Pediatric Flatfoot Research Articles

Calcaneo-stop Procedure in the Treatment of the Juvenile Symptomatic Flatfoot

Flexible flatfoot is the most prevalent condition seen in pediatric orthopedic clinics. It is characterized by an absence of the medial arch and a valgus position of the calcaneus. The purpose of the present study was to report on the results obtained in children treated using the calcaneo-stop procedure. A total of 410 flatfeet in 242 consecutive patients were treated using the calcaneo-stop procedure from January 1999 to March 2010 (10 years, 3 months) and were followed up to February 2012. The mean age at surgery was 11 (range 7 to 14) years, and the mean follow-up duration was 88 (range 14 to 157) months. A clinical evaluation, podoscopic examination, and radiologic assessment were performed in the participating patients preoperatively and at 6 months postoperatively. Of the 242 patients, 168 (69.42%) underwent bilateral foot surgery and 74 (30.58%) unilateral intervention, involving 33 right (44.6%) and 41 left (55.4%) feet. At follow-up, the outcome was satisfactory in 397 feet (96.83%); heel valgus was observed in only 12 feet (2.92%), and the footprint was normalized in 328 feet (80%). The calcaneo-stop procedure is a simple, reliable, and minimally invasive procedure for the treatment of pediatric flexible flatfoot. It allows alignment of the talus and calcaneus, restoring a proper foot arch.

Medial Arch Orthosis for Paediatric Flatfoot

To evaluate any correlation between various foot angles and their respective American Orthopaedic Foot and Ankle Society (AOFAS) scores for pain, and the effectiveness of a medial arch orthosis. 81 children with bilateral symptomatic flatfoot were randomised into orthosis (n=55) and control (n=26) groups. The orthosis group consisted of 33 male and 22 female patients aged 36 to 204 (mean, 99) months and they were given a medial arch support. The control group consisted of 15 male and 11 female patients aged 36 to 192 (mean, 100) months and they were managed with analgesics. Foot angles including anteroposterior (AP) and lateral talocalcaneal (TC) angles, AP and lateral talo- first metatarsal (TFM) angles, calcaneal pitch angle (in lateral plane), and talonavicular (TN) angle were measured, as were AOFAS scores for pain for the forefoot, midfoot, and hindfoot. After orthosis treatment, all AOFAS scores and all foot angles (except for the AP-TN angle) improved significantly. In the controls, all AOFAS scores (except for the midfoot score) and only the AP-TFM angle improved significantly. In the orthosis group, the AOFAS hindfoot score correlated positively with the lateral TC angle of the left foot (r=0.345, p=0.010) and negatively with the calcaneal pitch angle of the right foot (r=-0.33, p=0.015). In the control group, the lateral TFM angle of the left foot correlated negatively with the AOFAS forefoot (r=-0.566, p=0.003) and midfoot scores (r=-0.497, p=0.001), whereas the calcaneal pitch angle of the left foot correlated positively with the AOFAS forefoot score (r=0.497, p=0.010). Medial arch support orthosis significantly improved AOFAS scores and foot angles. Calcaneal pitch angle and lateral TC angle correlated well with AOFAS hindfoot scores.

Biomechanical Analysis of the Calcaneocuboid Joint Pressure After Sequential Lengthening of the Lateral Column

Lengthening of the lateral column by means of the Evans osteotomy is commonly used for reconstruction of adult and pediatric flatfoot. However, some reports have shown that the Evans osteotomy is linked with increased calcaneocuboid joint pressures and an increased risk of arthritis in the joint. The purpose of this study was to measure the pressure across the calcaneocuboid joint and demonstrate the changing trends of the pressure within the calcaneocuboid joint after sequential lengthening of the lateral column. Six cadaver specimens were physiologically loaded and the peak pressure of the calcaneocuboid joint was measured under the following conditions: (1) normal foot, (2) flatfoot, and (3) sequential lengthening of the lateral column by means of the Evans procedure (from 4 mm to 12 mm, in 2 mm increments). Peak pressures across the joint increased significantly from baseline in the flatfoot (P < .05). In the corrected foot, with the increment of the graft, the peak pressure decreased initially and then increased. The pressure reached its minimum value (11.04 ± 1.15 kg/cm(2)) with 8 mm lengthening of the lateral column. The differences were significant compared to the flatfoot (P < .05) and corrected foot with the other sizes of grafts (P < .05), but differences were not significant compared to the intact foot (P = .143). Lateral column lengthening within a certain extent will decrease the pressure in calcaneocuboid joint with a flatfoot deformity. Performing the procedure with an 8 mm lengthening may reduce the risk of the secondary calcaneocuboid osteoarthritis.

Treatment of pediatric flat feet by shoe insoles

Treatment of pediatric flat feet by shoe insoles

The Efficacy of Nonsurgical Interventions for Pediatric Flexible Flat Foot

The pediatric flat foot frequently presents as a common parental concern in the health care setting. Foot orthoses are often used, yet benefits are uncertain and disputed, having been variably investigated. A recent Cochrane review cites limited evidence for nonsurgical interventions. This critical and structured review evaluates the effect of pediatric foot orthoses from assessment of the current literature. A systematic search of the following electronic databases: Medline, CINAHL, AMED, and SPORTDiscus, using an array of search terms. A further search was also performed on relevant reference listings. Inclusion criteria were peer-reviewed journal articles, publication date from 1970 onwards, in the English language. Exclusion criteria were surgery interventions, adult subjects, rigid flat foot, articles based on opinion. A structured Quality Index was used to evaluate the research quality of articles. Three reviewers independently assessed the studies with disputes resolved by majority consensus. Studies were then grouped according to the outcome measures used. Thirteen articles, from an initial 429, met the criteria for quality evaluation. The mean Quality Index score was 35% (range: 13% to 81%), indicative of generally poor and varying methodological quality. The low quality of the studies negates definitive conclusions. Only 3/13 quality evaluations scored > 50%; hence, evidence for efficacy of nonsurgical interventions for flexible pediatric flat feet is very limited. Future research needs validated foot type assessment, applicable outcome measures for the intervention, the use of control groups, allowance for independent effects of footwear, age range comparisons, larger samples, and prospective, longer follow-up. There is very limited evidence for the efficacy of nonsurgical interventions for children with flexible flat feet. Clinicians need to consider the lack of good-quality evidence in their decision-making for the management of pediatric flat foot.

Recent Advances in Orthotic Therapy: Improving Clinical Outcomes with a Pathology-Specific Approach

It has been quite some time since any book has approached the practice of orthotic management of common foot problems. Dr. Scherer is one of the most respected acamedicians as well as clinicians and brings to the reader a text that is both intellectually enlightening as well as hands-on practical. Many have criticized publicly and privately the use of custom foot orthotics, noting that there is very little evidence that custom orthotic therapy is firmly rooted in scientific literature. Dr. Scherer shows how this criticism is no longer valid. He explains how some of the most quoted anti–custommade-orthotics literature is quite flawed in its methodology and cannot be relied on. In this book, Dr. Scherer brings to the reader important biomechanics theory that has been added to the literature since the basic Root theory that markedly aids the clinician in prescribing orthotics. Most literature that proposes surgical interventions for foot problems briefly mentions that orthotic therapy was unsuccessful. There is almost never any description of the prescription variables built into the failed orthotic therapy. Dr. Scherer brings into focus how important the small variables are in creating successful outcomes for various foot pathologies. The book has many pearls for differentiating various degrees of common diagnosis, and then shows how various therapies are needed for various severities of these problems. This concept is highlighted in the second chapter, which shows the proper uses of functional foot orthotics, Richie braces, and gauntlets for posterior tibial dysfunction. Other important therapy modifications are also presented in the other sections on plantar fasciitis, hallux valgus, pediatric flatfoot, cavus foot, tarsal tunnel syndrome, and knee pain. This book is directed to the clinician who already has a basic foundation of foot biomechanics theory and who has had some initial experience in prescribing orthotics. It assumes that the reader has a grasp of orthotic terminology and the Root theory of neutral orthotic casting. It has excellent illustrations to explain the solutions that it discusses. In summary, the book demonstrates that the clinician—and not the orthotic laboratory—needs to be in charge of the orthotic prescription. The reviewer strongly recommends that it be incorporated into the library of every clinician who prescribes orthotics, and that it should also be mandatory reading for all podiatric medical residents.

Piede piatto: “piatto” malattia o sintomo?

Regarding the so-called paediatric flatfoot, we question the meaning of “flat” since it should be considered not as a disease but as a symptom in the context of a multifactorial disease during post-natal growth.

The reliability of measurements taken from radiographs in the assessment of paediatric flat foot deformity

BackgroundRadiographic charted values are widely applied in the assessment of paediatric flat foot and as quantitative markers of intervention success. Nearly all literature pertaining to the reliability of these measures relates to the adult foot. In view of the importance placed on these charted values we assessed the inter and intra-rater reliability of 10 key radiographic measures in children aged 7–14 years. MethodsWe present the reliability of these measures in terms of intra class correlation and standard error based on repeated measures of 50 radiographs across five independent trained observers. Two new detailed methods are presented for the calculation of lateral and dorso-plantar talo-calcaneal overlap in an attempt to better define the talo-calcaneal inter-relationship. ResultsThe results demonstrate wide variation of measurement reliability, with some measures being highly reproducible and others showing poor reproducibility. A strong negative correlation between reliability and the number of steps required for the measurement was demonstrated. Consistent with other studies intra-rater reliability tended to be higher than that of inter-rater reliability. ConclusionIn conclusion, we have provided evidence as to which radiographic charted measures may be reliably used in evaluating the paediatric flat foot in children aged 7–14 years, and which measures are not reliable and we advise against their application.

Biomechanical assessment of the paediatric foot: using the current evidence

Background The paediatric flat foot is a frequent presentation in clinical practice, a common concern to parents and continues to be debated. As an entity, it is confused by varied classifications, the notion of well-intended prevention and unsubstantiated, if common, treatment [1]. The paediatric flat foot proforma (p-FFP) is a standardized framework from which to evaluate the paediatric flat foot [2].

Subtalar Joint Arthroereisis in the Management of Pediatric Flexible Flatfoot: A Critical Review of the Literature

Pediatric flexible flatfoot is a common deformity for which a small, but significant number undergo corrective surgery. Arthroereisis is a technique for treating flexible flatfoot by means of inserting a prosthesis into the sinus tarsi. The procedure divides opinion in respect of both its effectiveness and safety. A database search up until 2010 was used to find articles regarding arthroereisis in pediatric patients. We summarized the findings of this study. Seventy-six studies were identified. Eight of the nine radiographic parameters reported show significant improvement following arthroereisis reflecting both increased static arch height and joint congruency. Calcaneal inclination angle demonstrated the least change with only small increases following arthroereisis. Arthroereisis remains associated with a number of complications including sinus tarsi pain, device extrusion, and under-correction. Complication rates range between 4.8% and 18.6% with unplanned removal rates between 7.1% and 19.3% across all device types. Current evidence is limited to consecutive case series or ad hoc case reports. Limited evidence exists to suggest that devices may have a more complex mode of action than simple motion blocking or axis altering effects. The interplay between osseous alignment and dynamic stability within the foot may contribute to the effectiveness of this procedure. Although literature suggests patient satisfaction rates of between 79% to 100%, qualitative outcome data based on disease specific, validated outcome tools may improve current evidence and permit comparison of future study data.

Calcaneo-stop procedure for paediatric flexible flatfoot

Flexible flatfoot is a frequent deformity found in children. The aim of this study is to evaluate the pedographic outcome of the percutaneous arthroereisis with the use of a screw through the sinus tarsi into the talus. 43 calcaneo-stop procedures of 25 patients (18 bilateral, seven unilateral) were evaluated. Mean age at surgery was 10 years (7-14, SD 2.2) (SD: standard deviation), mean follow-up time was 9.7 months (3-19, SD 5.5). Patient satisfaction rate was recorded, the Meary's talus-first metatarsal angle was measured with lateral radiograms, and a dynamic pedographic assessment was also performed. Patient satisfaction rate was excellent for 33 feet of 19 children, good for eight feet of five children, and poor for either feet of one child. We did not observe any complications during or following the surgery.The mean rest heel valgus decreased from 13.4° (10°-17°, SD 1.5) to 2.8° (0°-6°, SD 1.7) post op. The Meary's angle improved from 160.2° (148°-177°, SD 6.8) to 175.9° (167°-179°, SD 3.5). By pedographic analysis, the area and the pressure-time integral (load amount, PTI) values increased on the lateral regions of the sole (except for the lesser toes) and decreased on the medial areas (except for the hallux). The relative contact time in the lateral midfoot increased from 63.8% (39.6-78.4%, SD 10.6) to 75.1% (50-86.1%, SD 9.4), and that in the lateral forefoot region from 81.2% (60.4-89.2%, SD 6.6) to 86.8% (78.1-97.1%, SD 4.8). The calcaneo-stop procedure is a simple and reliable method for the correction of severe flexible paediatric flatfoot. Our prospective, short-term results following the anterograde screw implantation into the talus correlate well with the results of similar or different arthroereisis methods. Further investigations are required to evaluate the long-term outcome of the screw calcaneo-stop method, including the conditions following implant removal.

When to Operate on Pediatric Flatfoot

When to Operate on Pediatric Flatfoot

Clinical measures of paediatric foot posture: a critical review

Background: The paediatric flat foot is a common concern and has long been regarded as a problem, and feared to be potentially disabling. Definition of what exactly constitutes a flat foot remains surprisingly debatable, given its common presentation. Estimates of flat foot prevalence in children have been influenced by the varied the methods of assessment used to assess the foot posture, and the subsequent criteria employed to delineate feet as flat versus not flat. The aim of this literature review was therefore to evaluate the techniques of foot posture assessment in children and the reported reliability and validity of these measures. Method: A systematic search of electronic databases including Medline (1966-present), CINAHL, SportDiscus, Embase, Scopus and Pedro occurred between 02/01/10 and 14/08/10. Eligible articles were selected according to pre-determined criteria. Methodological quality was evaluated by use of the Quality Index as described by Downs & Black, followed by critical analysis according to outcome variables. Results: The most widely reported measures of paediatric foot posture were footprints and measures of the heel angle and arch height. The current evidence suggests that the reliability of all measures of paediatric foot posture is highly variable and mostly poor to moderate. The only measures on which validity has been explored are navicular height and footprints. Conclusion: Whilst no definitive conclusions can currently be drawn from the existing evidence, the trend from the current literature indicates that static paediatric foot posture may be best-assessed using RCSP, NH or FPI-6. However the relationship between static measures and pain, static measures and gait function remain largely unsubstantiated in children. The direction of future research is to establish a universal method of assessment of paediatric foot posture, and the subsequent relevance of foot posture to pain and function across age groups. Continuation of research in this field will enable targeting of design parameters towards variables that are supported by evidence, and which may directly advance clinical decision-making.

The paediatric flat foot and general anthropometry in 140 Australian school children aged 7 - 10 years.

BackgroundMany studies have found a positive relationship between increased body weight and flat foot posture in children.MethodsFrom a study population of 140 children aged seven to 10 years, a sample of 31 children with flat feet was identified by screening with the FPI-6. Basic anthropometric measures were compared between subjects with and without flat feet as designated.ResultsThe results of this study, in contrast to many others, question the association of flat feet and heavy children. A significant relationship between foot posture and weight (FPI (L) r = -0.186 (p < 0.05), FPI(R) r = -0.194 (p < 0.05), waist girth (FPI (L) r = -0.213 (p < 0.05), FPI(R) r = -0.228 (p < 0.01) and BMI (FPI (L) r = -0.243 (p < 0.01), FPI(R) r = -0.263 (p < 0.01) was identified, but was both weak and inverse.ConclusionsThis study presents results which conflict with those of many previous investigations addressing the relationship between children's weight and foot posture. In contrast to previous studies, the implication of these results is that heavy children have less flat feet. Further investigation is warranted using a standardized approach to assessment and a larger sample of children to test this apparent contradiction.

Non-surgical interventions for paediatric pes planus

Paediatric pes planus ('flat feet') is a common childhood condition with a reported prevalence of 14%. Flat feet can result in pain and altered gait. No optimal strategy for non-surgical management of paediatric flat feet has been identified. To assess the effectiveness of non-surgical interventions for treatment of paediatric pes planus (flat feet). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, Index to Theses, and Dissertation Abstracts (up to June 2009). All randomised and quasi-randomised trials of non-surgical interventions for paediatric pes planus were identified. The primary outcomes were pain reduction and adverse events; secondary outcomes included disability involving the foot, goniometric measurements, quality of life and patient comfort. Two authors independently extracted data and assessed the risk of bias of included trials. Three trials involving 305 children were included in this review. Due to clinical heterogeneity, data were not pooled. All trials had potential for bias. Data from one trial (40 children with juvenile arthritis and foot pain) indicated that use of custom-made orthoses compared with supportive shoes alone resulted in significantly greater reduction in pain intensity (mean difference (MD) -1.5 points on a 10-point visual analogue scale (VAS), 95% CI -2.8 to -0.2; number need to treat to benefit (NNTB) 3, 95% CI 2 to 23), and reduction in disability (measured using the disability subscale of the Foot Function Index on a 100mm scale (MD -18.65mm, 95% CI -34.42 to -2.68mm). The second trial of seven to 11 year old children with bilateral flat feet (n = 178) found no difference in the number of participants with foot pain between custom-made orthoses, prefabricated orthoses and the control group who received no treatment. A third trial of one to five year olds with bilateral flat feet (n=129) did not report pain at baseline but reported the subjective impression of pain reduction after wearing shoes. No adverse effects were reported in the three trials. The evidence from randomised controlled trials is currently too limited to draw definitive conclusions about the use of non-surgical interventions for paediatric pes planus. Future high quality trials are warranted in this field. Only limited interventions commonly used in practice have been studied and there is much debate over the treatment of symptomatic and asymptomatic pes planus.

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.

Analysis of ankle alignment abnormalities as a risk factor for pediatric flexible flat foot

Majority of paediatric flat feet are flexible and asymptomatic;less than 0.1% of all flat feet are rigid. If these can be diagnosed and managed early, then various complications can be prevented and they will remain asymptomatic. This study was conducted to analyse the ankle rotational malalignments in the natural course of flexible flat foot in children. Seventy-six patients of flexible flat foot and one hundred controls were included in this study. The height of foot arches was judged clinically by inspecting the height of the medial arch and by measuring the arch index on weight-bearing podograms. Tibial torsion and bimalleolar angle were assessed in all subjects. Tibial torsion was assessed in the first twenty subjects (ten cases and ten controls) both by clinical methods (foot-thigh angle) and CT. As no statistical difference in the two methods was observed, tibial torsion was measured by clinical methods only in the remaining subjects. Bimalleolar angle was measured on weight-bearing podograms in all subjects. For a minimum of two years, cases were followed up regularly with a standard conservative protocol and the height of the arches observed. Majority of cases of flexible flat foot were found to have increased tibial torsion and increased foot-bimalleolar angle (high talar spin). The severity of collapse of the medial arch and the response to conservative treatment was found to correlate with these rotational mal-alignments of the ankle. Ankle rotational mal-alignments were seen to make these flexible flat foot deformities more complex and less responsive to conservative treatment.KEY WORDS: Flat foot; Pediatric flat feet; Flexible flat feet

(ii) Flatfoot deformity: an overview

Abstract Flatfoot deformity is a common complaint with various etiologies. It causes confusion as to when and how to treat it. Unnecessary treatment is a problem, especially in asymptomatic flexible paediatric flatfoot. The human foot is a sophisticated biomechanical structure. Interference with this complicated system of joints, ligaments, tendons and muscles has to be based on a sound knowledge of anatomical structures and their interactions. It is therefore important for every doctor dealing with this condition to be able to differentiate between cases needing treatment and cases that simply need reassurance. Historically, flatfoot deformities have been over treated with the aim to correct deformity, in the process not only failing to achieve the desired correction but also creating symptoms in previously symptom free individuals. A lot has been learned about flatfoot deformity and a more sensible approach based on symptoms and expected disability has been adopted. The adult acquired flatfoot is a complex condition, commonly caused by posterior tibial tendon deficiency (PTTD). Management of these patients is based on a thorough assessment of the underlying pathology. In this article we give an overview of the condition, with emphasis placed on assessment and management of the more common causes.

Rehabilitative treatment in flexible flatfoot: a perspective cohort study

Paediatric valgus flexible flatfoot is a common childhood paramorphism. Its treatment options consist of rehabilitation, corrective footwear and, if necessary, surgical intervention. The aim of our study was to compare a group of children who followed a rehabilitative programme versus a historical group of children who had been treated with insoles and orthopaedic footwear. Over a 2 year period (1995-1997), 300 children (mean age was 3.4-184 male, 116 female) with bilateral flexible flatfoot (600 feet) were recruited and underwent a rehabilitative programme for a mean period of 2.75 years. The feet were classified according to Viladot's method: 386 feet presented a type III degree deformity and 214 feet presented a type II degree deformity. The rehabilitative programme consisted of simple therapeutic exercises, which could be easily learnt by both patients and their caregivers. These children were compared to a historical group of children (674 feet) who had been treated in our department for infantile flexible flatfoot with the use of orthosis. In these groups, 396 feet presented a type III degree deformity and 278 feet presented a type II degree deformity. In the group of children who underwent the rehabilitative protocol, during follow-up at the age of eight, 352 of the 386 type III degree feet could be classified as normal and 210 of the 214 type II degree cases became normal. In the historical cohort of children treated with orthosis, at the age of eight, 214 of the 396 type III degree feet could be classified as normal; and 248 of the 278 type II degree cases became normal. Our results show that comparing the percentage of success (changing from type III or II degree to type I or N) in the two groups (children treated with rehabilitation and children treated with orthosis), the rehabilitative approach seems to be more effective. Probably it has a marginal influence on the natural history of paediatric valgus flexible flatfoot even though it plays a role in maintaining good flexibility of the flatfoot thus limiting functional impairment.

The paediatric flat foot proforma (p‐FFP): improved and abridged following a reproducibility study

BackgroundConcern about a child's flat foot posture is a common reason for frequent clinical consultations for an array of health care and medical professionals. The recently developed paediatric flatfoot clinical-care pathway (FFP) has provided an evidence based approach to diagnosis and management. The intra and inter-rater/measurer reliability of the FFP has been investigated in this study.MethodsFrom a study population of 140 children aged seven to 10 years, a sample with flat feet was identified by screening with the Foot posture index (FPI-6). Subjects who scored ≥ 6 on the FPI-6 for both feet became the study's flat foot sample. A same subject, repeated measure research design was used for this study which examined the reliability of the FFP in 31 children aged seven to 10 years, as rated by three examiners.ResultsApproximately half of the items of the FFP showed less-than-desirable inter-rater reliability, arbitrarily set at the conventional 0.7 level (intra-class correlations). Removal of the unreliable items has produced a shorter; more relevant instrument designated the paediatric flat foot proforma (p-FFP).ConclusionThe p-FFP is a reliable instrument for the assessment and resulting treatment actions for children with flat feet. Findings indicate that the simplified p-FFP is a reproducible instrument for the clinical assessment of flat foot in mid-childhood.