Pertinent Roundtable Pearls On Orthotic Management
These expert panelists expound on the use of orthotic treatment for a range of issues including hyperpronation, overuse injuries and posterior tibial tendon dysfunction. They also discuss treating pediatric patients with both flexible flatfoot and those with non-compensating equinus.
Q: What are your insights into the orthotic treatment of pediatric flexible flatfoot following reconstructive surgery?
A: Edwin Harris, DPM, divides the surgical management of pediatric flatfoot into two main types. The first type is implanting devices in the sinus tarsi to control excessive heel eversion. As he notes, it may be necessary to perform surgery on the medial column if there is a rigid sagittal plane deformity.
The second category entails managing both triplane and transverse plane dominant pronation. Dr. Harris notes one can accomplish this by lengthening the lateral column and plantarflexing the medial column as close to the apex of the deformity as possible. For both types of surgery, he advises DPMs to consider the impact of ankle equinus.
If one can perform a subtalar arthroereisis without doing osseous work along the medial column, Dr. Harris notes that subsequent orthotic control is not necessary. He does note an exception when either tendo-Achilles lengthening or some form of gastrocnemius/soleus recession is necessary to control equinus. For these patients, he prefers an ankle foot orthosis (AFO) for six months following surgery. Dr. Harris says the AFO protects the tendo-Achilles component of the surgery, preventing over-lengthening and rupture.
Lateral column lengthening and medial column plantarflexing correction almost always require surgical management of the equinus deformity, according to Dr. Harris. Incorporation of bone graft into the lateral column in children occurs very quickly and he notes this does not seem to be influenced by either the use of an allograft or an iliac crest graft. Incorporation is usually complete by eight weeks.
When it comes to osteotomies along the medial column, Dr. Harris follows the same aforementioned principles in postoperative management. When the patient no longer requires a cast, he places the patient in a solid ankle AFO for six months. After six months, he transitions the patient to a UCBL orthosis, which the patient wears for a year after surgery. At the one year mark, he will either continue use of a non-pronating orthosis or discontinue orthotic therapy altogether. However, Dr. Harris cautions that he does not necessarily recommend a solid AFO for all osteotomies of the medial column unless there has also been a surgery for equinus or a lateral column lengthening.
For Scott Spencer, DPM, treatment depends on the procedure(s) one performs during the reconstruction. For subtalar arthroereisis procedures, he concurs that orthotics may be overkill. On the other hand, for most other procedures or a combination of procedures, he feels a functional foot orthotic device should be part of the postoperative management.
Dr. Spencer notes the orthotic device one uses following flatfoot reconstruction should be designed to augment the correction. He adds that the device should also provide an extra layer of control and support while the patient heals and incorporates the surgical correction.
Q: Hyperpronation has a direct association with the development of overuse syndromes. What is your rationale in the treatment of these problems with orthotics?