Harris Et Al. (2004) - Diagnosis and Treatment of Pediatric Flatfoot

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CLINICAL PRACTICE GUIDELINE

Diagnosis and Treatmentof Pediatric Flatfoot

Clinical Practice Guideline Pediatric Flatfoot Panel: Edwin J. Harris, DPM,1

John V. Vanore, DPM,2 James L. Thomas, DPM,3 Steven R. Kravitz, DPM,4

Stephen A. Mendelson, MD,5 Robert W. Mendicino, DPM,6

Stephen H. Silvani, DPM,7 and Susan Couture Gassen8

This clinical practice guideline (CPG) is based on the con-

sensus of current clinical practice and review of the clinical

literature. The guideline was developed by the Clinical Practice

Guideline Pediatric Flatfoot Panel of the American College of

Foot and Ankle Surgeons. The guideline and references anno-

tate each node of the corresponding pathways.

Introduction to Pediatric Flatfoot ( Pathway 1 )

Foot and ankle specialists acknowledge that flatfoot de-

formity is a frequently encountered pathology in the pedi-

atric population. Flattening of the medial arch is a universal

finding in flatfoot and it is common in both pediatric andadult populations. Pediatric flatfoot comprises a group of

conditions occurring in infants, children, and adolescents

(1) that are distinguished by anatomy and etiologic factors

(2, 3– 8).

Flatfoot may exist as an isolated pathology or as part of

a larger clinical entity (4). These entities include generalized

ligamentous laxity, neurologic and muscular abnormalities,

genetic conditions and syndromes, and collagen disorders.

Pediatric flatfoot can be divided into flexible and rigid

categories. Flexible flatfoot is characterized by a normal

arch during nonweightbearing and a flattening of the arch on

stance (Fig 1). Flexible flatfoot may be asymptomatic or

symptomatic. Rigid flatfoot is characterized by a stiff, flat-

tened arch on and off weightbearing. Most rigid flatfeet areassociated with underlying pathology that requires special

consideration.

Skewfoot is an uncommon disorder characterized by se-

vere pronation of the rearfoot and an adductovarus forefoot.

Skewfoot has characteristics of flatfoot and adductovarus

deformity (8).

Significant History ( Pathway 1, Node 1)

Pediatricians and parents often are the first to recognize

foot and ankle pathology in infants and children, but prob-

lems may go unrecognized for a long period of time. The

age of onset is important for diagnostic and therapeutic

decision making. Additional considerations include family

history, associated medical conditions, presence or absence

of symptoms, trauma history, activity level, previous treat-

ment, and a thorough review of systems.

Documented failure to improve, or a clinical worsening,

is contrary to the normal course and suggests that the

problem is more likely to persist with the possibility of

pathologic sequel. A family history of flatfoot suggests that

there may be similar issues in the child. Obesity, neuromus-

cular disorders, and structural abnormalities above the level

of the ankle (eg, ankle valgus, tibia varum, genu valgum,tibial torsion, femoral anteversion, limb-length discrepancy)

can influence both the natural history and the severity of

pediatric flatfoot.

Flatfoot can be associated with a number of subjective

symptoms that may include pain in the foot, leg, and knee, and

postural symptoms. A history of trauma—acute or repetitive—

may cause or unmask the foot deformity. Flatfoot deformity

may result in decreased endurance and voluntary withdrawal

1Chair, Pediatric Flatfoot Panel, Westchester, IL; 2Chair, Clinical Prac-tice Guideline Core Committee, Gadsden, AL; 3Board Liaison, Birming-ham, AL; 4Philadelphia, PA; 5Pittsburgh, PA; 6Pittsburgh, PA; 7WalnutCreek, CA; 8Chicago, IL. Address correspondence to: John V. Vanore,DPM, Gadsden Foot Clinic, 306 South 4th St, Gadsden, AL 35901. E-mail: [email protected]

Copyright © 2004 by the American College of Foot and Ankle Surgeons1067-2516/04/4306-0002$30.00/0doi:10.1053/j.jfas.2004.09.013

VOLUME 43, NUMBER 6, NOVEMBER/DECEMBER 2004 341



from physical activities. Previous treatment may have modified

the clinical presentation (4). A comprehensive history and

review of systems may show previously unsuspected medical

conditions (4). For example, a history may disclose clumsiness

and frequent falling. Difficulty climbing and difficulty arising

from the floor in association with flatfoot may indicate Becker

or Duchenne muscular dystrophy.

Significant Findings ( Pathway 1, Node 2)

The appearance of the foot during weightbearing and

nonweightbearing suggests the presence and type of flatfoot

deformity (Fig 1). Physical findings may include low arch

structure, rearfoot eversion, medial talar head prominence,

altered walking, and the presence of calluses.

Evaluation of flatfoot requires assessment of ankle dor-

siflexion and plantarflexion (with knee extended and flexed)

and rearfoot, midfoot, and forefoot ranges of motion. The

forefoot-to-rearfoot relationship is also assessed. Tender-

ness may be present in pediatric flatfoot, occurring along the

medial column and at the metatarsal heads, plantar fascia,

sinus tarsi, and ankle.

Gait observation should be conducted when the child is

barefoot and is wearing shoes. Gait should be assessed

for prominence of the medial border of the midfoot, the

foot progression angle, calcaneal eversion (pronation and

resupination during stance phase), the heel-to-toe con-

tact, position of the knee, and presence of limp.Diagnostic observations and maneuvers include inver-

sion of the heel on toe rise, recreation of the medial arch

with dorsiflexion of the hallux, and the “too many toes

sign.” Other physical findings include obesity, tibia va-

rum, genu valgum, tibial torsion, femoral torsion, disor-

ders of muscle tone, and ligamentous laxity that can

modify both the natural history and the severity of flat-

foot (9).

PATHWAY 1

342 THE JOURNAL OF FOOT & ANKLE SURGERY



FIGURE 1 Clinical examination of the foot begins with nonweightbearing inspection. ( A ) The pediatric flexible flatfoot shows preservation

of the medial arch off weightbearing, whereas ( B ) the arch depresses or flattens with weightbearing. ( C ) The relaxed calcaneal stance position

is viewed from the posterior. The heels may evert and the tendo-Achilles bows laterally (positive Helbing sign). ( D ) Ankle dorsiflexion is

assessed during the examination, because equinus is a frequent component or etiologic factor of flatfoot pathologies. ( E ) The everted or

valgus heel in stance changes to ( F ) a varus position with the clinical maneuver of heel rise to the toes, showing the flexible nature and the

reducibility of the deformity.




Diagnostic Studies ( Pathway 1, Node 3)

Imaging options may include radiographs (Fig 2)

(weightbearing), computed tomography (CT), magnetic res-

onance imaging (MRI), and bone scans. Serologic studies

may be warranted to differentiate mechanical or overuse

symptoms from arthralgia, arthritis, and other childhood

inflammatory diseases.

Diagnosis ( Pathway 1, Node 4)

Information from the initial evaluation and diagnostic

tests is correlated into a diagnosis. The differential diagnosis

of the pediatric flatfoot includes the following: flexible

flatfoot (Pathway 2); rigid flatfoot: congenital vertical talus

(CVT) (Pathway 3); tarsal coalition (Pathway 4); peroneal

spastic flatfoot without coalition (Pathway 5); iatrogenic

and posttraumatic deformity (Pathway 6); skewfoot (Path-

way 7); and flatfoot caused by other, less frequent causes

(Pathway 8) (2, 4, 8, 10). Note that 4 of these conditions—

vertical talus, tarsal coalition, peroneal spastic flatfoot with-

out coalition, and iatrogenic/posttraumatic deformity—are

types of rigid flatfoot.

Flexible Flatfoot ( Pathway 2 )

Asymptomatic Flexible Flatfoot ( Pathway 2 )

The asymptomatic flexible flatfoot may be physiologic or

nonphysiologic (Nodes 5 and 6) (11). Most flexible flatfeet

are physiologic, asymptomatic, and require no treatment (7,

12, 13). Physiologic flexible flatfoot follows a natural his-

tory of improvement over time (Fig 3). Periodic observationmay be indicated to monitor for signs of progression (Node

5). Treatment generally is not indicated (14).

Nonphysiologic flexible flatfoot is characterized by pro-

gression over time. The degree of deformity is more severe

in nonphysiologic than in physiologic flexible flatfoot. The

amount of heel eversion is excessive; the talonavicular joint

is unstable. Additional findings include tight heel cords and

gait disturbance. Periodic observation is indicated in non-

physiologic flexible flatfoot (Node 7). Patients with tight

heel cords may benefit from stretching (Node 8) (13). Or-

thoses may also be indicated.

Children with asymptomatic flexible flatfoot should bemonitored clinically for onset of symptoms and signs of

progression (Node 7). Continued progression requires reas-

sessment to identify other underlying disease.

Symptomatic Flexible Flatfoot ( Pathway 2, Node 6)

Unlike physiologic and asymptomatic nonphysiologic

flexible flatfoot, symptomatic forms of flexible flatfoot

produce subjective complaints, alter function, and produce

significant objective findings. These include pain along the

medial side of the foot; pain in the sinus tarsi, leg, and knee;

decreased endurance; gait disturbances; prominent medial talar

head; everted heels; and heel cord tightness.

Initial treatment (Node 8) includes activity modifica-

FIGURE 2 Radiographic examination includes weightbearing ( A )

AP and ( B ) lateral radiogr aphs taken in the angle and base of gait

for further evaluation and documentation of the degree of

deformity. Radiographic flatfoot parameters focus on the rela-

tionship of the talus and calcaneus. The midtalar line (solid black

line), talocalcaneal angle (TC) and calcaneal inclination angle

provide information on the sagittal plane position of these bones

on lateral view and transverse plane position on the AP view. In

flatfoot, the talocalcaneal angle increases in size both on the AP

and lateral radiographs. The talus plantarflexes in flatfoot

deformity on the lateral radiograph. The normal midtalar line

should pass through the first metatarsal. On the weightbearing

AP radiogr aph, the talar head is no longer covered by its articu-

lation with the navicular. This results in a wide AP talocalcaneal

angle (Kite angle). Calcaneal inclination decreases in flatfoot.

(Further discussion can be found in the American College of Foot

and Ankle Surgeons Clinical Practice Guideline on Adult Flatfoot.)






tions and orthoses. Stretching exercises for equinus

deformity can be performed under physician or physical

therapist supervision. Nonsteroidal antiinflammatory

medications may be indicated in more severe cases. Co-

morbidities, such as obesity, ligamentous laxity, hypoto-

nia, and proximal limb problems, must be identified and

managed, if possible.

If there is a positive clinical response and symptoms

are resolved, observation and orthoses (when appropri-

ate) are instituted. If clinical response is not satisfactory,

reassessment and additional work-ups are indicated.

When all nonsurgical treatment options have been ex-

hausted, surgical intervention can be considered (13,

15–21).

Surgical Intervention ( Pathway 2, Node 10)

Surgical management of the flexible flatfoot can be

grouped into 3 types: reconstructive procedures, arthrodesis,

and arthroereisis.

Soft tissue reconstruction of the flexible flatfoot is rarely

successful as an isolated procedure. Bony procedures in-

clude rearfoot, midfoot, and forefoot osteotomies. Depend-

ing on the plane of dominance of the deformity, lateral

column lengthening (Fig 4) and/or medial displacement

osteotomy of the posterior calcaneus may be used. A heel

cord lengthening and medial plication are often included asa part of these procedures. Although excellent results from

surgical treatment of flatfoot have been described, questions

remain regarding successful long-term correction (14).

Arthroereisis involves insertion of a spacer into the sinus

tarsi for the purpose of restricting subtalar joint pronation

(22–25) (Fig 5). Proponents of this procedure argue that it is

a minimally invasive technique that does not distort the

normal anatomy of the foot (24, 26–28). Others have ex-

pressed concern about placing a permanent foreign body

into a mobile segment of a child’s foot (29, 30). The

indication for this procedure remains controversial in the

surgical community (25, 26, 28, 31–38).

Arthrodesis of the rearfoot has also been described fortreatment of symptomatic flexible flatfoot. Subtalar arthro-

desis is typically performed as the primary procedure. Triple

arthrodesis is reserved as a salvage procedure for previously

failed surgical treatment. Although arthrodesis provides a

FIGURE 3 Radiographic examination of foot deformities is essen-

tial for both diagnostic evaluation and documentation. Radiographs

of pediatric deformities allow comparison of progression with time

and assessment of therapeutic results. This case is a neurologically

healthy 4-year-old girl who was treated for flexible flatfoot with

nonpronating orthotics. ( A

) The initial AP and lateral radiographsshow medial talar head uncovering and a wide talocalcaneal angle.

( B ) The initial lateral radiograph shows decreased calcaneal inclina-

tion angle and increased talar declination angle. ( C ) Three years

later, there is improvement in the radiographic parameters with

increased talar head coverage on the AP view. ( D ) The lateral

radiograph shows improvement of arch height, although the calca-

neal inclination and talar declination are similar to the pretreatment

studies. Although it is tempting to credit orthotic therapy for the

observed improvement, it is equally possible that these changes are

the result of the natural history of spontaneous improvement.




FIGURE 4




stable foot and durable correction, eventual transfer of en-

ergy to the nonfused joints adjacent to the fusion is of

concern (39, 40).

If surgical intervention is successful in producing a func-

tional painless result, the child should be further treated by

periodic observation and appropriate orthoses. If surgery

fails, salvage through appropriate intraarticular or extraar-

ticular arthrodesis is appropriate.

Rigid Flatfoot (Pathway 3 to 6)

Rigid flatfoot is characterized by a lowered arch on both

weightbearing and nonweightbearing and by a decrease or

absence of motion of the rearfoot and midfoot. Rigid flatfoot

can be symptomatic or asymptomatic. Most cases are asso-

ciated with underlying primary pathology that can be diag-

nosed by clinical and imaging examinations.

The differential diagnosis of rigid pediatric flatfoot in-

cludes CVT (Pathway 3), tarsal coalition (Pathway 4), per-

oneal spastic flatfoot without coalition (Pathway 5), andiatrogenic or traumatic joint pathology (Pathway 6).

Congenital Vertical Talus ( Pathway 3 )

CVT deformity, also known as congenital convex pes

valgus, is characterized by severe equinus of the rearfoot

and by a rigid rocker-bottom appearance. There are 2

classes of this deformity: teratologic and idiopathic.

Teratologic CVT indicates the presence of underlying

comorbid conditions. These include genetic syndromes, spi-

nal dysraphisms (41–43), prune belly syndrome (44), de

Barsy syndrome (45), distal arthrogryposis (46), arthrogry-posis multiplex congenita (47), congenital metacarpotalar

syndrome (48), Rasmussen syndrome (49–51), and a host of

chromosomal abnormalities (52).

Idiopathic CVT lacks specific etiologic factors (52–61).

CVT has been associated with a tarsal coalition (62). Ge-

netic issues in idiopathic CVT have not been resolved

because of inconclusive data. Results of some studies sug-

gest a hereditary component (58, 63, 64), whereas others fail

to show patterns of inheritance (65, 66).


CVT deformity should be diagnosed at birth but it is

sometimes confused with calcaneovalgus deformity or

physiologic flatfoot. Symptoms begin at walking age, with

difficulty bearing weight and wearing shoes. There may be

a history of previous unsuccessful treatment.


CVT is characterized by a rigid rocker-bottom appear-

ance to the foot (Fig 6). Pathology findings include dorsal

dislocation of the talonavicular joint, ankle equinus, con-

tracture of the tendo-Achilles, long-toe flexors, posterior

ankle capsule, peroneal tendons, and the anterior compart-

ment tendons (59, 67). The tibionavicular ligament is con-

tracted; the calcaneonavicular (spring) ligament is elon-

gated.

The forefoot is most frequently abducted, but may occa-

sionally be adducted (68). The calcaneocuboid articulationoften remodels so that the entire plantar aspect of the foot is

convex (68). Tibialis posterior and the peroneals may be

displaced, the talar head becomes misshapen, and the de-

formity is extremely rigid. It is most likely resistant to

closed reduction (53, 66, 69–71).

Diagnostic Imaging ( Pathway 3, Node 3)

Plain radiographs are most often diagnostic (61). Lat-

eral weightbearing radiographs show parallelism between

the tibia and the talus. The calcaneus is in equinus

(Fig 6).If the navicular has not ossified, a plantarflexion stress

lateral radiograph will determine the reducibility of the

forefoot on the talus. The longitudinal axis of the first

metatarsal will not align with the bisection of the talus. If

the navicular has already ossified, its malposition in refer-

ence to the talus is visualized. It is not reduced on plantar-

flexion.

On the anteroposterior (AP) projection, the talocalcaneal

(Kite) angle will be very wide. The navicular (if visualized)

FIGURE 4 Selection of apropriate surgical treatment is based on the clinical and radiographic evaluation. Planal dominance is an important

factor. A flatfoot deformity will usually show significant deformity in one or more of the cardinal body planes. A 12-year-old boy had a 2-year

history of progressing pain in both feet after walking long distances and after athletic activities. ( A ) The medial border of the foot is

characterized by talar-head bulging and by the loss of medial arch height. ( B ) The lateral border is abducted and the calcaneus is everted.

( C ) The midtarsal joint complex is pronated on the AP radiograph, and the talar head is uncovered. ( D ) The lateral radiograph shows abnormal

calcaneal inclination, increased talocalcaneal angle, and sagittal collapse of the medial column. The patient underwent an Evans opening

calcaneal osteotomy with insertion of banked bone graft, a plantarflexing first metatarsal osteotomy, and a percutaneous tendo-Achilles

lengthening. ( E and F ) Marked improvement in the talocalcaneal angle, and improved calcaneal inclination and height of the medial arch, are

seen on the AP and lateral postoperative radiographs.




FIGURE 5 Arthroereisis is an evolving procedure for the

treatment of flexible flatfoot. Both polymer and metallic

implants are commercially available. ( A ) This weightbearing

preoperative AP radiograph shows a wide talocalcaneal

angle with approximately 50% of the medial talar head

uncovered. The midtarsal joint complex is completelypronated. ( B ) The preoperative lateral radiograph shows a

large lateral talocalcaneal angle, decreased calcaneal incli-

nation angle, anterior alteration of the Cyma line, and mid-

tarsal fault. ( C ) After metallic subtalar arthroereisis, the

postoperative AP shows the talonavicular joint completely

reduced. The AP talocalcaneal (Kite) angle is also reduced

compared with the preoperative study. ( D ) The postopera-

tive lateral shows significant change in the talotibial and

talocalcaneal relationships. The forefoot is supinated.

(Case courtesy of John Grady, DPM, Chicago, IL.)




PATHWAY 3




will be displaced laterally and will appear to overlap the

distal aspect of the talar head.

MRI, CT, and ultrasound studies may be useful in imag-

ing the deformity for diagnosis and for surgical planning

(72–75).


Diagnosis of vertical talus is made by the appearance of

a rigid and irreducible foot, with support from imaging

studies. The differential diagnosis must include calcaneo-

valgus deformity, which is flexible, does not have a rocker-

bottom configuration, and does not have a talonavicular

dislocation (76).

Initial Treatment ( Pathway 3, Node 5)

Initial management of CVT consists of manipulation and

serial casting for approximately 6 week s (77). During ma-

nipulation, an attempt is made to pull the navicular distally,downward, and medially to relocate it on the talar head.

If closed reduction occurs (Node 6), the talonavicular

joint can be pinned in percutaneous fashion (Fig 7). At that

point, the equinus may be corrected by casting. If complete

reduction is achieved, an ankle-foot orthosis can be pre-

scribed (Node 7). The patient must be carefully observed

because of an extremely high recurrence rate.


Long-term results of closed reduction have been reported

as poor (70). If closed reduction is not successful, opensurgical reduction is necessary (65, 66, 68, 69, 77, 78).

Reduction may be performed in 1 (52, 53, 59, 79, 80) or 2

(68, 81) stages. The benefits and value of the 2 techniques

have been examined by a number of authors (54, 82).

For infants, the Cincinnati incision gives excellent expo-

sure to the rearfoot components of the deformity (61).

However, this incision is not recommended for older chil-

dren because of concerns about skin perfusion after this

approach (83). The goal of surgery is to correct hindfoot

equinus, to restore talonavicular congruity, and to restore

functional anatomy. Recurrence is a common problem and

bracing is recommended (Fig 7).

In older children, the talonavicular joint may be so de-

FIGURE 6 Rigid flatfoot deformities are often congenital. Vertical

talus is 1 pathology that should be diagnosed early in life. ( A ) A child

with CVT (congenital convex pes valgus) is characterized clinically

by a pathologic plantigrade foot with weight borne at the midfoot

and the heel off the ground. ( B ) The lateral radiograph shows the

ankle and calcaneus in equinus position, the talus almost vertical,

and the talonavicular joint dislocated. The navicular is not ossified,

but a line passing through the first metatarsal shaft intersects the

dorsal talar neck instead of the talar head. ( C ) A stress plantarflexion

radiograph is diagnostic and shows that only partial reduction of the

talonavicular dislocation is possible.




FIGURE 7 Vertical talus is generally irreducible nonsurgically. This 3-year-old neurologically healthy girl was diagnosed at 22 months with

CVT deformity. Nonsurgical reduction was not successful. ( A ) The initial surgical approach is peritalar release and pinning of the talonavicular

joint. ( B and C ) These radiographs show some recurrence of the deformity after peritalar release. Note the deformed navicular and severe talar

declination combined with a rocker-bottom deformity.




formed that reconstruction is not possible. For these pa-

tients, naviculectomy may be the procedure of choice (53,

84–86). The Green-Grice procedure for extraarticular sta-

bilization may also be used (53, 58, 87–89) (Fig 8). It may

be necessary to consider lateral column lengthening (87),

osteotomy of the calcaneus, and subtalar arthrodesis to

maintain the corrected position. Talectomy may also be

indicated in selected cases (68). Tendon transfer for rebal-ancing is frequently added in the surgical treatment plan.

Continued observation and appropriate orthosis therapy fol-

lows.

Tarsal Coalition ( Pathway 4 )

Tarsal coalition is a congenital union between 2 or more

tarsal bones that may be an osseous, cartilaginous, or a

fibrous connection (90, 91). The incidence of tarsal coalition

is 1% to 2% (90–92). Talocalcaneal and calcaneonavicular

bars are the most common. Talocalcaneal coalitions are

most commonly found at the middle facet (90, 91, 93, 94).Talonavicular and calcaneocuboid coalitions also have been

described but are much less common. Autosomal dominant

inheritance has been proposed (90, 95–97).


Tarsal coalitions may be asymptomatic (91). The child

and parents may become aware of stiffness in the foot and

ankle, altered foot shape, muscle spasm, and protective gait

abnormalities. Symptoms of tarsal coalitions most com-

monly present in preadolescents or adolescents who sud-

denly gain weight and who take on physical activities, suchas sports and forms of manual labor. Onset of symptoms

may be insidious, precipitated by minor trauma or change in

activity (98, 99).


Most symptomatic coalitions present with local tender-

ness around the lateral ankle, sinus tarsi, subtalar joint, or

the coalition site. There is decreased or absent rearfoot

range of motion with or without muscle spasm and some

degree of rigid flatfoot.

FIGURE 8 Recurrence of vertical talus deformity is not uncommon

and may require further treatment with bracing or additional surgery.

( A ) This radiograph shows recurrent deformity in a young girl with

myelomeningocele. Equinus of the talocalcaneal complex, rocker-

bottom deformity, and talonavicular subluxation are present. ( B ) The

patient was treated with a Green-Grice extraarticular subtalar arth-

rodesis. ( C ) Excellent reduction of deformity is seen immediately

postoperative and is maintained on the follow-up radiograph. (Case

courtesy of Loyola University Department of Orthopaedics and Re-

habilitation Pathology Collection, Maywood, IL.)




PATHWAY 4




FIGURE 9 Tarsal coalitions account for most rigid flatfoot deformities seen at the community level. ( A ) Talonavicular coalition may be seen

as an incidental finding. These feet are usually asymptomatic. Calcaneonavicular bars are common. ( B ) The lateral radiograph shows an

exaggerated projection of the distal calcaneus (anteater sign). ( C ) Lateral oblique projection shows the connection between the calcaneus and

the navicular. ( D and E ) MRI and CT imaging techniques better delineate the pathology. The talocalcaneal coalition may be diagnostically

more difficult. ( F ) The lateral radiograph may show irregularity of the middle facet or complete obliteration of the middle facet. ( G ) Special

views, such as the Harris-Beath projection, should show parallel relationship between the middle and posterior facets. ( G ) Shown here is an

oblique and poorly visualized middle facet. ( H ) This is verified with a CT image.





Calcaneonavicular coalitions can be seen on both lateral

and oblique radiographs of the foot as an upward and medial

prolongation of the calcaneus toward the inferolateral na-

vicular (Fig 9). Depending on the degree of ossification of

the bridge, there may be a lucent line separating the 2 bones.

The 45° oblique plain radiographic view is best for detec-tion of the calcaneonavicular coalition.

Middle facet talocalcaneal coalitions are difficult to visu-

alize because of the complexity of the anatomy and because

many are cartilaginous. The lateral radiograph may show

the “C” or halo sign (the C-shaped line formed by the

medial outline of the talar dome and sustentaculam tali,

which is a secondary sign of a coalition) (100). Harris-Beath

projections may be useful, but they may be difficult to

interpret because of problems with underpenetration. If pos-

itive, the articular end plates of the middle facet are irreg-

ular, the facets angulate down and medial, and there may be

partial bridging evident (101). If angulation is more than

20°, coalition is probable (90, 93, 102). Because of thedifficulty of interpretation, CT and MRI studies have largely

replaced Harris-Beath projections (Fig 9).

CT is the diagnostic test of choice because of its ability to

show the osseous structures (103–105). It is particularly

useful for visualizing talocalcaneal coalitions and for eval-

uating multiple coalitions. Coronal images show the loca-

tion and extent of their involvement (106–111, 112).

MRI is particularly useful in evaluating the immature

skeleton and in determining the presence of other causes of

peritalar pain (90, 103). It is helpful in evaluating fibrocar-

tilagenous coalitions and nonossified coalitions in the very

young (90, 113–116).

Bone scans have been used to show increased stresses at

articular surfaces. Bone scans are sensitive but nonspecific

(117–119).


Diagnosis of tarsal coalition is based on pain and loss of

motion and supported by appropriate imaging studies. Co-

alitions are classified by site, type of interposing tissue,

extent of involvement, and secondary degenerative changes

(Table 1).


The initial treatment for any coalition should be nonsur-

gical (90, 120–122). Patients with mild symptoms may

respond well to footwear modifications, arch supports, or

custom orthoses. Activity modifications, weight reduction,

antiinflammatory medication, and local anesthetic blocks

may also be indicated (90). Cast immobilization for several

weeks may be indicated for patients with more severe

symptoms or with peroneal spasm (97).

Clinical Response ( Pathway 4, Node 6)

After a period of nonsurgical treatment, patients should

be reevaluated. If symptoms have been relieved, the initial

treatment options should be continued (Node 7), with peri-

odic observation of clinical progress (Node 8).


Surgical consideration should be given to those who fail

to respond to nonsurgical treatment (6, 101, 122). Surgical

treatment depends on the type of coalition. Resection of the

coalition may be indicated for individuals without signifi-

cant deformity or arthrosis (Fig 10). In some cases, arthro-

desis may be the procedure of choice.

In children with foot deformity, osteotomy should be

performed in conjunction with resection. If significant ar-

thritic changes are found, arthrodesis should be considered.Isolated talocalcaneal arthrodesis is indicated for subtalar

coalitions (96). If peritalar degeneration is evident, triple

arthrodesis may also be indicated (Fig 11) (101, 102,

120, 122).

Observation and supportive orthoses should follow sur-

gery (Node 8). If symptoms recur, the patient may need to

return to nonsurgical options. These measures are not likely

to provide adequate relief of symptoms.

TABLE 1 Classification of tarsal coalitions

Tissue types Anatomic

Extraarticular

Cartilaginous Calcaneonavicular

Fibrous Cuboidonavicular

Osseous Trigonal

Intraarticular

Talocalcaneal

MiddlePosterior

Anterior

Combination

Talonavicular

Calcaneocuboid

Naviculocuneiform

Articular

Juvenile (osseous immaturity) Adult (osseous maturity)

Type I: Extraarticular coalition Type I: Extraarticular coalition

A. No secondary arthritis A. No secondary arthritis

B. Secondary arthritis B. Secondary arthritis

Type II: Intraarticular coalition Type II: Intraarticular coalition

A. No secondary arthritis A. No secondary arthritis

B. Secondary arthritis B. Secondary arthritis




FIGURE 10 Calcaneonavicular coalitions may be fibrous, cartilaginous, or osseous. Younger patients may benefit by excision of the bar.

( A and B ) Oblique and lateral radiographs demonstrate the bar as well as the pronatory foot deformity. ( C ) Shown is an intraoperative view

of the excised fragment. Excision should restore the mobility of the rearfoot complex. ( D and E ) The postoperative oblique and lateral

radiographs show adequate resection of the extraarticular bar.




FIGURE 11 Talocalcaneal coalitions limit or prevent normal joint motion. Once they occur, degenerative joint changes are irreversible.

Treatment in the older adolescent or young adult usually requires subtalar or triple arthrodesis. ( A and B ) AP and lateral radiographs show

significant pronatory foot deformity with low calcaneal inclination, increased talar declination, and depression of the medial column. Clinically,

no subtalar motion is present. ( C ) MRI evaluation shows a middle subtalar facet coalition. ( D and E ) Surgical treatment with triple arthrodesis

restored rearfoot relationships and eliminated pain.




Peroneal Spastic Flatfoot Without Coalition

( Pathway 5 )

Peroneal spastic flatfoot without coalition is a painful foot

deformity made rigid by spasm of the extrinsic muscles.

Although tarsal coalition is the most common cause of

peroneal spastic flatfoot (see Pathway 4) (123–132), its

presence cannot be confirmed in a number of cases. Otherpossible causes (133) include juvenile chronic arthritis

(134), osteochondral fractures in the rearfoot, osteoid os-

teoma, neoplasms (135), dysplasia epiphysealis hemimelica

(Trevor disease) (136), and problems more proximal in the

limb (slipped capital femoral epiphysis) (137). When no

cause can be found, the condition has been labeled idio-

pathic peroneal spastic flatfoot.


The patient develops pain in the foot, followed by pro-

tective limitation of motion by the extrinsic muscles. Pain isexperienced with activity, and symptoms may be precipi-

tated by trauma. Many patients have been previously eval-

uated for tarsal coalition, but there have been no objective or

imaging findings to support the diagnosis.


Peroneal muscle spasm, restricted subtalar and ankle mo-

tion, valgus appearance of the foot, and constant or inter-

mittent pain in response to activity are the hallmarks of the

condition. Clinical findings are not limited to the peroneal

muscles alone. The extensors, tibialis anterior, and tibialisposterior are involved.

Gait pattern is antalgic with external rotation of the foot

to the line of progression. There is little or no propulsion

during late stance phase of gait.

Diagnostic Studies ( Pathway 5, Node 3)

Diagnostic imaging that fails to show a tarsal coalition or

typical secondary findings of a tarsal coalition (see Pathway

4) may show other pathologies that might explain the con-

dition such as osteochondral defect, pathologic fracture

through a bone cyst, or osteomyelitis (Fig 12).A preliminary bone scan may help localize the pathology.

A total body bone scan is useful to rule out otherwise silent

multiple anatomical sites in systemic disease. In some cases,

all imaging studies may be normal and further clinical

investigation is indicated.

Laboratory studies (Node 4) should include a complete

blood cell count with differential and acute phase reactants

(erythrocyte sedimentation rate and C-reactive protein). El-

evated inflammatory markers suggest a rheumatologic cause

and merit further investigation or consultation (Node 5).


Peroneal spastic flatfoot without coalition is a diagnosis

of exclusion and may be ultimately considered idiopathic.


When a specific cause is detected, appropriate treatment

is directed toward that cause. If no cause can be identified,

symptoms dictate the type of treatment. When symptoms

are intermittent, activity modifications may prove useful.

This may include stopping sports, discouraging running and

jumping activities, and taking the child out of physical

education class. Activity modifications can be supple-

mented with nonsteroidal antiinflammatory medications.

Footwear modifications, arch supports, and orthosis mayalso be beneficial.

In more difficult cases, immobilization in a walking boot

may prove helpful. However, patient compliance is often a

problem. This can be solved with a nonweightbearing be-

low-knee cast and crutches. In extreme cases, an above-

knee cast can be considered. Common peroneal nerve

blocks can be both therapeutic and diagnostic.


If clinical response to treatment results in resolution of

the symptoms and restoration of painless range of mo-tion, follow-up orthotic treatment may be indicated and

the patient should be observed periodically (Nodes 9 and

10).


If symptoms do not resolve with nonsurgical treatment,

surgical options can be considered (Node 11). Surgical

procedures include arthrodesis and realignment osteotomy.

Observation and supportive orthoses should follow surgery

(Node 10).

Iatrogenic and Posttraumatic Deformit y ( Pathway 6 )

Iatrogenic and posttraumatic flatfoot are uncommon

and encompass a broad spectrum of foot disorders. Man-

agement can be challenging and complex, necessitating

case-by-case consideration. Surgical treatment of infant

foot deformities often results in undercorrection or over-




PATHWAY 5




correction. This is particularly true for talipes equinova-

rus (138–144). The goal of treatment is a flexible, plan-

tigrade, painless foot. In many cases, a perfect outcome is

not possible. Often, the end result is a rigid and, hope-

fully, plantigrade foot.

Etiologic factors include overcorrected clubfoot (Fig 13),

undercorrected vertical talus (145–148), failed flatfoot sur-

gery, and end-stage trauma. Iatrogenic or posttraumatic

flatfoot may also be caused by manipulation or casting of

the pliable, easily damaged infant foot.

FIGURE 12 Rigid flatfoot deformity with peroneal spasm may

occur in the absence of coalition. Multiple etiologies have been

implicated. ( A ) This is an adolescent patient with a medial talar

dome lesion that produced the patient’s symptoms and ( B )

flatfoot deformity. Other pathologies include lesions of rearfoot

bones. ( C and D ) Plain films and CT images of an osteoid

osteoma of the talar neck that produced a symptomatic rigid

flatfoot.




PATHWAY 6





Patients with iatrogenic or posttraumatic flatfoot present

with variable degrees of pain, loss of function, and progres-

sive deformity. All feet in this category have a history of

previous manipulation, surgery, or trauma. Onset of flatfoot

deformity may be either immediate or delayed by months oryears.


Examination may determine pain, stiffness, scarring, ab-

normal function, and gait disturbances.


Plain radiographs may show postsurgical changes, re-

tained implants and hardware, malalignment, and arthri-

tis. CT, MRI, and bone scans may be useful in further

defining the deformity and in evaluating residual pathol-

ogy.


The patient’s history, coupled with diagnostic imaging, con-

firms the diagnosis of iatrogenic or posttraumatic flatfoot.


Shoe modifications and bracing may be indicated in the

initial management of these deformities. Activity modifica-

tions, weight reduction, physical therapy, and nonsteroidal

antiinflammatory medication may be helpful.


If the clinical response is satisfactory, continued nonsurgical

management and observation are in order (Nodes 7 and 8).


If there is no response to nonsurgical treatment, surgical

intervention (Node 9) may be necessary to achieve the goal of

a stable pain-free plantigrade foot. The specific procedures aredirected to the deformity, the condition of the soft tissues, and

the joints and osseous structures. Patient and parental educa-

tion should be provided to encourage realistic expectations.

Soft tissue release, osteotomy, and arthrodesis (145–148)

are the procedures most frequently used. In certain cases,

severe deformities may be realigned with distraction osteo-

genesis (Ilizarov) (139). Rarely, in the case of intractable

pain and unstable deformity or chronic osteomyelitis, an

FIGURE 13 ( A and B ) The long-term results of posteromedial release of clubfoot deformity.

There has been overcorrection, resulting in rigid flatfoot deformity and marked sagittal breechwith subluxation of the talonavicular articulation. The first ray is supinated with metatarsus primus

elevatus.




amputation followed by a functional prosthesis is a reason-

able choice to allow the patient to return to activities.

Patients should be followed up for observation (Node 8).

Recurrence is possible and necessitates reevaluation.

Skewfoot ( Pathway 7 )

Skewfoot is characterized by forefoot adduction (meta-tarsus adductus) and heel valgus (149–151). The more

severe cases have midfoot abduction. There are no univer-

sally accepted clinical or radiographic criteria for skewfoot

(150) and the natural history of idiopathic skewfoot is

poorly understood (150, 152, 153). There are 4 types of

skewfoot: congenital idiopathic, congenital associated with

syndromes, neurogenic, and iatrogenic (151).


Skewfoot may be asymptomatic or associated with

activity-related pain and difficulty in fitting shoes (150,154). It is often misdiagnosed as metatarsus adductus and

flexible flatfoot. Skewfoot should be suspected if the

infant does not respond favorably to treatment for meta-

tarsus adductus.


The deformity is characterized as an S- or Z-shaped foot

with forefoot adductovarus and rearfoot valgus (149) (Fig 14).

In children younger than 1 year of age, the rearfoot valgus is

not as apparent as the forefoot deformity (151). Contracture of

the tendo-Achilles may be present (150, 151). Calluses and

other skin problems may occur (150, 154).


Standard radiographs show metatarsus adductus and se-

vere heel valgus (Fig 14).


Clinical findings and supportive radiographs confirm the

diagnosis of skewfoot.


Asymptomatic skewfoot in older children needs no treat-

ment (Node 5). Management of skewfoot is based on age,

degree of severity, and presence of symptoms (155). Ma-

nipulation and serial casting may be indicated for infants

(155). Stretching exercises and activity modification may

relieve mild symptoms but they will not change the defor-

mity (150). Orthoses may be used for symptomatic relief but

may exacerbate the symptoms in the presence of ankle

equinus (150). Nonsteroidal antiinflammatory medications

may also be beneficial. Management of comorbid condi-

tions is important.


Clinical response to treatment is evaluated. Observation

and continuation of initial treatment options are recom-

mended for children whose symptoms resolve (Node 8).


Persistence of severe symptoms may require surgical

intervention. Surgical treatment must address both the fore-

foot and the rearfoot components (Fig 15). Useful proce-

dures include metatarsal osteotomies and midfoot osteot-

omy to correct the forefoot. Lateral column lengthening,

calcaneal displacement osteotomy, and tendo-Achilles

lengthening are used to correct the rearfoot (149–151,

155, 156).




PATHWAY 7




FIGURE 14 Skewfoot, an uncommon but very severe variant of the flatfoot deformity, is characterized by rearfoot pronation, midfoot abduction,

and metatarsus adductus. ( A ) This clinical photograph of an adolescent patient with skewfoot shows forefoot adduction—unlike forefoot abduction

seen with most other flatfoot deformities. ( B ) The AP radiograph shows very prominent metatarsus adductus deformity with a large talocalcaneal

angle. ( C ) The lateral radiograph shows sagittal plane failure of the medial column with talar ptosis (pathologic declination).




FIGURE 15 Surgical treatment of skewfoot requires addressing the forefoot and rearfoot

pathologies separately. ( A ) The AP radiograph is generally diagnostic. There is a Z orientation of

the rearfoot, midfoot, and forefoot areas. ( B ) The lateral radiograph shows the typical findings of

pronatory deformity. ( C and D ) AP and lateral radiographs show the surgical results of meta-

tarsal–first cuneiform arthrodesis in combination with lesser metatarsal osteotomies to correct

the metatarsus adductus, and a lateral column lengthening osteotomy of the calcaneus (Evans

procedure).




Other Causes of Pediatric Flatfoot ( Pathway 8 )

Some forms of pediatric flatfoot deformity do not fit

into the previous schemes. They are unique because their

clinical findings are dictated by the underlying pathology.

Additionally, the clinical approach to diagnosis and treat-

ment is dependent on the cause. Some have natural

histories that are totally unpredictable, and early inter-vention is undesirable until the problem has fully ex-

pressed itself.


These forms of pediatric flatfoot are associated with

generalized ligamentous laxity; Marfan disease; Ehlers-

Danlos; and Down syndrome, cerebral palsy, myelomenin-

gocele, developmental delay, genetic diseases, and other

syndromes (Fig 16).


A variable pattern of foot deformities may be seen. Thedeformities range from hypermobile to rigid. Physical ex-

amination of these children must include observational gait

analysis, assessment of generalized joint mobility for hy-

perlaxity and hypolaxity, and thorough neurologic exami-

nation. Examination of the foot for mobility, calluses, and

skin irritation is necessary.


Diagnostic imaging should be performed as clinically

indicated.


There is nothing unique about this group of pathologies

that has not been previously discussed. Refer to previous

pathways for detailed discussion.


In planning the treatment of flatfoot in children with

underlying diseases, it is important to consider the patient’s

baseline function, the demands placed on the feet, and the

natural history of the underlying disease. Asymptomatic

hypermobile flatfeet in syndromatic children are usually

best left alone (Node 5).

Treatment is based on structural deformity and func-

tional demands placed on the foot. Treatment is usually

indicated if the child is ambulating or likely to become

ambulatory. Children with an unstable base of support

secondary to flatfoot may be treated with supportive

orthoses (Node 7).


If bracing is not tolerated or does not provide a solid base

of support, surgical intervention may be considered. Surgi-

cal options are aimed at the specific pathoanatomy and

include osteotomies, arthrodesis, arthroereisis, and tendon

transfers. Long-term orthosis management after surgical

intervention is usually recommended to maximize function

(Node 7).




PATHWAY 8




FIGURE 16 Flatfoot deformities in combination with systemic disease and syndromic patterns may be extremely difficult to treat. ( A )

Children with congenital myotonic dystrophy show characteristic facial weakness with a cupid bow mouth and inexpressive appearance. ( B )

Pronatory foot deformities are a regular feature shown clinically by excessive relaxed calcaneal stance position. ( C and D ) AP and lateral

radiographs show typical features of severe flatfoot deformity. ( E ) This is the standing lateral photograph of an 8-year-old with chromosomal

abnormality, showing pronation with equinus. ( F and G ) The AP and lateral radiographs show complex midfoot and rearfoot coalitions. ( H–L )

Shown is a boy with a congenital ball-and-socket ankle with a talonavicular coalition and absence of a lateral ray. Hindfoot instability with

a valgus heel and forefoot abduction are shown clinically and radiographically.




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