Harold Schoenhaus, DPM, FACFAS discusses diagnosis and treatment of the flatfoot deformity in pediatrics and adolescents. Dr Schoenhaus outlines age specific concerns, underlying etiology, co-morbidity, history of orthotic designs and planar control factors. He also discusses the therapeutic merits of extra articular osteotomy, grafts and distraction arthrodesis, and presents case studies.
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Harold Schoenhaus, DPM
Surgical Editor for PRESENT e-Learning
Penn-Presbyterian Medical Center
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Male Speaker: At the end that brings to light a thought and that is I always felt that we have a tendency of trying to correct everything on the table, osseous, soft tissue, whatever, block things so that when we walk out of the OR, everything is perfect. Recognizing that functional adaptation will take place, certainly in the children, pediatric population. There are times where you can simply isolate a gastroc or do a TAL and do nothing else than control the patient with orthotics and watch the change that’ll take place by eliminating the deforming force. In any event, the last 45 minutes or 40 minutes, I will share a couple of thoughts with you that I have on pediatric flatfoot considering again the amount of time that I've had in treating them from a number of different directions, both conservative as well as surgical. I'm going to start on the slow side going on the use of orthotics, heel stabilizers for the management of this pediatric flatfoot deformity or adolescent, recognizing that there are times and in order to get that arch, you better release or eliminate the deforming force which may be equinus. So let’s take a look at orthotics. Certainly we talk a lot about them. There's been a ton of articles written about orthotics. Our evidence-base medicine states a long-term followups or comparative studies of people with orthotics and without lacks a lot of information and certainly substance. But from an anecdotal standpoint, what do we think it accomplishes? Maintain stability of the foot or obtain stability, allow for normal development, neutralize deforming forces, allow for normal motion, support a deformity which relates back to Root orthopedics, control the compensation and then control the foot in three planes. Now that sounds pretty good. That is a lot of work for an orthotic to do. In my opinion, in order to obtain good functional control of an orthotic, you're going to need a good neutral position cast. In the pediatric population, a DPOC is critical. I like an offset calcaneal position, in other words, put it in some varus. Long phalanges, to the first and fifth metatarsal neck and allow for independent medial and lateral column function and rearfoot posting. To me, these are critical factors in what we have termed an uncontrollable or a severe hypermobile flatfoot that we’re going to use some type of an orthotic in an attempt to control it. The orthotic itself in my opinion can be both therapeutic and diagnostic. If it works, eliminate some of the symptoms that kids might present with, which is rare and few. But it certainly can attribute to control of symptoms, prevent additional deformity, identify uncontrollable forces, as the equinus. The patient that can’t tolerate this type of orthotic is showing you that if you want to change the shape of my arch, you're going to have to eliminate the deforming force and determine the need for surgical intervention and certainly in tarsal coalition. So we’re looking again in the diagnostic part, provide support to allow function and adaptation, allow for reduction of deformity, primarily forefoot supinatus and allow for normal phasic activity of muscle. What kind of symptoms do we see in these kids that we’re trying to alleviate? Growing pains? Is there such a thing or is it overactivity of muscle trying to support or maintain an arch, awkward gait, abducted gait, clumsiness, calcaneal apophysitis, truly associated with poor shock absorption mechanisms, the pressure of the arch, it’s a traction compression environment, the apophyses, pulling of the Achilles up, the fascia from underneath. And in the pediatric population, they are continuous structure, the adult separates the fascia from the Achilles. Maintain positions postoperatively, that’s a nice thing to be able to do with an orthotic and prevent recurrence of deformity. So let’s take a little look at these youngsters who have hyperpronation syndrome, abduction of the foot and the question certainly arises, should you do anything with this kid. It’s asymptomatic. So three or a four-year-old youngster, now hyperpronating, you're seeing the abduction component and you say, don’t worry, they're going to outgrow it. I never understood why people think you're going to outgrow a deformity that has significant deforming forces both active and reactive taking place and you think this thing is going to spring back.
Part of that probably goes to the fact that in early development, the kids one-year-old up to two years old and you see this fat foot and it’s flat, you got to differentiate from the fat flatfoot, from the flatfoot that’s fat, and has the combination. If you watch the foot that’s maturing, you say, I knew they would develop an arch, sure. As the osseous structures become more involved and the fat, that baby fat starts to dissipate, you now see the true architecture. But don’t sit and wait thinking that a flatfoot springing back to a normal foot. So here what that is, fat flatfoot versus the flat fat foot. That’s my tongue twister of the day. Take a look at the gait. When you see a youngster walking who is hyperpronating, we already see changes that are not good. You see the prominence of the medial side where the talar head bulges pulling the navicular with it, you see an abduction of the forefoot relative to the line of progression and you will even see the first ray showing elevation or hypermobility in gait. And as we’re looking at it from the back, the more involve foot that’s flattening you see this abducted calcaneus which appears to be everted and look at the foot as the arch comes off the ground, you don’t see this resupination taking place. This is already showing us this foot is not going to readapt to a more supinated position. Our objective findings, loss of the arch in the sagittal plane, transposition, talar escape, Helbing sign, frontal or transverse and I suggest it’s primarily transverse and forefoot supinatus. When I see supinatus, I know I've got a compensatory problem that has to be handled. Symptoms, pain, local, within the arch or heel, postural problems. These kids can show knock-knee condition. They may have problems with their legs, low back or ankle, awkward clumsiness of gait, fatigue and associated pathology, which is HAV. Why do we develop juvenile hallux abducto valgus, talk about that. I'm not going to bother you with all these angles. You’ve seen angles and dangles all day with x-ray. It’s very interesting that when you look at a lateral x-ray, one of the things we always talk about is the CYMA line and if we look at an anterior break or if it’s normal or whatever, that’s suggestive of hyperpronation. Yet you will see foot types that have a normal CYMA line that are severely pronated. Those are the foot types that are transverse plane dominant, secondary to abnormal torsion abnormalities. Certainly obliteration of the sinus tarsi, but in youngsters, you don’t have that triangular portion of talus, the [indecipherable] [08:09] of that bone is the cartilage which is radiolucent. So you still see some evidence of a sinus tarsi. Then of course looking at all these things, I'm not going to bother you with those. This is a thing that's very interesting. What happens in the transverse plane around the ball and socket talonavicular joint. As one recognizes, the talonavicular joint’s ball socket and it’s almost like the entire foot moves in the transverse plane around the body of the talus and the head of the talus. The calcaneal cuboid remains stable in certain foot types, and in others we’ll see calcaneal cuboid transverse plane subluxation and that’s why we do evidence procedures. So the ball and socket joint. If you take a transection through the midtarsal joint, you see what happens as the calcaneus everts, it does rotate a little bit and abducts away from the talus as you pronate allowing the talus to drop down because it’s lost its osseous support which is the sustentaculum tali and now it’s relying on spring ligament and soft tissues of the medial arch. When one looks at the genetics or hereditary and you look at a mother with a bunion and the daughter who's got a foot that’s pronating but doesn’t have the bunion yet, give it a little time. We will watch the progression of hallux abducto valgus which occurs in my opinion secondary to the transverse plane dominant pronation deformities. I did wrote an article on this about 15 years ago identifying that if you look at the long axis of the cuboid and the long axis of the proximal phalanx of the hallux, they are often parallel.
Here's a good example of juvenile HAV where we see pronation occurring in the transverse plane, the adductor pulls the hallux and the sesamoid apparatus laterally as the forefoot abducts. This is hyperpronation in the transverse plane leading to the development of hypermobile first ray and HAV deformity. I think it’s clearly identifies for the association of hallux abducto valgus and hyperpronation syndrome. I'm not going to bother you with all these. When we go into orthotic management control, in order to control that foot, you’ve got to control it in all planes. The standard Root orthotic that had a rearfoot post or a forefoot post without phalanges and without a deep heel seat allows the foot to slide off the orthotic like you're on a sliding pad or sliding board. Not effective. You look historically of other types of orthotics, Whitman plates and Robert plates, plates with a calcaneal clip on it to stop the calcaneus from everting, we didn’t need about eversion, it’s transverse plane we’re trying to stop. When I say triplanar control in an orthotic, I specifically mean that, which is going to prevent this talar escape, prevent the plantarflexion of the talus, calcaneal eversion and/or abduction and calcaneonavicular cuboid abduction stability. That’s when I develop along with my prior partner what was called a dynamic stabilizing inner sole system, which had the components, very similar to UCBL, but I extended it and made it even further controlling, deep heal seat, five degree offset copula, long medial and lateral phalanges to the necks of the metatarsals and independent medial and lateral column function. That's what it looked like. And it's taken from a neutral position cast. We take the foot that’s pronating and this is the disaster that we see when we use standard orthotics even with the rearfoot post with the lateral clip on the calcaneus, look what the forefoot is doing, abducting directly off the rest of the orthotic because of the ball and socket talonavicular joint. So here we take the orthotic, extend the phalanges all the way down, nice copula for the heel and now we've controlled the arch, calcaneus, calcaneocuboid articulation and TN joint in all planes. That is a controlling device that now becomes diagnostic and therapeutic. The child who cannot tolerate this, you now are at the point where you decide they're either going to live with the problem or you're going to recommend some form of intervention and there would be a prime example of doing a TAL or a gastroc along with this type of orthotic device. Here we could take a look at the difference with an x-ray of the youngster wearing the DSIS that controlling device and you see the portion on the right side showing a talocalcaneal diversion of 23 degrees, look at even the IM angle of 15 and you put them in this insert and you reduce the talocalcaneal diversions and the IM angle, which I found to be remarkable that we could reduce the IM angle by controlling the posture and the position of the foot, reducing that transverse plane dominance that I just talked about. Why don’t we go to that next one? When I talk about an orthotic, we use that term in my opinion too loosely, too generically. Everything you see is an orthotic, which is probably true, by term, I don't know what that definition truly means. Some of them are used very effectively as ice scrapers in Philadelphia. If my patients come in, I say, what is this? So don’t throw it away, the next snow storm you'll use it to clean off your windshield. Alright, we’re going to go to the next portion I believe which we assume that the axis of the subtalar joint is consistent, 16 degrees deviated from the sagittal, 42 from the transverse frontal planes. Where did that come from? What was the foot type that was looked upon to determine where that axis is. That axis in my opinion is variable. The youngster that is going to hyperpronate because of deforming force has a shift in the axis. The axis changes.
Just as we talk about an active first MPJ changing as the joint goes through motion. Changing position will change the posture and the position of that axis. But we could talk more about that. Alright, let’s take a look at a couple of surgical interventions that I have found to be necessary and effective. I will tell you my philosophy on flatfoot is very simple. If I can accomplish extraarticular procedures, which include arthroereisis, Evans, Koutsogiannis and Cotton, I'm a happy camper because I will not invade or violate joints. Once we go beyond adolescence, you're going to have to go into adult populations and we start going in to fusions, we significantly alter function of the foot and it won’t only have impact on the foot itself, but it will have impact at the ankle, knee and low back. The younger I can intervene if necessary by doing extraarticular osteotomies, that’s when I would like to attack the deformity. We’re now looking at uncontrollable hypermobile flatfoot. I threw in a PTTD stage 3 in this forefoot supinatus and equinus. I see too many surgeons identifying that a forefoot supinatus is present, then you're doing an Evans or a Koutsogiannis, that you need to do a Cotton procedure to plantarflex the first ray. If you’ve selected the patient appropriately, an Evans procedure will reduce forefoot supinatus and I’ll talk about that when we look at it. Goals of surgery, relocate the midtarsal subluxation, rotate the midfoot at the ball and socket talonavicular joint recognizing the midtarsal joint has two axes, a longitudinal and the oblique. The longitudinal gives me this supination around the TN joint, the supinatus component. The oblique axis gives you transverse and sagittal plan deformation. You want to increase tension on the peroneus longus. The procedure that we talk about that does that is the Evans, so very strong procedure and derotate the long axis which I just said at the midtarsal joint. So my criteria? Uncontrollable hypermobile flatfoot. They pass the test of the proper orthotic. They are painful. Or they’ve been corrected with orthotics by someone else and now they're finally coming to me for surgical intervention. They have a painful flatfoot usually. There is equinus. It’s transverse plane domination supinatus and no DJD of the associated joints. Ideal age, 8 to 14 and usually in the presents of talar escape. We’re looking at this apparent calcaneal eversion that we've been talking about that has as much component of abduction and very little eversion. The transverse plan component where we see those extra toes sticking out as everything moves in a lateral direction. If I'm looking at cuboid abduction and Guido wrote an article a number of years ago talking about this x-ray finding of cuboid abduction, it is a transposition that I need to change and swing the entire forefoot back in front of the talonavicular articulation. Now the Evans calcaneal osteotomy is designed to be performed one to one and a half centimeters proximal to the CC joint. Some people recommend doing attack the joint itself as an extension type of arthrodesis done in the adult population more than the child. The actual Evans, you can use interpositional grafts when I first started doing them, we were using bone bank bone, you could use femoral head. You could take bone from the calcaneus or we get in to the orthobiologics such as Cancello-Pure or biofoam wedges. The incisional planning is kind of simple. You can make a transverse or I should say vertical incision or you can make a longitudinal incision. Some of these is determined by what you're going to do with the actual plug that you're putting in the calcaneus. Are you going to hold it in place with a bone plate which all of a sudden is very popular today, which is going to require more exposure or you're just pushing this plug into the calcaneus to transpose the forefoot. So you're going down, you gut through the calcaneus and then you need to open it up.
There are different clamps you can use. This was a navicular clamp which opens the joint, the bone very nicely. It gives you access for the bone graft to go in and you could see there's the bone graft being shaped and bone being placed in. I will tell you that I no longer use bone. When I'm doing this procedure, my technique of choice is usually actually titanium plug which is something I’ll show you. But in essence what you’ve accomplished is a transposition of the forefoot on the rearfoot so we now look talonavicular congruity. We’re back in the cap and do not overcorrect. I always want that foot to be able to pronate a little bit. In addition, by moving the forefoot over and lengthening the lateral column, we are putting increased tension on the peroneus longus. The benefit of increased tension on the peroneus longus is it derotates the medial column. It pulls down the forefoot. Now on the table, you may not appreciate that active component from the peroneus longus. Patient is asleep. Wait for that patient to begin to ambulate and allow the peroneus longus to function with a rearfoot maintained in vertical or slight supination and it has plenty of ability now to derotate the medial column without having to do a Cotton osteotomy and yet there are times I do Cotton osteotomies, more times than not when the residents try to talk me into doing it. Early stages when I started doing Evans, one of the things that I found very quickly was I didn’t like all of the lateral views and I'm sure anybody in here who has done this shares this experience with me. When you look at the x-ray overall you say, well, you did a great job. You relocated the talonavicular articulation, the CIA is increased, the talar declination angle is improved. But look at the sinus tarsi. What do I have in there? I could see the bone graft and the distal aspect of the calcaneus has dorsiflexed. It’s actually moved up. Now I could say, that’s alright, that’s a new type of sinus tarsi plug that I'm putting in there. But I'm pointing a fact on x-ray it looks worse than it is functionally but I went back and said, wait a minute. This has to be an intraoperative complication. Never ever dissect the ligaments off the calcaneal cuboid joint. You don’t need that exposure. Secondly, prior to me doing any osteotomy of the calcaneus now, I put a wire right through the cuboid into the distal part of the calcaneus to hold its position. Then I do the osteotomy. There's the wire by the way that I've used. Once I've done the osteotomy, if I'm putting it into positional graft or even the titanium plug I’ll show you, you just advance the wire posteriorly and it maintains everything aligned in position until that graft totally is incorporated. Here's another example. This is a great clamp to open up the calcaneal osteotomy. One of the difficulties I have found early on is you make this cut, you try to open it up and then you're trying to jam a piece of bone in or a graft in a you have difficulty doing it. This little clamp puts a lot of pressure on it. It also maintains the position of the distal calcaneus that peroneal tendons are pulled down and this was the graft that I use now. This is actually a product from one of the companies that you actually have a lollipop of different sizes in width and height to put in to the osteotomy and then take an x-ray and see whether you're satisfied with the amount of correction you’ve obtained. To me I added titanium. Once you’ve selected the appropriate size, there's the implant in place, very stable. It actually has an open space in the middle. So if I wanted to put that pin from the cuboid through, I could easily do that. There is the plug in place. There are times when I’ll do a combination osteotomy with their significant transposition of the calcaneus, this is the case where I do a Koutsogiannis, which is the offset osteotomy to move the calcaneus. So I want to medialize it, get it back underneath the tibia and talus so it’s going to support the vertical position. So there are times when I’ll do a combination deformity.
You could see on this lateral view where the distal cuboid is pretty much in line, this one’s a little elevated compared to the calcaneus. There's a combination of the Koutsogiannis with an offset plate and the plug that again that's a little high for my liking. There's another one of an isolated Evans. Here's a good shot of the lollipop. Some people recommend putting plates and I have used plates over the graft that you're putting on the calcaneus and it does a couple of things. One it helps hold the graft in place. Not that I've ever seen one slip out. There's so much tension, it’s held in place very well by the peroneal tendons. However, that transposition that we see in the vertical direction where the distal cube calcaneus goes up, if you put a plate on it, it will hold the calcaneus in exact alignment. The only problem is how much soft tissue sits over the lateral aspect of the calcaneus. This plate becomes a little too bulky and can be a cause of shoe irritation and then you got to go back in as a second procedure and take the plate off. Here's an example of we’re looking for places to put plates now. I think probably one of the best places to put a plate is on your car, the license plate. Now we got plates going on every darn thing possible. Use them in the appropriate places and they are the most effective things you're going to use. But too often, we go the other direction. There's an example of distraction arthrodesis. If you wanted to do it at the calcaneocuboid articulation, this is in a little bit older patient that had degenerative changes and we went right into the CC joint to get our transposition and then put a big plate over it. You don’t only have to use plates by the way. I don’t care what you use to move the calcaneus over to transpose if you're doing a Koutsogiannis, I use headless screws, I use anything that will hold its position and the calcaneus heals unbelievably fast. Here's other plates that we use for this type of procedures. That is a beautiful position right there. They have plates now. I won’t mention any company’s names, but there are plates now that have a prominence within the plate itself that’s the exact millimeters you want to open up the calcaneus. Then if you want to backfill it, you can. So things have gotten pretty interesting. There's one of those plates and here's a Koutsogiannis with a screw. There's a good graphic demonstration of a plate with about an 8 or 10 millimeter wedge that’s in there, and then you just backfill the rest of the calcaneus with bone. Adjunctive procedures, this is the one I said I really don’t like to do. That’s that beautiful Cotton. It’s a simple procedure by the way, but I'm not too keen on it. Here's the Koutsogiannis in detail. This is an interesting and easy procedure to do. If I'm doing a Kouts in addition to an Evans, I use a curvilinear incision. I do both procedures through the same incision. As I said, I don’t care what type of fixation you want to use on those. The object is to get the calcaneus out of the abducted position into correct one. I do like tendo-Achilles lengthenings and/or gastrocs. I did a study many, many, many years ago showing the difference of the anatomy of the gastroc versus the soleus. I'm going to talk a little bit about that I think in the Charcot talk in another day or two as to TAL when and when not to, and how important and influence this tendon is in our sagittal plane deformities in the foot. I do like a double incision approach on TALs. It’s interesting I've heard people say, oh, I stay away from TALs because you weaken the tendon too much, you could create a calcaneal gait. I've been doing TALs for 41 years and have not seen those complications, and I do a lot of TALs. I think it’s all a matter of how you do things. I don’t want to bore you any more than that. There's the combination. That's the incision on it. I will give you a little suggestion, a little pearl when you're doing a Koutsogiannis.
When you make your cuts, you smooth tooth laminar spreaders to open it up, allow the soft tissues at the medial side to relax, and then you're going to be able to move it over without any difficulty. So you just take a couple of minutes, allow that incision, that area to be open and then you slide it over. Here's an example of an offset plate for a Koutsogiannis. Until you get an exact amount of millimeters that you want to displace it. Complications, nonunion, that’s a very rare complication in the pediatric or adolescent in the calcaneus. Displacement of the graft, no question. The care is to not overcorrect dramatically. The tendency as I said earlier in this talk that we have to make it perfect on the table. To me, perfect is if that foot has to pronate a little bit, that’s okay. That I can control if I need to use an orthotic. But functionally, a pronating foot that’s mildly pronating is far better than a fixed supinated position.