Moderator: Prof. Sudesh Sharma

Presented by: Dr. Mohammad Azhar

2nd year post graduate

Deptt of Orthopaedics

G.M.C Jammu

This truism from a British Medical Journal editorial sums up the problem of ‘normally abnormal’ feet

Also known as FLAT FOOT.

Medial border of the foot is abnormally in contact with the floor during weight bearing

Low or absent medial longitudinal arch

When associated with deformities of the hind, mid and fore foot – pes plano valgus

ANKLE – plantarflexion and dorsiflexion

SUBTALAR (TALOCALCANEAL) – inversion and eversion

MIDTARSAL – adduction and abduction, flexion and extension, supination and pronation

Forefoot - abduction and supination (relative to hind foot)

Talar head - displaced medially, anteriorly and downwards

Calcaneum everts, dorsiflexes - hindfoot is in valgus

Navicular- subluxates dorso-laterally, uncovering the talar head

The medial column of the foot appears to be longer than the lateral column

Navicular, cuneiform, cuboid become wedge-shaped, with apex directed dorso-laterally

Plantar, spring and deltoid ligaments are stretched

Anterior, posterior tibial tendons and plantar muscles are stretched whereas the achilles tendon and peronei become adaptively shortened

Calluses develop over the medial bony prominences

Standing anterior-posterior (AP) (dorsoplantar), lateral, and oblique views Harris-Beath views if a tarsal coalition is suspected

There are basically 3 components that are involved in producing the alignment abnormalities of symptomatic adult flatfoot:

1. Collapse of the longitudinal arch

2. Hindfoot valgus3. Forefoot abduction

Meary’s angle - between long axis of talus and long axis of first metatarsal on a standing lateral X ray

long axis of the talus should nearly bisect the navicular and first metatarsal shaft

0 degrees – normal

0 – 15 degrees – mild

15 – 40 degrees – moderate

> 40 degrees – severe

The location of the sag, talo-navicular, naviculo-cuneiform or both can also be determined

Two lines are drawn, one connecting the edges of the articular surface of the talus, and one connecting the edges of the articular surface of the navicular. The angle formed by these two lines is the talonavicular coverage angle

Normally it is less than 7 degrees

This is an indication of forefoot abduction

Calcaneal pitch – A line is drawn from the plantar-

most surface of the calcaneus to the inferior border of the distal articular surface. The angle made between this line and the transverse plane is the calcaneal pitch

Normal 17-32 degrees, in flat foot is decreased May be 0 or negative in case of tightened TA

Normal talar-1st metatarsal angle on AP view. A line drawn trough the mid-axis of the talus passes through the base of the first metatarsal and is angled laterally in relation to the long axis of the shaft of the metatarsal.

Abnormal talar-1st metatarsal angle, angled medial to the first metatarsal.

it indicates pes planus.

The normal range is 25-45 degrees

This is the angle formed by the intersection of a line bisecting the head and neck of the talus and a line running parallel with the lateral surface of the calcaneus. The range of normal for adults is 15 - 30°

Abnormally increased AP talocalcaneal angle, more than 30 degrees indicating hindfoot valgus in pes planus.

is an architectural term designating the union of two curve lines. A normal midtarsal joint should create a smooth cyma between the talonavicular joint and calcaneocuboid joint on both the AP and lateral views

If the cyma line is broken it suggests “shortening” of the calcaneus relative to the talus

This is often just a radiographic shortening possibly due to rotation of the talus on calcaneus (typically seen in a patient with adult flatfoot including loss of the medial arch)

Exact incidence not known???

One of the most common orthopedic deformities

Affects 15 - 20% of adults, mostly asymptomatic

Of this 2/3rd have flexible flatfoot , 1/4th have a contracted tendo-achilles associated with a

flexible flatfoot and the remainder have rigid flatfoot the most common

cause being tarsal coalition

The medial longitudinal arch normally develops during the first decade of life

Therefore flatfeet are usual in infants, common in children and rare in adults

Flatfoot in an infant is actually a ‘fat foot’ as the excessive amount of fat obscures the arches

An arched foot is a distinctive feature of man

A) Two longitudinal arches

Medial longitudinal arch

Lateral longitudinal arch

B) Transverse arch

Supports body weight in upright posture

Acts as a lever to propel the body forwards in walking, running and jumping

Acts as a shock absorber

Concavity of the arches protects the soft tissues of the sole against pressure

Ends : Anterior : 1-3 MT heads Posterior : Medial tubercle of calcaneum

Summit: Superior articular surface of body of talus

Pillars : Anterior: Talus, navicular, 3 cuneiforms, 1-3 MTPosterior: Medial half of calcaneum

Shape of bones: wedge shaped with apex pointing downwards. The talus acts as a key-stone

Intersegmental ties: ligaments and muscles

Spring ligament

Dorsal ligaments - interosseus talocalcaneal ligament

Tendinous extensions of tibialis posterior

Tie beams or bow strings : connect two ends of an arch

Medial part of plantar aponeurosis

Medial part of the FDB

Abductor hallucis, FHL, FHB

Medial part of FDL.

FACTORS RESPONSIBLE FOR MAINTENANCE OF MEDIAL ARCH (as compared to stone bridge)

FLEXIBLE

Depending on mobility of tarsal joints

RIGID

PHYSIOLOGIC – due to ligamentous laxity in 1st decade

HYPERMOBILE FLATFOOT – excessive ligamentous laxity – familial, Down’s, Marfan’s, Ehlers-Danlos, Osteogenesis Imperfecta

BONY ABNORMALITIES – hypoplasia of sustentaculum tali, hypoplastic calcaneum

OCCUPATIONAL OBESITY

MOTOR WEAKNESS – PTTD, accessory navicular, muscular dystrophy, peripheral nerve lesions, cerebral palsy, spinal cord conditions like polio, myelodysplasia, Werdnig – Hoffman disease, spina- bifida

SECONDARY TO ANATOMIC DEFECTS ELSEWHERE :

Ext. rotation of the limb

Genu valgum

Equinus deformity of the ankle (tight tendo- achilles)

Varus deformity of the foot

Congenital

Tarsal coalition

Congenital vertical talus

Acquired

Inflammatory arthrosis, Traumatic arthrosis

Charcot foot

Residua of clubfoot

Contractures of peronei or TA - Rheumatoid arthritis, Gout, Degenerative arthritis, Infection, Acute sprain, Osteochondral fracture, Foot tumors especially osteoid osteoma

Hereditary condition

Marked ligamentous laxity

Deformity disappears when feet are freed of weight bearing

Weight bearing axis - shifted medial to normal position

Prolonged weight bearing in the everted foot - Heel cord

contractures ( flexible flatfoot associated with tight heel cord)

No broad consensus

Unstable architecture of tarsal bones

Congenitally short tendo achilles

Weakened muscle power

Ligamentous laxity

Age of presentation: adolescence

Usually bilateral and asymptomatic

Family history of flatfeet and joint hyper mobility

Pain, discomfort, burning sensations and fatigue on activity and prolonged standing, cramping at night

Felt around the navicular, talocalcaneal joint, below the medial malleolus or at the ant. or post. extremities of the plantar ligaments

Flatfoot only on weight bearing

Deformity correctable on tip toe standing

Jack’s (great toe extension) test - the arch can be restored by simply dorsiflexing the great toe – suggests that sag is at the naviculocuneiform level

Examine the tendo-achilles for tightness (TA contracture tends makeS flexible flatfoot symptomatic)

Short tendo-achilles: limited dorsiflexion(not able to walk on heels)

Harris and Beath documented that presence or absence of the longitudinal arch did not corelate with the disability and a flatfoot was compatible with normal function unless associated with a tight tendo-achilles

Examine ROM of ankle,subtalar, midtarsal joints

Examine the gait

Generalized ligamentous laxity

Hypermobility of the subtalar and mid-tarsal joints: the forefoot can be bent outwards and upwards to an unusual degree

Spine, hips and knees should be examined

General examination for neuromuscular abnormalities

Don’t forget to examine the shoes

shoes show excessive wear along the medial border

Pedobarography A record of pressures can be obtained by making the patient

to stand and walk on a force plate. Mainly used to compare pre and post operative function

Footprints made with the aid of an ink pad show the difference between normal sole contact andflat-footed contact. (a) Normal footprint, showing the main contact areas across the anterior metatarsal arch, thelateral border of the foot and the heel, with a ‘hollow’ corresponding to the medial arch.

(b) Flat-footed contact, across the sole to the medial side of the foot

Physiological flexible flatfoot with full ROM is asymptomatic

It does not cause pain or disability Xrays are not indicated and

treatment is not required Child should be left alone If symptomatic always look for

associated causes most commonly tight heel cord

Mainstay of treatment as This is what is required in majority

Condition is essentially benign

Only symptomatic treatment possible

No change in ultimate shape of the foot – it is the parents and grand parents who need

treatment and not the child

Conservative treatment should always be tried first

Arch supports, rubber inserts, Plastizote

Whitman valgus brace

UCBL (University of California Biomechanics Laboratory) heel inserts

Shoe modifications –Thomas heel or a 1\4 inch wedge on the inner border

Custom molded orthotics

Medial heel wedge

Do not alter underlying structural fault

Do not encourage redevelopment of the arch

Running sports shoes have been found to be as effective as traditional orthoses and are more socially acceptable

They reduce shoe wear and are said to be more effective in treating shoes rather than feet

Excercises are designed to improve the strength of invertors and the plantar flexors

Toe-walking and multiple toe-ups If tendo-achilles is contracted, stretching it actively and

passively is an important form of management Grasping marbles with toes Heel to toe walking Playing in sand Ballet dancing Walking on a supination board

There is no scientific study evaluating the effectiveness (or lack of it) of these exercises

Reserved for patients with intractable symptoms unresponsive to shoe or orthotic modifications and who are unable to modify pain producing activity

Limitation of daily activities is an indication for surgery

Surgery for flexible flatfoot should not be performed for cosmetic reasons

Arthrodesing procedures should be delayed until 10 and preferably 15 years

Before 10 years arthrodesis is difficult because of excessive cartilaginous component of tarsal bones

Subsequent bony growth is retarded

Patient must be prepared to accept permanent loss of inversion-eversion motion

Achilles tendon lengthening is included if the ankle lacks at least 10 degrees of dorsiflexion with the knee extended

If patient has severe enough symptoms to warrant surgery, then heel cord lengthening should be part of a comprehensive procedure to reconstruct the arch

TECHNIQUE 3 small insicions( 2 medial, 1 lateral) along the length of the

tendon Tendon is cut from midline outwards Tendon sheath is repaired to prevent scarring Closure is done with knee extended and ankle dorsiflexed Long leg cast with ankle in neutral is given for 6 weeks

TECHNIQUE Elevation of tibialis posterior tendon Elevation of osteoperiosteal flap from proximal

to distal Naviculocuneiform arthrodesis Advancement of osteoperiosteal flap Advancement of tibialis posterior

Displacement of the posterior half of the calcaneus medially

Reestablishes the weight bearing line

Indicated in cases with excessive heel valgus

Koutsogiannis calcaneal osteotomy

Osteotomy is fashioned in a coronal plane 1.5 cm

posterior to the calcaneocuboid joint between the anterior and middle facets

This is not a simple opening wedge osteotomy, but rather a lengthening distraction wedge osteotomy, and it requires a trapezoid graft

Tricortical iliac crest graft is inserted between the anterior and middle facets of the calcaneus

Additional internal fixation is required

Nonunion of calcaneal graft

Displacement of the graft requiring revision

Diplacement of the calcaneocuboid joint

Recurrence of deformity or pain

Indicated for correction of residual deformities in flat foot

Forefoot supination is corrected by a plantar medial closing wedge osteotomy of first cuneiform

The goal is to plantar flex the first ray down to the level of the fifth metatarsal to restore Cotton's normal “tripod” configuration.

Tarsal coalition (peroneal spastic flatfoot, congenital rigid flatfoot) [most common cause]

Heel cord tightening

Accessory navicular

Vertical talus

Cannot be passively manipulated without causing pain

Feet are flat - regardless of weight bearing / position

Pain is usually a prominent symptom.

Thin or thick bar composed of bone (synostosis), cartilage (synchondrosis) or fibrous tissue (syndesmosis) connects tarsal bones

Failure of embryonic segmentation

Calcaneum is held in eversion

An irritative focus is produced which causes painful spasm of the peronei

Impossible for the patient to walk on the lateral border of the foot due to limited inversion

Mechanics of the tarsus is impaired and abnormal stresses result casing sec. degenerative arthritis

Symptoms : do not develop until ossification of the fibrous syndesmosis or the cartilagious synchondrosis

Syndesmosis and synchondrosis are usually more troublesome than synostosis

Symptoms – vague active adolescents with dorsolateral foot pain around the sinus tarsi, difficulty in walking on uneven surfaces, foot fatigue, painful limp

Tenderness is present along the bar

The condition is known to run in families

Auto. dominant inheritance with variable penetrance

50% bilateral

Incidence - 0.4-6%

Symptomatic at 8 – 12 yrs

Varying loss of subtalar motion

Best seen on a 45 degree lat oblique projection

Beaking of dorsal articular margin of talus is uncommon

CT is usually not required

Middle facet talocalcaneal coalition is most common

Symptomatic at 12 – 16 yrs of age

Marked reduction or absence of subtalar motion (cardinal sign)

Best seen on a Harris Beath axial calcaneal view – posterosuperior oblique projection

Talar beaking is commonly seen – traction spur and not a sign of degenerative arthritis

CT is usually needed for diagnosis(in coronal plane at 3mm increments)

Harris axial calcaneal view for middle facet coalition

Most patients respond to conservative treatment – Rest

Shoe inserts (arch supports)

Orthotics (AFO, Plastizote, UCBL insert)

Shoe modifications (high top shoes, Thomas heel, Whitman plate) 4-6 weeks of immobilization in a short leg walking cast with the foot

plantigrade may provide lasting relief of symptoms

Splintage with an outside iron and inside T-strap

Resection of the bar and interposition of muscle, fat or gelfoam – should be performed before secondary degenerative changes have set in

Calcaneal osteotomy can be combined to to correct hind foot valgus

Subtalar arthrodesis

Triple arthrodesis

Extensive talocalcaneal coalition

Multiple coalition

Development of sec. degenerative arthritis

Ball and socket ankle joint

When the coalition involves more than 50% articular surface of talocalcaneal joint or more than 50% of the posterior facet

The concept

“limiting the ability of the calcaneus to externally rotate and the talus to internally rotate”

maintenance of correction of the arch was possible.

inserted in a screw fashionbetween the lateral process of the talus and the anteriorprocess of the calcaneus and prevents external rotation of the calcaneus on the talus

intraarticular device that is inserted under the lateral processof the talus in the lateral most portion of the subtalar joint andelevates the lateral aspect of the talus

is inserted in bone in the floor of the sinus tarsi and acts in a similar fashion to the selflockingwedge by preventing external rotation of the calcaneusunder the talus

In summary, after review of the literature, several findings seem to be consistent:

1. Insertion of a sinus tarsi blocking implant, whichever design is used, seems consistently to reduce the pes planus deformity and, at least in short-term follow-up studies

2. A significant incidence of sinus tarsi pain requiring implant removal has been noted, and this pain does not always resolve with removal of the implant.

3. Follow-up can be characterized as midterm at best with no truly long-term studies available at this point.

4. Further studies are needed before these devices can be recommended for general use.

5. The literature appears to indicate that the best use of these implants is in children with symptomatic pes planus who have combined neuromuscular disorders

First described by Bauhin in 1605

Also called prehallux, accessory scaphoid, os tibiale externum, os naviculare secondarium and navicular secundum

Separate ossification center for the tuberosity of the navicular

Prevalance 5-10%

Cause and effect relationship with flatfoot has not been shown

3 types

Round sesamoid bone within TP tendon - rarely symptomatic

8-12 mm ossicle connected to the navicular by a synchondrosis. This is the type that is usually symptomatic as the synchondrosis is at risk of disruption from traction injury / shear forces

Navicular beak / Cornuate navicular -fusion of acc. navicular with the primary navicular.

Usually asymptomatic, noticed incidentally

Presentation - adolescence

Pain over an enlarged area at the medial aspect of the navicular just at the insertion of the tibialis posterior tendon

Pain aggravated by wearing tight-fitting shoes

Accessory navicular is best seen on the external oblique view

Accessory navicular ossifies even later than a normal navicular which is the last tarsal bone to ossify

CT can identify an accessory navicular

Bone scan can identify a hot accessory navicular

Soft pads, avoid wearing tight fitting shoes

Special shoes, valgus correcting shoe inserts( UCBL devise)

Steroid and analgesic injections

Strenghening of tibialis tendon and treatment of tendonitis

Immobilization in a short leg cast

Simple excision of the accessory navicular shelling it out of the post. tibial tendon

Navicular is resected until it is slightly depressed relative to the talus and cuneiform

Bone wax is applied to the to prevent regrowth

Good or excellent result in 93% cases

Involves excision of the accessory navicular with re-routing of the central slip of the tibialis posterior laterally onto the plantar surface of the navicular, where it is sutured under tension to the surrounding ligaments

Gives no added advantage in short term and long term follow up and therefore the simpler procedure is preferred

Congenital rigid flat foot, rocker bottom foot, convex pes valgus or teratologic dorsolateral dislocation of

the talo-naviculo-cuneiform joint

First description by Henken in 1914

Characteristic features described by Lamy and Weissman

X-ray shows the vertical talus pointing downwards towards the sole and the other tarsal bones rotated around the head of the talus

after bilateral operative correction at age 14 months in which transverse circumferential approach was used.

Congenital dislocation of talonavicular joint such that the talus is disposed vertically with its head forming the most prominent part of the sole

The navicular is displaced dorsolaterally firmly lodged on to the neck of the talus, preventing reduction. The navicular abuts the ant. surface of the tibia

The calcaneum is displaced posterolaterally in relation to the talus, is rigidly locked into equinus and in contact with the distal fibula

The angle between the long axis of the talus and calcaneum is markedly increased

The forefoot is deviated outwards and dorsally and hence the sole has a convex contour

Dorsolateral dislocation or extreme subluxation of calcaneocuboid joint might occur

Abnormal relationship of tarsal bones remain constant whether the foot is plantar flexed or dorsiflexed, this is in contrast to congenital flexible flatfoot

Achilles tendon is contracted, ant. tibial and peroneal tendons are taught

The subtalar joint is abnormal with the anterior facet absent and the middle facet hypoplastic

Adaptive changes occur in the tarsal bones with weight bearing

The talus becomes shaped like an hour glass, with its longitudinal axis almost same as the tibia

Only the posterior 1/3rd of the superior articulating surface of the tibia articulates with the tibia

Anterior part of the plantar surface of the calcaneus becomes rounded

Callosities develop beneath the anterior end of the calcaneus and along the medial border of the foot superficial to the head of the talus

Muscle imbalance

Intra-uterine compression

Arthrogryposis

Autosomal dominant transmission

Arrest of fetal development of the foot between 7th and 12th weeks of gestation

Usually bilateral Sole is characteristically convex at birth, so that it

resembles the bottom of a rocking chair and hence the name

Dorsolateral fold is deep and situated at the mid-tarsal area Talar head is prominent over the medial and plantar

aspects Deformity from the outset is rigid Deformity may be so severe that heel might not touch the

ground at all Gait is awkward and resembles a waddle Shoes are rapidly worn out over the inner sides Pain - at adolescence or soon thereafter

Idiopathic flatfoot

Paralytic flatfoot

Spurious correction of clubfoot

Talipes calcaneovalgus (benign condition easily amenable to correction)

Tarsal coalition

Calcaneus is held in eversion by contracted interosseous ligament, bifurcated ligament and calcaneofibular ligament

Calcaneus is fixed in equinus by contracted posterior capsule and achilles tendon

Dorsal capsules of talonavicular, calcaneocuboid joints and tibio-navicular portion of the deltoid ligament are markedly contracted and prevent reduction

Tibialis anterior, long toe extensors, peroneus brevis and triceps surae are contracted

Posterior tibial and peroneal tendons may be displaced anteriorly so that they act as dorsiflexors rather than plantar flexors

Forefoot dorsiflexors are contracted

Calcaneonavicular ligament is elongated and attenuated

Posterior tibial tendon becomes attenuated as it passes over the displaced head of talus

If deformity persists into late childhood, alterations in the bony shape develop that encourage redisplacement even after surgery

Talus assumes hour-glass constriction, calcaneus becomes curved dorsally at its anterior end becoming beak shaped and navicular becomes wedge shaped

Difficult to treat tends to recur Serial casting to stretch the foot in

plantarflexion and inversion while counterpressure is applied to the medial aspect of the talus

Reverse Ponseti method Complete correction rarely achieved. Open reduction is generally required

1 - 4 yrs : soft tissue release, open reduction and realignment of the talonavicular and subtalar joints (KUMAR, COWELL, RAMSEY)

Children > 3 yrs with severe deformity generally require navicular excision at the time of open reduction

4 - 8 yrs : soft tissue release and open reduction with Grice-Green subtalar extra-articular arthrodesis

>12 yrs failure of above procedure striple arthrodesis

Should be done before 2 yrs Best done as a single stage release at 1 yrSTEPS Dorso-lateral soft tissue release Medial soft tissue release Reduction of talonavicular and calcaneocuboid

jts Posterior soft tissue release Internal fixation

Kodros and Dias reported a single-stage procedure

in which a threaded Kirschner wire is used as a “joystick”

To manipulate the talus into correct position.

The corrected position is held with threaded Kirschner wires across the talonavicular and subtalar joints

Results are satisfactory if surgery is done before 27 months

All feet have some residual midfoot sag and forefoot abduction and some have decreased motion

Commonest reason for surgical failure is inadequate reduction of the navicular

Aseptic necrosis of the navicular

Aseptic necrosis of the talus

These can be averted by limited amount of dissection

Examination of the flatfoot compares the (A) nonweightbearing and (B) weightbearing arch of the foot. As the arch depresses,(C) the forefoot abducts and (D) the lesser toes become visible upon posterior observation of the foot. The relaxed calcaneal stance position is viewed standing behind the patient. A flatfoot deformity will demonstrate heel eversion that is accentuated with apparent bowing of thetendo-Achilles (Helbing sign). The too many toes sign, indicative of excessive forefoot abduction in the flatfoot, may also be noted.

Most common cause of adult onset acquired flat foot

The components of the deformity are 1. hindfoot valgus, 2. midfoot abduction at the midtarsal joint, 3. forefoot pronation, primarily at the

midtarsal joint.

Chronic tenosynovitis (either traumatic, degenerative, or secondary to inflammatory arthritis), loss of continuity of the tendon (either complete or incomplete), and loss of the normal anatomical relationships of the tendon to its insertion or insertions (the accessory navicular or prehallux syndrome)

may render the posterior tibial tendon insufficient to perform its tasks of plantar flexion and inversion

and stabilization of the medial longitudinal arch.

The classification system originally developed by Johnson and Strom in 1989

Conservative management of stage II disease often is successful, and most patients obtain pain relief withapplication of an orthotic device that has a medial post anda double upright AFO with a medial T-strap.

The brace is configured to allow 20 to 30 degrees of plantarflexion and 10 degrees of ankle extension.

arthrodesis is indicated if conservative measures, including a double upright ankle-foot orthosis, have failed.

For rigid deformities, the procedure of choice usually is arthrodesis of the ankle or tibiotalocalcaneal arthrodesis

In a select group of patients with flexible, reducible deformity, less than 10 degrees of tibiotalar tilt, and minimal lateral ankle joint arthrosis

Jeng et al. described a “minimally invasive”allograft technique for deltoid ligament reconstruction for stage IV flatfoot deformity done in conjunction with triple arthrodesis.

Unilateral deformity that develops rapidly

History of trauma

Young patient- tendon transfer using flexor digitorum longus

Elderly- splintage

If this fails and symptoms are marked triple arthrodesis

THANKTHANK

YOUYOU