Foot and Anklevalgus foot deformity. In cases of collagen disorders, where soft-tissue laxity complicates management, deformity correction may be of higher importance. Overall alignment

© 2015 AAOS Instructional Course Lectures, Volume 64

8SECTION

Foot and Ankle

37 Management of Idiopathic and Nonidiopathic Flatfoot

38 Posterior Tibial Tendon Dysfunction in the Adult: Current Concepts

© 2015 AAOS Instructional Course Lectures, Volume 64 429

37

Flatfoot deformity is common. This condition is characterized by collapse of the arch, lateral deviation of the forefoot, and uncovering of the ta-lar head. Although most patients are

asymptomatic, when pain is present and there is no response to nonsurgical treatment, surgery may be warranted. This chapter discusses the evaluation and management of idiopathic fl atfoot,

particularly in conjunction with a tight heel cord (equinovalgus). In addition, the differences in the pathology and treatment in peroneal spastic fl atfoot and equinovalgus deformities associ-ated with neuromuscular or connective tissue disorders are outlined.

Epidemiology A child’s foot changes with growth, with continued development of the longitudinal arch.1,2 The prevalence of fl atfoot deformity in one school-based study was approximately 40% in chil-dren aged 3 to 5 years but only 6% in the teenage group.3 In the younger group, the proportion of children with fl atfoot will decrease approximately 14% per year. Flatfoot will normalize in 40% of children over a 1-year period, whereas fl atfoot will develop in 10% of children who previously had an arch.4 Increased weight, neuromuscular delay, and loose connective tissue are risk factors for the development of fl atfoot.5 Children aged 3 to 6 years with delayed motor development are 1.5 times more likely to have fl atfoot. In obese children with delayed motor development, the rate of fl atfoot is 96%; however, the natural

Management of Idiopathic and Nonidiopathic Flatfoot

Jenny M. Frances, MD, MPHDavid S. Feldman, MD

Dr. Feldman or an immediate family member has received royalties from Orthopediatrics; is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet and Stryker; and serves as a paid consultant to or is an employee of Biomet, Stryker, and Orthopediatrics. Neither Dr. Frances nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

AbstractFlatfoot in a child may be normal before development of the arch, but the prevalence de-creases with age. Treatment is indicated only in the presence of pain and should begin with nonsurgical management options such as stretching of the Achilles tendon and the use of soft shoe orthotics. If pain persists, a modifi ed Evans procedure, together with additional procedures to address forefoot supination, can be successful in correcting deformity and addressing pain. A thorough understanding of the patholog y and correction desired will help minimize complications and recurrence.

If neuromuscular patholog y is present, treatment principles are altered and greatly depend on the severity of the deformity, the association of tibialis posterior spasticity, and ambulatory status. In mild to moderate patholog y in walking patients with cerebral palsy, osteotomies can be successful. Various forms of arthrodesis can decrease recurrence when the deformity is severe in a nonambulatory patient with cerebral palsy and a symptomatic valgus foot deformity. In cases of collagen disorders, where soft-tissue laxity complicates management, deformity correction may be of higher importance. Overall alignment always should be evaluated and corrected when necessary to optimize the outcome in patients with valgus foot deformities. The successful treatment of fl exible or rigid fl atfoot deformity must take into account underlying patholog y to optimize outcomes.

Instr Course Lect 2015;64:429–440.

Foot and Ankle

430 © 2015 AAOS Instructional Course Lectures, Volume 64

history of the condition and how many children become symptomatic later in life is unknown.6

In 1947, Harris and Beath7 observed that 23% of Army recruits did not have an arch, but very few reported symp-toms. Approximately 25% of adults with fl atfoot also have a tight heel cord; this combination is more commonly associated with pain and symptoms.8 Less than 10% of adults with fl atfoot have rigid fl atfoot, and these cases are associated with symptoms approxi-mately 20% to 24% of the time.9,10

HistoryIn symptomatic patients, there is typically a report of a long period of pain worsened by increased activity and relieved by rest. The pain usually occurs over the medial prominent talar head and is diffuse over the arch and/or the anterolateral foot or ankle from impingement. Some shoes may be more comfortable than others. Night-time pain is uncommon and may indi-cate other pathology. There is often a family history of fl atfoot.

ExaminationOn examination, collapse of the arch can be observed. The heel is often in valgus, and midfoot valgus is associ-ated with prominence of the talar head (Figure 1). If the arch reconstitutes when the patient is asked to stand on his or her toes, the deformity is noted to be fl exible. The fl exibility of the deformity and the motion of the subtalar joint also can be tested while sitting, with the examiner using his or her hand to reduce the foot from the planovalgus position. The tight-ness of the Achilles tendon can then be assessed but only when the subtalar joint is in a neutral position (Figure 2). This tightness of the Achilles tendon is often missed on examination, when dorsifl exion is tested with the subtalar joint unreduced in the valgus position (Figure 2, A) After reduction of a hindfoot valgus deformity, a supina-tion deformity of the forefoot may be revealed (Figure 2, B through D). If the foot is not reducible and the defor-mity is rigid, the physician should eval-uate for other pathology, including

signs of tarsal coalition or other causes of spastic peroneal fl atfoot.

If there is a history of pain, de-termination of the exact location is important. Tenderness in the calcaneo-navicular space could indicate a coali-tion. Palpating all structures of the foot and ankle to evaluate for tenderness helps rule out other potentially inciden-tal and unrelated causes of pain, such as severe apophysitis or recent injuries. The function and strength of posterior tibialis, peroneal, and anterior tibialis tendons are tested. An evaluation for signs of generalized ligamentous laxity may suggest a connective tissue disor-der. Shoes will usually show signs of excessive lateral wear on the sole of the heel. If the foot is not reducible in young infants and toddlers without an arch, radiographs with the foot in plan-tar fl exion should be obtained to rule out congenital vertical talus.

ImagingRadiographs are generally not indi-cated for asymptomatic fl atfoot. When evaluating a symptomatic patient with fl atfoot, weight-bearing AP, lateral, and oblique radiographs are useful to identify the pattern and severity of the deformity, which in certain cases can help guide surgical treatment. The Meary angle can be determined by measuring the angle formed between the long axis of the talus and the fi rst metatarsal on a lateral radiograph; if less than 0°, this indicates plantar sag and loss of the arch. The calcaneal pitch is the angle between a line parallel to the fl oor and the plantar aspect of the calcaneus and describes the posi-tion of the calcaneus (Figure 3, A). In patients with severe neuromuscu-lar equinovalgus foot deformity, the lateral talocalcaneal angle also can be

Clinical photographs of the AP (A) and PA (B) views of the feet of an ambulatory 7-year-old boy with cerebral palsy and planovalgus deformity. Worsening ability to ambulate was reported because of turning out of a foot.

Figure 1

Management of Idiopathic and Nonidiopathic Flatfoot Chapter 37


helpful in determining treatment.11 A normal lateral talocalcaneal angle is 25° to 55°, whereas more than 55° indicates valgus of the hindfoot or cal-caneus. An AP radiograph is used to evaluate for coverage of the talar head (Figure 3, B). The AP talus-fi rst meta-tarsal angle can be helpful in quanti-fying valgus. If there are radiographic signs of severe adjacent joint arthritis, joint-sparing procedures are not likely to be successful. The C sign, a C-shaped line created by the talar dome and the inferior margin of the sustentaculum tali seen on a lateral foot radiograph, is specifi c for the presence of fl atfoot; however, contrary to previous belief, it is not always present in patients with talocalcaneal coalitions.12 The oblique radiograph best shows a calcaneonavic-ular coalition (Figure 3, C), whereas CT helps delineate the extent of talocal-caneal coalitions (Figure 3, D).

Radiographic fi ndings do not pre-dict symptoms, but among symptom-atic patients the deformity is likely to be more severe than in a cohort of asymp-tomatic patients. In a retrospective case

control study comparing 50 patients with and without symptoms, the av-erage talonavicular angle measured on

weight-bearing AP radiographs was 25° for asymptomatic patients and 38° for symptomatic patients.13

Clinical photographs showing foot deformity and Achilles tendon tightness revealed with reduction. A, Testing dorsifl exion without reducing the subtalar joint shows 15° of apparent dorsifl exion. B, After the subtalar joint is reduced to neutral position and dorsifl exion is tested, the tightness of the heel cord is revealed (−5°). C, The neutral appearance of the forefoot before reducing the valgus subtalar joint. D, After correcting hindfoot valgus, the underlying supination of the forefoot is revealed.

Figure 2

A, Weight-bearing lateral radiograph showing the Meary angle (T-1MT), calcaneal pitch (CP), talocalcaneal angle (TC), and the talus horizon-tal line (TH). B, AP radiograph demonstrates the anterior talocalcaneal angle (TC), talonavicular coverage angle (TN), and loss of talonavicular coverage. C, An oblique view of the foot shows a talonavicular coalition. D, CT scan of a talocalcaneal coalition.

Figure 3

Foot and Ankle


Treatment of Idiopathic FlatfootThere is no indication for the treatment of idiopathic asymptomatic fl atfoot in a child. Parents often seek care having heard that orthoses in early childhood can prevent fl atfoot in adulthood. Wenger et al14 showed that the use of orthoses in childhood does not pre-vent fl atfoot in adulthood and has no bearing on the natural history of the disorder.

Symptomatic fl exible fl atfoot often can be well managed with orthoses and an arch support. Often, the heel cord is tight (equinovalgus); in these cases, stretching the Achilles tendon may be suffi cient to relieve symptoms. Dorsi-fl exion orthoses used at night can be helpful in stretching the Achilles ten-don; however, if the foot is not held in a reduced subtalar position, these orth-otic devices can exacerbate lateral sinus tarsi impingement and symptoms. In-verting and reducing the subtalar joint prior to dorsifl exion of the ankle allows a stretch of only the Achilles tendon, without further stress of the sinus tarsi and the talocalcaneal joint. Orthotic in-serts may be helpful, but hard orthoses can exacerbate symptoms and, in these cases, soft orthoses can sometimes be useful to cushion the prominent painful talar head.

Surgical Treatment of Symptomatic Idiopathic Equinovalgus DeformityIn patients with an equinovalgus de-formity and pain that is refractory to nonsurgical treatment, surgery may be benefi cial.

Modified Evans ProcedureThe modifi ed Evans procedure has been well described and popularized by

Mosca15-17 (Figure 4). A modifi ed Ollier incision is made over the sinus tarsi, with care taken to prevent damage to the sural nerve and the superfi cial branches of the peroneal nerves. After release of the inferior extensor retinaculum off the calcaneus, the extensor digitorum brevis is elevated off the dorsum of the calcaneus. A Z-lengthening of the pero-neus brevis is performed. The location of the calcaneocuboid joint capsule is noted to avoid exposure or injury to the capsule because this may predispose the patient to calcaneocuboid subluxation. The calcaneus is exposed at the interval between the anterior and middle facet and is retracted above and below with Hohmann retractors or jokers. A pin is placed retrograde through the cal-caneocuboid joint to prevent sublux-ation. The calcaneal osteotomy can be completed using a small oscillating saw 2 cm proximal to the calcaneocuboid joint. A 0.062-inch Kirschner wire is placed on either side of the osteotomy to allow manipulation of the fragments, or the wires can be used together with a Hintermann distractor to control wid-ening and rotation of the fragments. Alternatively, a lamina spreader can be used to lengthen the osteotomy site until the desired correction of the foot is obtained. The interval is measured, and a trapezoidal bone allograft of the desired length is placed and impacted. To allow contact between the calcane-al cortex and the allograft to maintain length and strength, care is taken not to impact the allograft too deeply. The calcaneocuboid joint pin is advanced retrograde and bent outside the skin. A gastrocnemius recession or Achil-les tendon lengthening is performed, depending on which structure is tight on the Silfverskiöld test. Medially, a soft-tissue plication of the talonavicular

joint capsule and the tibialis posterior tendon is performed.

If the forefoot is supinated after cor-recting the valgus deformity, a plantar fl exion osteotomy of the medial cunei-form is performed to restore the tripod and prevent recurrence. Incisions are closed with absorbable sutures. Postop-eratively, a well-padded bivalve cast or a splint is placed to allow for swelling. Eight weeks in a non–weight-bearing short leg cast helps protect healing. The calcaneocuboid pin is removed in the offi ce at 6 weeks during a cast change.

Phillips18 reported that 17 of 20 pa-tients had good or better than good re-sults in a study with an average 13-year follow-up. In 1995, Mosca15 reported satisfactory clinical results in 29 of 31 feet treated with the modifi ed Ev-ans procedure for symptomatic severe valgus deformity of the hindfoot. Al-though 26 patients in this series had an underlying neuromuscular disorder and only 1 patient had symptomatic se-vere idiopathic fl atfoot, this procedure has been popularized and is the most commonly used osteotomy to address symptomatic idiopathic deformities.

Calcaneo-Cuboid-Cuneiform OsteotomyA calcaneo-cuboid-cuneiform oste-otomy entails a sliding calcaneal oste-otomy, an opening wedge cuboid osteotomy, and a plantar fl exion closing wedge cuneiform osteotomy to address supination (Figure 5). If indicated, lengthening of the Achilles tendon and/or peroneus brevis is performed. The calcaneus is approached lateral-ly, with protection of the sural nerve, and cut with a saw or an osteotome. A narrow bridge is left medially; the cut is then carefully completed with an osteotome or a Kerrison rongeur under



direct vision. The medial soft tissue is freed to allow mobilization of the tu-berosity fragment. If needed, removing a wedge of bone medially allows for a closing wedge osteotomy. Through the distal part of this incision, the cuboid opening osteotomy can be performed and the wedge inserted. A medial in-cision centered over the cuneiform is made. A plantar closing wedge cune-iform osteotomy allows correction of residual supination and re-creates the

arch. If needed, a medial reefi ng of the talonavicular joint can be performed through the same incision.19

Moraleda et al20 compared lat-eral calcaneal lengthening with the calcaneo-cuboid-cuneiform osteotomy in patients with idiopathic equinoval-gus. The authors found that both tech-niques were effective and comparable with regard to clinical and radiographic results. Although the lateral calcaneal lengthening group had slightly better

talar head coverage by the navicular on the AP radiograph, complications were also somewhat more frequent and more severe.

ArthroereisisArthroereisis involves placing a silicone or metal plug within the sinus tarsi to limit valgus of the subtalar joint. The rationale is that correcting subtalar val-gus with a simple and quick procedure allows quick return to weight bearing.

The podiatric literature has many reports of outcomes of subtalar ar-throereisis;21 however, indications for the procedure are often unclear in the data presented because the study populations often also include patients with painless pes planus deformities. Concerns among pediatric orthopaedic surgeons include foreign body reaction, synovitis, the effect on a child’s normal cartilaginous surface, a 30% rate of si-nus tarsi pain, and the potential need for a repeat procedure to remove the insert.21,22 Researchers from the Rizzoli Institute reported on their experience using a bioabsorbable implant when performing an extra-articular arthro-ereisis in 22 children (aged, 8 to 15 years) with functional fl atfoot. Eighty-one percent of the patients reported dis-comfort before the procedure, and 5% had discomfort after the procedure.23 There may be specifi c indications for this procedure to treat idiopathic and nonidiopathic equinovalgus in children and adolescents under specifi c circum-stances; however, these indications have not yet been fully delineated.

Nonidiopathic Pes PlanusIn patients with cerebral palsy and spina bifi da, the underlying pathology of the equinovalgus deformity is a neuromus-cular imbalance. In patients with tarsal

AP (A) and lateral (B) schematics of an equinovalgus foot defor-mity with collapse of the arch and loss of talonavicular coverage. AP (C) and lateral (D) schematics shows correction of the Meary angle, normalization of the arch, and improved coverage of the talar head by the navicular after insertion of the lateral calcaneal graft as part of a modifi ed Evans procedure. (Reproduced with permission from Mosca FS: Calcaneal lengthening for val-gus deformity of the hindfoot: Results in children who had severe, symptom-atic fl atfoot and skewfoot. J Bone Joint Surg Am 1995;77[4]:500-512.)

Figure 4

Foot and Ankle


coalitions, there is a structural problem. In other conditions, such as osteogene-sis imperfecta and Down, Marfan, and Ehlers-Danlos syndromes, collagen de-fects are sometimes combined with hy-potonia, and treatment principles must address the bony column to optimize success. These conditions may result in a more severe valgus foot deformity, with a higher rate of complications if the ini-tial pathology is not considered carefully when deciding on a surgical plan.

Whenever possible, this chapter’s authors aim to correct a symptomatic foot deformity without fusion to pre-vent adjacent joint arthritis, which has been reported to be as high as 40% in long-term studies.24,25 Fusions may be necessary to maintain correction in some patients with severe neuro-muscular deformity; however, many patients do well with osteotomies or partial fusions. Although the litera-ture has no clear answers as to when

deformity correction is suffi cient and exactly when a fusion is needed, the following sections may provide help in discerning the indications for various treatment options. Situations in which fusions may result in poor outcomes, such as spina bifi da and collagen dis-orders, are highlighted.

Tarsal CoalitionA rigid fl atfoot deformity in a child or adolescent may be associated with tarsal

Illustrations showing lateral (A through D and G) and medial (E and F) views of a calcaneal-cuboid- cuneiform osteotomy. This triple osteotomy can be used to correct a severe valgus foot deformity. A, The location of the planned calcaneal osteotomy is shown. The sural nerve and peroneal tendons are retracted superiorly. B, A Kerrison rongeur is used to complete the medial cortical osteotomy. C, The tuberosity fragment is mobilized using a Chandler retractor, which is placed medially to displace the calcaneus laterally. This allows easier removal of the medial wedge. D, The cuboid opening-wedge osteotomy is performed with the peroneal tendons retracted inferiorly. E, Location of the closing-wedge osteotomy of the medial cuneiform. Removal of approximately the middle third of the cuneiform is accom-plished. F, Plantar fl exion and pronation of the forefoot are accomplished with a closing-wedge osteotomy of the medial cuneiform, which reconstructs the longitudinal arch. G, The opening-wedge graft is inserted from the cuneiform into the cuboid.

A

D

B C

E

G

F

Figure 5



coalitions, and the patient usually has pain in the area of the coalition. Ra-diographs may be helpful in identifying a coalition, and CT can help delineate the extent of the bony coalition, which will help guide treatment. MRI may be helpful in fi brous coalitions. Surgery is indicated if the coalition is symptom-atic and nonsurgical treatment has been unsuccessful. If the tarsal coalition can be excised and good subtalar motion obtained, treatment can proceed as would be indicated for an idiopathic fl atfoot. If the deformity is unlikely to be symptomatic, a simple excision is indicated. If symptoms arise, defor-mity correction can be addressed at a later time. In a retrospective review of 49 feet, Gantsoudes et al,26 reported that 34% of the feet treated with co-alition excision later needed an oste-otomy to correct foot alignment. In severe cases, in which there is marked deformity (hindfoot valgus more than 16°), pain from the deformity under the talar head or in the sinus tarsi area, and symptoms from the deformity that are expected to continue after resection, combining the resection with defor-mity correction should be considered.27 Mosca and Bevan27 recently advocated a release of the talonavicular joint to loosen foot stiffness when performing a modifi ed Evans procedure in addition to coalition resection. If joint stiffness remains in the subtalar, talonavicular, or calcaneocuboid joint after resection of the talar coalition, a sliding calca-neal osteotomy, medial closing wedge osteotomy, cuboid opening wedge oste-otomy, and cuneiform closing wedge osteotomy can help address the defor-mity without necessitating a fusion.19 Subtalar or triple arthrodesis are salvage procedures and are indicated only as a last resort in patients with an extensive

coalition or with arthritis of the subtalar or Chopart joint.28-31

Equinovalgus Foot Deformities in Patients With Cerebral PalsyThe indications for reconstruction of a valgus deformity in a child with cerebral palsy include an unbraceable foot, skin breakdown, or severe lever arm disease affecting gait. Khadim and Miller32 showed that correcting the equinovalgus foot deformity alone in ambulatory patients with cerebral palsy and a crouched gait could par-tially correct the gait abnormality. In their series, the extent of improvement in knee extension was directly related to the decrease in ankle dorsifl exion afforded by the deformity correction.

A thorough preoperative evalua-tion of both radiographs and muscle spasticity is important before choosing surgical treatment options for a severe pes valgus deformity in a patient with cerebral palsy. When poor outcomes are observed in medium- and long-term studies, they are usually the re-sult of recurrence, undercorrection, or overcorrection.18,33 When deciding on a treatment plan for a patient with ce-rebral palsy and a symptomatic fl atfoot deformity, it is important to differenti-ate spasticity from dystonia or hypo-tonia. When spasticity is not a clinical issue, the deformity can be treated as an idiopathic deformity. When spasticity is present, treating the deformity itself is the key to successful treatment be-cause botulinum toxin injections and isolated lengthening of the peroneals or the gastrocnemius does not provide long-term relief.

When there is no notable arthritis, osteotomies to correct the deformity can be effective. Andreacchio et al34

recommended using lateral-column lengthening in ambulatory children with cerebral palsy when the deformi-ty was mild to moderate and a subtalar fusion for more severe cases. Their data also illustrated the importance of cor-recting forefoot supination to prevent recurrence. Yoo et al11 further delin-eated the indications for lateral column lengthening in children with cerebral palsy, using radiographic indicators. They showed a 75% rate of satisfactory outcomes after performing calcaneal lengthening on 92 feet in 56 children with cerebral palsy. Based on their re-sults, lateral column lengthening was recommended only if the preoperative talocalcaneal angle is less than 35º, the talo-fi rst metatarsal angle is less than 25º, and the calcaneal pitch is more than 5° on a standing lateral radiograph.11,35 When there is concomitant tibialis posterior spasticity, overcorrection is a risk. Yoo et al11 reported a 7% inci-dence of postoperative hindfoot varus deformity, which was often associated with increased spasticity of the poste-rior tibialis tendon.

The triple C osteotomy described by Rathjen and Mubarak19 also can be effective in correcting deformity and relieving symptoms in patients with ce-rebral palsy and symptomatic pes val-gus. Kim et al36 compared the outcomes of lateral opening wedge osteotomy with the calcaneo-cuboid-cuneiform osteotomy in 60 feet undergoing cor-rection for symptomatic planovalgus feet. Twenty-fi ve percent of the cases reviewed were idiopathic, and the re-mainder were neuromuscular in origin. No difference was found for mild to moderate deformities; however, with severe deformities, the correction was slightly better after a triple C osteotomy.

Foot and Ankle


Ambulation status should infl uence the choice of procedure. Approximately 80% of the ambulatory patients with cerebral palsy had satisfactory results with lateral column lengthening com-pared with approximately 50% satis-factory results in the nonambulatory patients. Arthrodesis is likely a better option in a nonambulatory patient with severe deformity and spasticity.11,37,38 Ad-jacent joint arthritis has been reported after triple arthrodesis but is less likely to be an issue among nonambulatory patients in whom the most concerning complication is recurrence. An extra-ar-ticular arthrodesis can be benefi cial in nonambulatory children with cerebral palsy who are younger than 10 years and have growth remaining.39,40

Extra-articular Arthrodesis: Grice and Dennyson-Fulford TechniquesExtra-articular arthrodesis was fi rst described by Grice41 in 1952 as a pro-cedure for patients with polio, but it also can be a treatment option in young,

ambulatory patients with cerebral palsy (Figure 6). In this procedure, a lateral incision is made in the sinus tarsi and, after exposure, a narrow osteotome is used to prepare the location and bed for the bone graft within the inferior portion of the neck of the talus and the dorsal surface of the calcaneus. A tricortical bone graft is taken from the iliac crest, fi bula, or tibia, and is shaped appropriately to fi t in the narrow grove and formatted to allow the desired cor-rection of the deformity. After closure, a short leg cast or splint is applied and should remain in place until union, which may take 10 to 12 weeks.41,42

The Dennyson-Fulford technique of arthrodesis is a modifi cation of the Grice technique and is aimed at obtain-ing a more stable graft position, which decreases the risk of nonunion. In this technique, cancellous bone instead of a cortical graft is used, and internal fi xa-tion stabilizes the deformity correction. After exposure of the sinus tarsi, the area is prepared by removing the corti-cal bone from the undersurface of the talar neck and the dorsal surface of the calcaneus. An area is exposed on the dorsal surface of the talar neck, between the extensor digitorum longus and the neurovascular bundle, to prepare for a 4.5-mm talocalcaneal screw. Cancellous bone from allograft or the iliac crest is then packed into the sinus tarsi. After closure, a splint is placed and a cast is worn until full union is achieved, usual-ly at 6 to 8 weeks. Some physicians allow weight bearing at 3 weeks.42,43

Shore et al40 reported functional im-provement across all patients in a retro-spective review of 46 children treated with a modifi ed Dennyson-Fulford technique that incorporated extra- articular subtalar arthrodesis with in-ternal fi xation. Yoon et al44 reported

reliable correction of hindfoot valgus but less consistent improvement in supi-nation or calcaneal pitch when using ex-tra-articular subtalar arthrodesis to treat valgus deformity in ambulatory patients with spastic diplegia. Dogan et al45 compared lateral-column lengthening and Dennyson-Fulford extra- articular arthrodesis and found comparable results in a group of patients with equinovalgus of mixed etiology. The exception was the most advanced cases, where the Dennyson-Fulford technique resulted in slightly better deformity cor-rection than lateral column lengthening. Although many authors have reported successful results with extra-articular arthrodesis,40,43,45,46 others caution that these results are not universally repro-ducible, and failure can occur in as high as two-thirds of cases.19,47-49

Arthroereisis in Neuromuscular DisordersThe use of arthroereisis also has been reported in patients with neuromuscu-lar disorders. In 1990, Crawford et al50 described 85% good to excellent radio-graphic results using subtalar staple ar-throereisis. Vedantam et al51 reported 96% satisfactory results in 1,135 patients using a silicone plug. However, revision surgery was required in approximately 50% of the feet (16 of 34) treated with staple arthroereisis when used to ad-dress severe fl exible planovalgus defor-mity in patients with neuromuscular conditions.52 Although arthroereisis is simple and has less immediate post-operative morbidity, lateral column lengthening is often preferred because it is not associated with foreign-body complications and has the same rate of recurrence.19,53-55

Illustration of the extra-articular arthrodesis de-scribed by Grice that uses a cortical bone graft placed in a prepared narrow bed in the sinus tarsi to pre-vent valgus collapse of the subtalar joint. (Reproduced with permission from Grice DS: An extra-articular arthrodesis of the subastragalar joint for correction of paralytic fl at feet in children. J Bone Joint Surg Am 1952;34[4]:927-940.)

Figure 6



Talonavicular Fusion Talonavicular fusion is a useful addition to an osteotomy if joint pain is present or in hyperlax, severe equinovalgus foot deformities in patients with neuro-muscular disorders. In a cadaver study, Astion et al56 evaluated the effect of fusion of the subtalar, calcaneocuboid, or talonavicular joint on motion of the foot. A fusion of the subtalar joint re-sulted in 26% of the motion of the talo-navicular joint and 56% of the motion of the calcaneocuboid joint. A simu-lated calcaneocuboid joint arthrodesis resulted in 67% of the motion of the talonavicular joint. Any combination of fusions that included the talonavicular joint limited motion of the other joints to approximately 2°. To prevent under-correction or recurrence of deformity, Huang et al57 recommended adding a talonavicular fusion to the Evans proce-dure when treating severe symptomatic valgus deformities in patients with cer-ebral palsy. Although this fusion elim-inates most subtalar motion, it can be argued that subtalar motion was limited preoperatively because of the severity of the deformity and spasticity.

Triple Arthrodesis Triple arthrodesis, a fusion of the sub-talar, talonavicular, and calcaneocuboid joints, is indicated only for severe, rigid, spastic valgus foot deformities or cases where marked arthritis has been noted. In this procedure, wedges of the joints are resected, allowing correction of the deformity, and are fi xed with staples or screws (Figure 7). Soft tissues are balanced as needed. Postoperatively, the patient is placed in a non–weight- bearing cast, followed by a walking cast, and later an orthosis until the fusion is secure.42

Complications include malalignment from undercorrection of deformity, nonunion of the talonavicular fusion, and later adjacent joint arthritis. Long-term follow-up has shown up to a 40% incidence of adjacent joint arthritis, in-cluding the ankle joint.24,25,58,59

Additional Deformity Evaluation and Correction Concomitant deformities should be noted and addressed to optimize out-comes. When examining valgus of the foot and the subtalar joint, it is impor-tant to ensure (through a weight-bearing AP radiograph of the ankle) that there is no distal tibial valgus masking as sub-talar valgus. In a skeletally immature patient, ankle valgus may be corrected

with guided growth. It is important to correct rotational malalignment, partic-ularly external tibial torsion, at the time of equinovalgus foot deformity correc-tion. In patients with cerebral palsy, a concomitant dorsal bunion (dorsifl ex-ion of the fi rst metatarsal) may require correction.

MyelomeningoceleAnkle and foot valgus is common in ambulatory patients with spina bifi da.55 Indications for corrections usually in-clude a poor lever arm or skin break-down. It is important to determine the extent of the deformity that is arising from the ankle or the subtalar joint and if there is associated external tibial rotation.

Lateral (A) and weight-bearing AP (B) radiographs of the foot of a 15-year-old patient with a severe neuromuscular bilateral valgus foot defor mity. The patient had previously been treated with a tibial osteotomy to address rotational alignment. Postoperative lateral (C) and AP (D) radio-graphs showing alignment after a triple arthrodesis with lengthening of the lateral column via calcaneocuboid joint arthrodesis to restore the foot anatomy and arch.

Figure 7

Foot and Ankle


Sharrard and Grosfi eld60 highlighted the advantage of soft-tissue correction in children with spina bifi da compared with other neuromuscular etiologies because paralyzed tendons could be divided without undue concern. They noted that additional soft-tissue releases often provided more correction than originally expected, and procedures performed earlier in life had the best outcomes. They also reported a 4% inci-dence of cast sores after surgery, which were all attributed to overenthusiasm in obtaining postoperative correction.

Extra-articular arthrodesis was de-signed to allow early deformity cor-rection in young patients who have substantial remaining growth. Hoiness and Kirkhus61 reported good long-term deformity correction and function after extra-articular subtalar arthrodesis in 35 feet in 25 young ambulatory children with spina bifi da. Torosian and Dias62 showed good results using a medial sliding osteotomy in 27 patients with myelomeningocele.

Caution is advised against the use of foot arthrodesis in patients with spina bifi da because heel ulcers can result from the insensate foot.55,60,63,64 Additional procedures addressing re-lated deformities are often necessary, in particular tibial derotation osteoto-mies, Achilles tendon lengthening, and anterior tibialis tendon transfers. Con-comitant ankle valgus can be addressed with guided growth or, in very young patients, an Achilles tendon–fi bular arthrodesis.65

Correction of Flatfoot Associated With Collagen DisordersThe most diffi cult group of patients to treat with joint-preserving surgery are patients with hyperlaxity and associated

syndromes, such as Down or Marfan syndromes, and osteogenesis imper-fecta. The incidence and rate of symp-toms vary depending on etiology. In a study by Berglund et al,66 55% of the patients with Ehlers-Danlos syndrome reported having fl atfoot and a medi-an pain level of 5 of 10 compared with 0 of 10 in control patients. In contrast, Lindsey et al67 recently showed that the incidence of fl atfoot in patients with Marfan syndrome is similar to the gen-eral population.

As with idiopathic fl atfoot, surgical treatment should be indicated only if symptomatic and when nonsurgical treatment has failed. If surgery is in-dicated, soft-tissue procedures are of limited or no benefi t and should never be considered in isolation. Although there are no simple answers regarding the best procedure in these cases, it is important to aim for restoring the bony column and obtaining optimal defor-mity correction. Careful attention to soft-tissue complications, such as poor healing, also is important. A modifi ed Evans procedure may fail, but some surgeons are adding an arthroereisis to this procedure to prevent recurrence. Additional follow-up studies will de-termine if this is an effective method.

SummaryIdiopathic fl atfoot causes symptoms in most patients. If pain is present, addressing heel cord tightness nonsur-gically and using supportive soft or-thotics may relieve symptoms. When nonsurgical treatment fails to relieve pain, a modifi ed Evans procedure can address the deformity. Careful attention to indications and technique and the proper selection of deformities to treat can help optimize outcomes. Arthro-ereisis is gaining popularity, particularly

in podiatry practices, but evidence to clearly delineate indications and out-comes is pending.

In patients with nonidiopathic pla-novalgus, such as tarsal coalitions, neuromuscular deformities, or colla-gen disorders, careful attention to the specifi c pathology will help the surgeon choose the optimal procedure. Surgi-cal options include a modifi ed Evans procedure, triple C osteotomy, ex-tra-articular arthrodesis, talonavicular arthrodesis, subtalar arthrodesis, and triple arthrodesis.

References 1. Staheli LT, Chew DE, Corbett M:

The longitudinal arch: A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am 1987;69(3):426-428.

2. Adams SB Jr, Simpson AW, Pugh LI, Stasikelis PJ: Calcaneocuboid joint subluxation after calcaneal lengthen-ing for planovalgus foot deformity in children with cerebral palsy. J Pediatr Orthop 2009;29(2):170-174.

3. Reimers J, Pedersen B, Brodersen A: Foot deformity and the length of the triceps surae in Danish children between 3 and 17 years old. J Pediatr Orthop B 1995;4(1):71-73.

4. Chen KC, Tung LC, Yeh CJ, Yang JF, Kuo JF, Wang CH: Change in fl atfoot of preschool-aged children: A 1-year follow-up study. Eur J Pediatr 2013;172(2):255-260.

5. Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M: Prevalence of fl at foot in preschool-aged children. Pediatrics 2006;118(2):634-639.

6. Chen KC, Tung LC, Tung CH, Yeh CJ, Yang JF, Wang CH: An inves-tigation of the factors affecting fl atfoot in children with delayed motor development. Res Dev Disabil 2014;35(3):639-645.

7. Harris R, Beath T: Army Foot Survey: An Investigation of Foot Ailments in Cana-dian Soldiers. Ottawa, Canada, National Research Council of Canada, 1947.



8. Harris RI, Beath T: Hypermobile fl at-foot with short tendo achillis. J Bone Joint Surg Am 1948;30(1):116-140.

9. Leonard MA: The inheritance of tarsal coalition and its relationship to spastic fl at foot. J Bone Joint Surg Br 1974;56(3):520-526.

10. Mosca VS: Pes planovalgus: From in-fancy to adolescence. Handout #223, in 2013 Annual Meeting Handouts-Flash-drive, Rosemont, IL, American Acade-my of Orthopaedic Surgeons, 2013.

11. Yoo WJ, Chung CY, Choi IH, Cho TJ, Kim DH: Calcaneal lengthening for the planovalgus foot deformity in children with cerebral palsy. J Pediatr Orthop 2005;25(6):781-785.

12. Brown RR, Rosenberg ZS, Thornhill BA: The C sign: More specifi c for fl at-foot deformity than subtalar coalition. Skeletal Radiol 2001;30(2):84-87.

13. Yan GS, Yang Z, Lu M, Zhang JL, Zhu ZH, Guo Y: Relationship be-tween symptoms and weight-bearing radiographic parameters of idiopathic fl exible fl atfoot in children. Chin Med J (Engl) 2013;126(11):2029-2033.

14. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL: Corrective shoes and inserts as treatment for fl ex-ible fl atfoot in infants and children. J Bone Joint Surg Am 1989;71(6):800-810.

15. Mosca VS: Calcaneal lengthening for valgus deformity of the hindfoot: Results in children who had severe, symptomatic fl atfoot and skewfoot. J Bone Joint Surg Am 1995;77(4):500-512.

16. Mosca VS: Pediatrics, in Tolo VT, Skaggs DL, eds: Master Techniques in Orthopaedic Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2008, pp 263-276.

17. Mosca VS: Calcaneal lengthening osteotomy for the treatment of hind-foot valgus deformity, in Wiesel SW, ed: Operative Techniques in Orthopaedic Surgery. Philadelphia, PA, Lippin-cott Williams & Wilkins, 2010, pp 1608-1618.

18. Phillips GE: A review of elongation of os calcis for fl at feet. J Bone Joint Surg Br 1983;65(1):15-18.

19. Rathjen KE, Mubarak SJ: Calcaneal-cuboid-cuneiform oste-otomy for the correction of valgus

foot deformities in children. J Pediatr Orthop 1998;18(6):775-782.

20. Moraleda L, Salcedo M, Bastrom TP, Wenger DR, Albiñana J, Mubarak SJ: Comparison of the calca-neo-cuboid-cuneiform osteotomies and the calcaneal lengthening oste-otomy in the surgical treatment of symptomatic fl exible fl atfoot. J Pediatr Orthop 2012;32(8):821-829.

21. Yen-Douangmala D, Vartivarian M, Choung JD: Subtalar arthroereisis and its role in pediatric and adult population. Clin Podiatr Med Surg 2012;29(3):383-390.

22. Koning PM, Heesterbeek PJ, de Visser E: Subtalar arthroereisis for pediatric fl exible pes planovalgus: Fifteen years experience with the cone-shaped implant. J Am Podiatr Med Assoc 2009;99(5):447-453.

23. Giannini BS, Ceccarelli F, Benedetti MG, Catani F, Faldini C: Surgical treatment of fl exible fl atfoot in chil-dren: A four-year follow-up study. J Bone Joint Surg Am 2001;83(suppl 2 pt 2):73-79.

24. Adelaar RS, Dannelly EA, Meunier PA, Stelling FH, Goldner JL, Colvard DF: A long term study of triple arthrodesis in children. Orthop Clin North Am 1976;7(4):895-908.

25. Tenuta J, Shelton YA, Miller F: Long-term follow-up of triple arthrodesis in patients with cerebral palsy. J Pediatr Orthop 1993;13(6):713-716.

26. Gantsoudes GD, Roocroft JH, Mubarak SJ: Treatment of talocal-caneal coalitions. J Pediatr Orthop 2012;32(3):301-307.

27. Mosca VS, Bevan WP: Talocalcaneal tarsal coalitions and the calcaneal lengthening osteotomy: The role of deformity correction. J Bone Joint Surg Am 2012;94(17):1584-1594.

28. McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17(1):13-15.

29. Swiontkowski MF, Scranton PE, Han-sen S: Tarsal coalitions: Long-term results of surgical treatment. J Pediatr Orthop 1983;3(3):287-292.

30. Wilde PH, Torode IP, Dickens DR, Cole WG: Resection for symptomatic

talocalcaneal coalition. J Bone Joint Surg Br 1994;76(5):797-801.

31. Scranton PE Jr: Treatment of symp-tomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69(4):533-539.

32. Kadhim M, Miller F: Crouch gait changes after planovalgus foot deformity correction in ambulatory children with cerebral palsy. Gait Posture 2014;39(2):793-798.

33. Zeifang F, Breusch SJ, Döderlein L: Evans calcaneal lengthening procedure for spastic fl exible fl atfoot in 32 patients (46 feet) with a fol-lowup of 3 to 9 years. Foot Ankle Int 2006;27(7):500-507.

34. Andreacchio A, Orellana CA, Miller F, Bowen TR: Lateral column length-ening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy. J Pediatr Orthop 2000;20(4):501-505.

35. de Coulon G, Turcot K, Canavese F, Dayer R, Kaelin A, Ceroni D: Talona-vicular arthrodesis for the treatment of neurological fl at foot deformity in pediatric patients: Clinical and radio-graphic evaluation of 29 feet. J Pediatr Orthop 2011;31(5):557-563.

36. Kim JR, Shin SJ, Wang SI, Kang SM: Comparison of lateral opening wedge calcaneal osteotomy and medial calcaneal sliding-opening wedge cuboid-closing wedge cuneiform osteotomy for correction of planoval-gus foot deformity in children. J Foot Ankle Surg 2013;52(2):162-166.

37. Ettl V, Wollmerstedt N, Kirschner S, Morrison R, Pasold E, Raab P: Calcaneal lengthening for pla-novalgus deformity in children with cerebral palsy. Foot Ankle Int 2009;30(5):398-404.

38. Noritake K, Yoshihashi Y, Miyata T: Calcaneal lengthening for planoval-gus foot deformity in children with spastic cerebral palsy. J Pediatr Orthop B 2005;14(4):274-279.

39. Frost NL, Grassbaugh JA, Baird G, Caskey P: Triple arthrodesis with lateral column lengthening for the treatment of planovalgus deformity. J Pediatr Orthop 2011;31(7):773-782.

40. Shore BJ, Smith KR, Riazi A, Symons SB, Khot A, Graham K: Subtalar

Foot and Ankle


fusion for pes valgus in cerebral palsy: Results of a modifi ed tech-nique in the setting of single event multilevel surgery. J Pediatr Orthop 2013;33(4):431-438.

41. Grice DS: An extra-articular arthro-desis of the subastragalar joint for correction of paralytic fl at feet in children. J Bone Joint Surg Am 1952;34(4):927-940.

42. Morrissy RT, Weinstein SL, Kida B: Atlas of Pediatric Orthopaedic Surgery, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2001.

43. Dennyson WG, Fulford GE: Subtalar arthrodesis by cancellous grafts and metallic internal fi xation. J Bone Joint Surg Br 1976;58(4):507-510.

44. Yoon HK, Park KB, Roh JY, Park HW, Chi HJ, Kim HW: Extraarticular subtalar arthrodesis for pes planoval-gus: An interim result of 50 feet in patients with spastic diplegia. Clin Orthop Surg 2010;2(1):13-21.

45. Dogan A, Zorer G, Mumcuoglu EI, Akman EY: A comparison of two different techniques in the surgical treatment of fl exible pes planovalgus: Calcaneal lengthening and extra-ar-ticular subtalar arthrodesis. J Pediatr Orthop B 2009;18(4):167-175.

46. McCall RE, Lillich JS, Harris JR, Johnston FA: The Grice extraarticular subtalar arthrodesis: A clinical review. J Pediatr Orthop 1985;5(4):442-445.

47. Grice DS: Further experience with extra-articular arthrodesis of the subtalar joint. J Bone Joint Surg Am 1955;37(2):246-259.

48. Ross PM, Lyne ED: The Grice pro-cedure: Indications and evaluation of long-term results. Clin Orthop Relat Res 1980;153:194-200.

49. Scott SM, Janes PC, Stevens PM: Grice subtalar arthrodesis followed

to skeletal maturity. J Pediatr Orthop 1988;8(2):176-183.

50. Crawford AH, Kucharzyk D, Roy DR, Bilbo J: Subtalar stabilization of the planovalgus foot by staple arthro-ereisis in young children who have neuromuscular problems. J Bone Joint Surg Am 1990;72(6):840-845.

51. Vedantam R, Capelli AM, Schoeneck-er PL: Subtalar arthroereisis for the correction of planovalgus foot in chil-dren with neuromuscular disorders. J Pediatr Orthop 1998;18(3):294-298.

52. Sanchez AA, Rathjen KE, Mubarak SJ: Subtalar staple arthroereisis for planovalgus foot deformity in chil-dren with neuromuscular disease. J Pediatr Orthop 1999;19(1):34-38.

53. Andreacchio A: Lateral column leng-thening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy [comment]. J Pediatr Orthop 2007;27(3):364.

54. Mosca VS: Flexible fl atfoot in chil-dren and adolescents. J Child Orthop 2010;4(2):107-121.

55. Herring JA, Tachdjian MO; Texas Scottish Rite Hospital for Children: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Saunders/Elsevier, 2008.

56. Astion DJ, Deland JT, Otis JC, Ken-neally S: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79(2):241-246.

57. Huang CN, Wu KW, Huang SC, Kuo KN, Wang TM: Medial column stabilization improves the early result of calcaneal lengthening in children with cerebral palsy. J Pediatr Orthop B 2013;22(3):233-239.

58. Seitz DG, Carpenter EB: Tri-ple arthrodesis in children: A ten-year review. South Med J 1974;67(12):1420-1424.

59. Angus PD, Cowell HR: Triple arthro-desis: A critical long-term review. J Bone Joint Surg Br 1986;68(2):260-265.

60. Sharrard WJ, Grosfi eld I: The man-agement of deformity and paralysis of the foot in myelomeningocele. J Bone Joint Surg Br 1968;50(3):456-465.

61. Høiness PR, Kirkhus E: Grice arthro-desis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study. J Child Orthop 2009;3(4):283-290.

62. Torosian CM, Dias LS: Surgical treatment of severe hindfoot valgus by medial displacement osteotomy of the os calcis in children with myelomeningocele. J Pediatr Orthop 2000;20(2):226-229.

63. Hayes JT, Gross HP, Dow S: Surgery for paralytic defects sec-ondary to myelomeningocele and myelodysplasia. J Bone Joint Surg Am 1964;46:1577-1597.

64. Maynard MJ, Weiner LS, Burke SW: Neuropathic foot ulceration in patients with myelodysplasia. J Pediatr Orthop 1992;12(6):786-788.

65. Stevens PM, Toomey E: Fibu-lar-Achilles tenodesis for para-lytic ankle valgus. J Pediatr Orthop 1988;8(2):169-175.

66. Berglund B, Nordström G, Hag-berg C, Mattiasson AC: Foot pain and disability in individuals with Ehlers-Danlos syndrome (EDS): Impact on daily life activities. Disabil Rehabil 2005;27(4):164-169.

67. Lindsey JM, Michelson JD, MacWil-liams BA, Sponseller PD, Miller NH: The foot in Marfan syndrome: Clinical fi ndings and weight- distribution patterns. J Pediatr Orthop 1998;18(6):755-759.

Documents

Foot and Anklevalgus foot deformity. In cases of collagen disorders, where soft-tissue laxity complicates management, deformity correction may be of higher importance. Overall alignment