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EVALUATION
Proper diagnosis is contingent upon a thorough history
and physical examination. A full history should be
obtained including the onset of deformity, progression of
the deformity, pain associated with deformity, family
history of foot deformities, and concurrent medical
conditions, such as neurological disorders. Although some
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TREATMENT
After appropriate diagnosis of a pathologic flatfoot, the
next critical step is selecting the proper treatment protocol.
Treatment protocols vary greatly and depend on many
factors including the severity of the deformity, the flexibility
of the deformity, the progression of the deformity, pain
associated with the deformity, and the age of the child.
As with the majority of other foot and ankle deformities,
conservative therapies are attempted before any surgical
intervention for pediatric flatfoot. Conservative therapies
may include but are not limited to manipulation and
stretching, activity modifications, appropriate shoe gear,
orthoses, and anti-inflammatory medications.
Unless severe deformities are present, such as vertical
talus, conservative therapies are typically the only form of
treatment the author performs on children under the age
of 3. Serial casting and manipulation can be performed for
those under the age of 1. At this age the foot is still
somewhat moldable and often correction of the deformity
can be obtained. Casting may also be attempted for those
over this age however the results are usually not as good,
and children are often reluctant to casting once they have
begun to walk. Bracing is another option and can be
utilized during hours of sleep.
SURGICAL OPTIONS
Indications for surgical repair include failure of all
conservative therapies to reduce the patients pain or
prevent progression of the deformity. Surgical considerations
include severity of the deformity, flexibility of the deformity,
planal dominance, concomitant medical conditions, patients
age, and functional demands.
Arthroereisis
The arthroereisis implant is extra-articular and limits
excessive or abnormal motion across the subtalar joint. It
is designed to block abnormal talar motion without
damaging the subtalar joint itself. The implant is placed
in the sinus tarsi and blocks abnormal anterior talar
displacement and adduction and prevents calcaneal
eversion. This repositioning then allows the subtalar joint
to function in a corrected position. The author prefers this
technique in the younger patient with a flexible deformity
typically between the ages of 3 and 12 years old (Figure 1).
With the anatomic realignment after placement of the
arthroereisis implant, the peroneus longus tendon
functions more efficiently by restoring plantarflexion of
the first ray and stabilizing the medial forefoot. After
placement of the arthroereisis implant however, the
medial arch should be assessed to determine if any
deformity remains necessitating adjunctive procedures to
provide for adequate correction.
When arthroereisis is performed at an early enough
age, often it is the only procedure that needs to be
performed. If further surgical procedures are necessary
however to stabilize the medial arch or to correct for
further deformity, typically it consists of soft tissue
procedures such as a Youngs tenosuspension and/or
tightening of the spring ligament. Less commonly, in this
age group and for this degree of deformity, osteotomies
or arthrodesis in the medial arch can be performed to
achieve stability and correction. It is critical that the
surgeon also identify and correct an equinus deformity if
present. A gastrocnemius recession is performed if
only the gastrocnemius muscle is tight. If both the
gasctrocnemius and soleus muscles are tight then an
Achilles tendon lengthening is performed.
The arthroereisis procedure is geared towards
correcting a rearfoot deformity with a frontal plane
dominance; therefore, it should not be utilized in a
flaftfoot deformity with an absence of calcaneal eversion.
This procedure should also be avoided in rigid
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Osteotomies
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Arthrodesis
When selecting surgical procedures for the correction of
pediatric flatfoot deformity, attempts should be made for
joint salvage and maintenance of joint motion whenever
possible. There are some patients however, where joint
salvage is not possible in order to obtain adequate
correction of the deformity and reduce pain. This is
particularly true for subtalar joint coalitions. Due to the
significant restriction of the joint motion, secondary
arthritic changes often occur and joint salvage is
impossible. Although the surgeon may have good
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CONCLUSION
Treatment of pediatric flatfoot can be very rewarding. The
key to successful treatment is to correctly diagnose the
deformity and individualize treatment. Pediatric flatfoot is
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Figure 4D.
Figure 5A. Preoperative radiograph of a 13-yearold with back pain and lateral column pain. Notice
the significant decreased calcaneal inclination angle
and increased talocalcaneal angles. There is also a
naviculocuneiform fault or sag and an anterior
break in the cyma line.
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REFERENCES
1. Jani L. Pediatric flatfoot. Orthopade 1986;15:199-204.
2. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am
Acad Orthop Surg 1999;7:44-53.
3. Bahler A. Insole management of pediatric flatfoot. Orthopade
1986;15:205-11.
4. Cappello T, Song KM. Determining treatment of flatfeet in children.
Curr Opin Pediatr 1998;10:77-81.
5. Lin CJ, Lai KA, Kuan TS, et al. Correlating factors and clinical
significance of flexible flatfoot in preschool children. J Pediatr
Orthop 2001;21:378-82.