Key Insights On Surgical Correction Of Pediatric And Adult Flatfoot
The correction of flatfoot deformity has been an evolving and somewhat troublesome treatment in the realm of foot and ankle ailments. The treatment has differed in children versus adults and has gained extended popularity as simpler procedures have become available. The problem with simple procedures is they do not always treat the full complex of the underlying deformity.
Accordingly, let us take a closer look at the treatment of flatfoot in children and adolescents. We will consider the underlying deformity, its causes and treatment options. I will also provide my treatment preferences and reasoning for each type of treatment. In a subsequent article, we will deal with adult-acquired flatfoot and its treatment options. As I noted, the treatment of adult versus pediatric flatfoot differs greatly and one should consider each case as a different animal.
Biomechanically speaking, the pediatric flatfoot is due to one of several causes. One should initially differentiate between a rigid flatfoot and a flexible flatfoot. In cases of rigid flatfoot, the clinician must consider a tarsal coalition and you may also see a fracture with joint impingement in rare cases of rigid flatfoot.
In flexible cases, one must consider the main cause of deformity. Is the problem due to a tight or lax tendon? Is the problem due to a foot deformity? Is the problem a combination of issues? With a flexible deformity, I will often talk to my patient and the parent about the mechanics of a tripod. The foot is essentially a tripod and unless all three planes of the tripod are aligned in a stable position in relation to each other, there will be instability.
In most pediatric flatfoot cases, a combination of causes leads to the ailment. The most common and problematic cause of pediatric flatfoot is a tightness of the gastrocnemius tendon and, to a lesser degree, the Achilles tendon. Due to the lack of possible ankle dorsiflexion, there is a pronation of the foot with pain along the medial ankle and arch. A second common cause of problems is a short lateral column. In rare cases, one may note a valgus heel position in addition to or instead of a short lateral column.
The final and most commonly overlooked aspect of pediatric flatfoot deformities is the laxity of the medial column and elevated position of the first ray. There is a great deal of controversy as to the location of the actual laxity. Some believe the laxity is at the naviculocuneiform joint while others believe it to be at the first metatarsocuneiform joint.
I believe either joint can be the culprit but the more common finding in my hands has been an elevated or lax first ray. A forefoot varus deformity is a common finding and the podiatrists must differentiate this from a laxity of the first ray. A forefoot varus is a more difficult problem and more rare problem due to a complete varus of the entire forefoot. In contrast, a first ray laxity and elevatus is a single ray problem and does not involve the entire forefoot.
Helpful Diagnostic Pearls
The physical exam begins with a gait analysis of the patient. Observe the patient walking in both posterior and anterior positions. Pay attention to the foot in static stance and compare it to walking gait. Be sure to differentiate between a valgus heel and a midtarsal abduction. Direct your attention to the tightness of the Achilles complex and midfoot pronation during late gait due to the equinus deformity. Then check the foot in a non-weightbearing exam. Check flexibility. In the rigid foot, make a diagnosis of the rigid joint and check equinus. In the flexible foot, individually check the laxity of the heel, the midfoot and the forefoot-first ray complex.