete knowledge of biomechanics, diagnosis, and indication of treatment for talocalcaneal coalition with flatfoot. The objectives of this review are to provide an overview of the current knowledge about etiology, biomechanics, classification, diagnosis, and treatment options for talocalcaneal coalitions with flatfoot and highlight its therapies in children.

Flatfoot deformity in children and adolescents: surgical indications and management.

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 the medial 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 [corrected] flatfoot.

The operative correction of symptomatic flat foot deformities in children

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot.A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available.We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot.Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group.Cite this article: Bone Joint J 2013;95-B:706–13.

Outcomes of Subtalar Arthroereisis for the Planovalgus Foot

Chronic pain and gait disturbance are possible complications of subtalar arthroereisis. Despite literature indicating a considerably high rate of such complications, subtalar arthroereisis continues to be commonly performed for children with pes planus. The goals of this study are to identify common presenting features and an approach to the treatment of foot pain after subtalar arthroereisis. This case report includes six feet in which subtalar implants were used to treat flatfoot deformities in children. After failing conservative management for chronic postoperative pain, all patients had their implants removed resulting in relief of pain. The expedited removal of subtalar implants in cases of chronic foot pain after arthroereisis is encouraged. The authors do not recommend the use of subtalar arthroereisis in pes planus given its potential complications and literature review indicating a paucity of cases with improved function and activity level as a result of the procedure.

Treatment of Painful Pediatric Flatfoot With Maxwell-Brancheau Subtalar Arthroereisis Implant A Retrospective Radiographic Review

The purposes of this study were to evaluate the outcome of pediatric patients who have undergone Maxwell-Brancheau arthroereisis (MBA) subtalar implants for the treatment of painful pediatric flatfoot deformities. In a retrospective study, 39 patients (68 feet) were evaluated clinically and radiographically. The mean age of the patients was 12 years (range, 6-16 years). The mean period of follow-up was 24 months (range, 6-61 months). Statistical evaluation was performed on all radiographic measurements. Additional surgical procedures (gastrocnemius recession, Achilles tendon lengthening, Kidner posterior tibial tendon advancement) were performed in 22 of 68 feet. There were 10 (15%) complications, which consisted of 10 reoperations in 10 feet. Implants were exchanged in 9 feet because of implant migration, undercorrection, and overcorrection. There was 1 reoperation (in 1 foot) for implant removal because of persistent sinus tarsi pain. Radiographic evaluation demonstrated an improvement of all parameters determined. The parameters that were evaluated include talonavicular joint coverage, as well as lateral and anterior-posterior talocalcaneal angles. There were significant changes noted in pre- and postoperative measurements (P < .001). The MBA implant is effective for the correction of painful, flexible flatfoot deformity in children in short-term follow-up. However, this is a multiplanar deformity, and additional procedures may be needed in addition to the MBA.

Use of Allograft in Skeletally Immature Patients for Calcaneal Neck Lengthening Osteotomy

PurposeTo date, there have been no studies evaluating the usefulness of allograft as a substitute for autograft in calcaneal neck lengthening osteotomy. This retrospective study examined the results of calcaneal neck lengthening osteotomy using allograft for pathologic flatfoot deformity in children and adolescents with various neuromuscular diseases.Materials and Methods118 feet in 79 children treated surgically between Mar 2000 and July 2005 were reviewed. The mean age at the time of the operation was 9 + 3 years (range, 3 - 17 years) and follow-up averaged 15.4 months (range, 13 - 21 months) postoperatively. Talo-1st metatarsal angle, talo-calcaneal angle, calcaneal pitch were measured before and after operation and bony union was estimated.ResultsBony union was noted at the latest follow-up and there were no postoperative complications such as reduction loss, infection, nonunion, delayed union or graft loss during the follow-up period in all but one foot. All radiographic indices were improved postoperatively in all cases.ConclusionOur results indicate that use of allograft in calcaneal neck lengthening osteotomy is a useful option for correction of the planovalgus deformity in skeletally immature patients whose enough autobone can not be obtained.

Extensive Implant Reaction in Failed Subtalar Joint Arthroereisis: Report of Two Cases

Foreign body synovitis with extensive granulomatous giant cell reaction to refractile polyethelene debris is a complication of subtalar arthroereisis not previously reported. We present two cases whereby STA-peg implants were used to treat bilateral painful flexible flatfoot deformities in children. Two boys, presented at 7 and 10 years of age, 2 years after STA-peg procedures and tendo-Achilles lengthening for painful flatfeet. They each had minimal subtalar motion and pain at the sinus tarsi. Radiographs demonstrated surgical defects in the calcaneus with surrounding high signal on the magnetic resonance imaging (MRI) in the subchondral bone of the calcaneus and talus. Both patients failed conservative management and had their implants removed with good relief of their pain. Histology was submitted at the time of implant removal. We present the radiographic and pathologic findings seen in these two patients with failed subtalar arthroereisis due to extensive implant reaction. The pathologic process seen in these patients is a previously unreported complication of this procedure. We do not recommend arthroereisis in the treatment of painful flexible flatfoot in children.

Evans Calcaneal Lengthening Procedure for Spastic Flexible Flatfoot in 32 Patients (46 Feet) with a Followup of 3 to 9 Years

The purposes of this study were to evaluate the outcome of calcaneal lengthening in severe pediatric flexible flatfoot deformities of spastic origin and to determine the necessity of additional procedures. In a prospective study, 32 patients (46 feet) were evaluated clinically and radiologically. The mean age of patients was 11 (range 4 to 22) years. The mean period of followup was 66 (range 36 to 108) months. Additional soft-tissue procedures (Strayer procedure, peroneus lengthening, reefing medial capsule) were performed in 39 of 46 feet; other bony procedures were performed in eight. Among the 46 feet, 11 outcomes were classified as excellent, 19 as good, nine as fair, and seven as poor. Poor outcome was related to overcorrection in three and deformity relapse in four. Calcaneocuboid subluxation was seen in nine feet. Radiographic evaluation demonstrated an improvement of all parameters determined. The Evans procedure is effective for the correction of severe, flexible flatfoot deformity in children with cerebral palsy in the short and mid term. Additional soft-tissue procedures frequently are required. However, correction of this multiplanar deformity predominantly occurs in the forefoot abduction component of the deformity, and the concomitant naviculocuneiform sag remains uncorrected. Despite successful outcomes, overcorrection and undercorrection remains a problem of clinical relevance.

Tibialis posterior tendon rupture in children

The complete traumatic rupture of tibialis posterior tendon (TPT) is very rare [6]. Acquired mobile flat foot deformity in children due to TPT dysfunction is usually due to penetrating trauma [3]. Presentation of such deformity in children due to closed ankle injury without associated fracture has not been described before. We present one child who sustained posttraumatic unilateral flat foot deformity. Investigation confirmed a close rupture of TPT. The child underwent a primary repair with a good result.

Biomechanical analysis of Maxwell-Brancheau arthroereisis implants

The Maxwell-Brancheau arthroereisis (MBA) implant is currently used in treating flexible flatfoot deformities in children and adults. However, no guidelines have been established to determine the degree of correction with the five different MBA implant sizes (6-, 8-, 9-, 10-, and 12-mm diameters). A biomechanical analysis of these implants was performed in fresh-frozen cadaver limbs to quantitate the effects on subtalar joint (STJ) motion restriction and radiographic angles. This study found a restriction of subtalar joint range of motion that ranged from 32.0 +/- 5.4%, 44.8 +/- 7.7%, 59.0 +/- 7.2%, 65.5 +/- 8.7%, and 76.8 +/- 7.6% restriction with successively larger sized implants respectively (p < .001). Repeated measures analysis of variance (ANOVA) revealed alterations in the first intermetatarsal, lateral talo-first metatarsal, talar declination, calcaneal inclination, and first metatarsal declination angles with successively larger implant use. Analysis of the dorsal talo-first metatarsal, talo-second metatarsal, lateral talocalcaneal angles, and first to fifth metatarsal head splay showed no changes as implant size was altered. The study also attempted to assess the effects on the tendo Achillis when the subtalar joint was changed from a pronated to a supinated position. The observations showed a 6.33 +/- 1.40% (p = .001) increase in tendon length which suggests increased tension to the tendon. These findings can aid the surgeon in selection of the MBA implant size based on the desired amount of subtalar joint motion restriction. In turn, this may reduce errors in the correction of flexible flatfoot with the MBA implant.

The severe flexible flatfoot: A combined reconstructive procedure with rerouting of the tibialis anterior tendon

A combined procedure is described that addresses all the components at fault in the severely flexible flatfoot deformity in children. The Evans calcaneal distraction wedge osteotomy will lengthen the lateral column, correcting the heel valgus and forefoot abduction. A naviculo--first cuneiform wedge resection (medial and plantar) and fusion will shorten and reshape the collapsed medial arch. This is augmented by reconstruction and plication of the lengthened plantar ligaments, with plantar rerouting of the tibialis anterior tendon to act as a strong plantar ligament. In addition, shifting the tibialis anterior's pull proximally acts as a sling to the talar head. Z plasty of the tight tendo Achillis is always needed. Nineteen feet in 11 patients were the subject of this study. The period of follow-up ranged from 8 to 42 months. The results were assessed according to the relief of foot strain and calf pains, improvement in shoewear, general activity, and foot shape. To evaluate foot shape, reconstruction of the medial arch and heel posture were assessed. The children and parents were satisfied with the final results in 17 feet (89.5%). Improvement of the radiological measurements was evident and was statistically significant.

The role of osteotomy in the treatment of a flatfoot deformity in children

Most pediatric flatfeet require no treatment. Some may benefit from early, corrective orthotic management. Certain symptomatic, dysfunctional flatfeet require surgical correction. Osteotomy provides correction without losing subtalar function. Consideration of etiology and biomechanical examination are keys to an appropriate treatment plan.