Section: New Board Review Category: Surgery

Uncontrollable Hypermobile Flatfoot

Harold Schoenhaus, DPM

Harold Schoenhaus, DPM discusses the etiology of hypermobile flatfoot, indications for osseous versus soft tissue procedures, as well as the role of equinus in the development of flatfoot.

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Goals and Objectives
  1. Describe the etiology of hypermobile flatfoot
  2. Describe indications for osseous versus soft tissue procedures
  3. Review the role of equinus flatfoot
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  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Speaker: I want to give you a few thoughts that I have cultivated for 46 years of being in practice and dealing with this condition called uncontrollable hypermobile flatfoot. And this can occur within any age group. Obviously, in the pediatric population, we have a tendency of identifying hypermobile flatfoot and what it can lead to and therefore deal with it on a certain level. Right into the adult who might have a posterior tibial dysfunction component, which can also be hypermobile, uncontrollable. Unfortunately, in the adult population we often see associated changes at adjacent joints, which make it somewhat more advanced and a little bit more involved if a surgical approach is going to be entertained. So what is this really mean uncontrollable? As my disclosure information, let me step back a minute. We have to share with you our learning objectives, so we are going to understand etiology of hypermobile flatfoot, described indications for osseous versus soft tissue procedures and understand the role of equinus. So uncontrollable implies that we have tried something that is not improving the posture position symptoms or signs that are developing as a result of this condition. So that might include shoe gear and certainly orthotic management and control. So once we have tried those things and that foot is not responsive, then we categorize it as uncontrollable. In the adult with posterior tibial dysfunction, it may include leg bracing, Arizona bracing.

    [02:04]

    Something that's going to stabilize the lower extremity. Unfortunately, patients don't enjoy wearing those cumbersome devices because it's annoying every day to put that on and obviously it doesn't do anything to really treat the underlying condition. But you can see by the way the effect of hyperpronation even in the pediatric population with significant talar bulging that you see medially, loss of the longitudinal arch, elevation of the first metatarsal, which will lead to hypermobility of the first ray and the concomitant problems associated with it. I have always found that interesting to hear people say, oh they are going to outgrow that flatfoot. I don't know how you outgrow a flatfoot unless you are dealing a population one and half and two years old and that flatfoot is a fat foot that looks flat. This is a more advanced portion now. Three years old, four years old, right through geriatric population. That arch is not springing back into shape because of the forces that are coming through that foot that are already in the deforming nature. Equinus is not going to release itself from harming the foot and creating this major change across the joints. So the symptoms that you typically see with these hypermobile flatfeet; groin pains, leg cramps, sedentary tendon sheath, arch pain, heel pain, postural symptoms, fatigue easily, children who don't want to wear shoes, can't tolerate neutral position orthoses, shin splints, plantar fasciitis, it goes on and on and on. I think the recognition that a flatfoot is not a healthy foot.

    [04:02]

    And what it will lead to and be associated with are something we have grown to identify and recognize that you just don't leave that flatfoot alone. You see clinical signs of poor posture, break downs of shoes, loss of the arch, propulsive gait, early heel lift, abduction of forefoot on rear foot, abnormal calcaneal position, Helbing's sign. What does that mean Helbing sign? Forefoot changes, the development of HAV, digital contractures, lesions, tylomas, keratomas. So our job is really to deal with this form of deformity and the deforming forces that lead to this breakdown in a way that we feel will be most effective. This is an orthosis to me, which is probably the most controlling of any device where it has a DPL cup and long lateral phalanges that go down to the next of the first and fifth metatarsal with the rear foot being held neutral. Now, you have a controlling orthotic. If you put a foot that's hypermobile on a flattened type of shell, it's going to slide right off. That shell will not be controlling and the root concept of just using a rear foot post and forefoot post, which I grew up with in early practice is also ineffective with the tri-planar component of deformity that we visualize with this uncontrollable foot. Arthroereisis is still a procedure, which I happen to love. Soft tissue extra-articular, very easy to perform with maximum effect and benefit to the patient.

    [06:02]

    No osteotomies. If you have to do a concomitant tendo-Achilles lengthening, we do it. God gave podiatry the sinus tarsi. It's the podiatric canal into which we can put something and reposition this talocalcaneal subluxation, which is taking place with severe hyperpronation. So it's like you going inside the foot to do what needs to be done to re-establish the position and the earlier you do it, the better off we are. Functional adaptation takes place in the growing population. The adult population doesn't undergo functional adaptation quite as readily. Instead, we undergo degenerative changes of adjacent joints. So we are looking at an extra-articular reversible, ease of implantation, ease of removal if you have to and early weightbearing. All we are trying to do is relocate the position of the talus on the calcaneus and now hold it in that position. So you are realigning the joint, direct influence of both axes of the midtarsal as well as first ray repositioning but allow normal motion to continue. You are not trying to stop all motion, just the excessive. So here we are looking at foot where you could see the talocalcaneal relationship is flattened upon the top right. You re-position the foot. It's simple to just put it back into a neutral position, the canal opens. Now, fill the canal. That holds the position of the talus relative to the calcaneus and the rest of the forefoot winds and unwinds around that position.

    [08:04]

    So certainly we want to take that foot from a fully compensated position whether it's secondary to forefoot varus, internal torques, primary equinus, and get it back around the functional point. And it's amazing how bad a foot might look but as long as it has a component of hypermobility to it that you could fill very easy clinically, that foot is a candidate for arthroereisis. And I will talk a little bit later about the ones that now have to advance into osteotomies. So we know all the x-ray criteria and I look at it and I review that carefully with parents and the patient for their understanding of what we are trying to accomplish. On this lateral review, look at the supreme position of all the lesser metatarsals. That's passing the [indecipherable] [00:09:01] forefoot supinatus. That's the foot that you put it in neutral position, look at the forefoot-to-rear foot relationship and go wow, how it can be inverted by that many degrees and you are certainly not going to put a forefoot post of 10 degrees or 15 degrees in an orthotic. That's the problems that occur secondary to the changes in the rear foot. So you can certainly do all the things that we have talked about radiographically to help in evaluating planes of deformity. Now here is an example of dorsal plantar view where we see a significant amount of cuboid abduction. That to me is a little bit of red flag that I might have to consider doing an osseous procedure to lengthen the lateral column, the Evans osteotomy and I will show you that later on.

    [10:01]

    But you recognized that the TN joint's ball and socket and as that uncovers the head of the talus, the whole forefoot moving in a lateral direction. If it keeps going, you have significant abduction visible on an x-ray. So I look at these things very carefully. You can also see the hypermobility of the first ray in the development of HAV deformity starting on that young foot. I wrote an article about 20 years ago on the etiology of the bunion associating it with hypermobility of the first ray and hyperpronation syndrome. Adjunctive procedures along with arthroereisis include tendo-Achilles lengthening, gastroc lengthening, Kidner procedures. Everything extra-osseous and I don't care how you do your TALs or your gastroc, this is my preferred approach almost like a percutaneous cut. I usually do TALs and not isolate just the gastroc. But there are many surgeons who will just do gastroc lengthening. Materials for the sinus tarsi, I have used everything that man knows or that has been man-made. A few things I have also made that goes into the canal. But interestingly I started with [indecipherable] [00:11:38] polypropylene and then the metallic insertable materials even ones that can be absorbed. So it's amazing how many different implants are available for our use. Once the determination is made that an arthroereisis is indicated, the procedure itself is very simple to perform.

    [12:04]

    It actually is so simple, it takes you about 5 to 10 minutes and that's when you don't have any experience doing it. The canal is easily palpable. We go right down over the canal and you could see the alignment of the ligamentous structures over the canal, maintain that alignment, take a rongeur, clean out the fibrofatty plug. You have re-positioned the foot. It's flexible and then you are going to implant your device and then close over that same canal with suture. And there is different techniques you can use. Some people use guidewires so you know the direction of the canal, the direction of the implant as you insert it and here is fluoro guide showing us that. I rarely do this by the way. I just don't find it necessary. Once you have done a number of these, you can feel the canal very easily. There is only one way you can go in that canal and just put your finger in there, your little finger and you feel it very nicely. And then put varying sizes of plug in the canal, determine the appropriate size, do not over correct this. You can actually supinate a foot too much putting an arthroereisis plug in. So I am very careful. I pronate the foot to its maximum when the plug is in place, palpate the talonavicular joint medially. As long as I have little over hang or little over prominence to the talar head, I am happy. If you over correct, you have got a patient walking on the outside part of the foot supinated, uncomfortable, not very functional. So I would rather err on the side of the little extra pronation.

    [14:00]

    One of the problems with plugs through the years is that the tendon [indecipherable] [00:14:03] extrusion. The other problem is incompatibility as far as patient not tolerating metallic device between bone, which is the inferior aspect of the talar neck and obviously the canal into which the plug is sitting, which is the calcaneus. So that can be uncomfortable. And here we are in the canal. I do not recommend going through the interosseous talocalcaneal ligament on the medial side of the sinus tarsi. That's where the neurovascular bundle is going to the body of the talus. So I do not violate that space. It's not necessary. Here we are evaluating the range of motion. Here is a plug in place with repositioning. You now eliminated the subluxation, the peritalar subluxation, which is occurring with this uncontrollable hypermobile flatfoot. So now we have got this foot back into a functional position. If you want to place an orthotic back in the shoe, you might not have been able to get as much control as you want. This foot is now controllable and can tolerate a neutral position orthotic. And we can see the difference when you look at x-ray from one that is severely pronated to the repositioning of this foot. The talus back up on the calcaneus. In my mind, the earlier I can do this for a patient, the better it's going to be because the functional adaptation will take place over time.

    [16:00]

    Usually, in the vicinity of six months to three years, depending on the age when you perform the procedure will determine at what point the plug that you put in the sinus tarsi is no longer necessary. It's done its job. You eliminated the deforming force as such as equinus by lengthening the Achilles. Now, the foot is put back into position, functional adaptation of bone occurs at the joint level as well as all of the soft tissues. All the major tendons now passing beyond the joint re-adapt to the new functional position and you will have an arch for life. That to me is beautiful. To tell the patient you are going to have wear orthotics for the rest of your life when you are six years old, what's the chance that's going to happen. Adults don't wear them when they need them. So if we can correct deformity, why not do it? And there is the change in the position. Look at the reduction in supinatus. Look at the film on the top where the supreme position of all the metatarsal is. Look at on the bottom, we can now differentiate the metatarsals. That's the beauty of the relocation that you are doing in the rear foot simply by putting the plug in and eliminate the deforming force. Let me go back to them. Calcaneal position is important. We talk about a Helbing's sign, which is a bowing of the Achilles tendon, which we have always talked about. It develops because the calcaneus is everting and it looks like the calcaneus is everting relative to the leg. However, I will contend and share with you the fact that more times than not we will get a Helbing's sign when the calcaneus simply displaces laterally.

    [18:05]

    Not sitting underneath the position of the leg that it needs to, the foot has shifted laterally. So I would see all of this excess out here. You want to re-position everything so that it lines up once again. So it doesn't have to be everted, it could be abducted and that's when you take calcaneal axial views to determine that. Again postoperatively, if you want to go back into this stabilizing insert, we haven't lost anything in a way of finances to a parent who says, well, you are going to try this orthotics. It's going to cost me $400 to $500. What happens after if it doesn't work? Then you have to operate. I just lost that money. Well, you really didn't because I am going to put the patient back in this insert to act as an external brace during the healing process and a functional adaptation, which will occur. There is other materials that I have experimented with for the sinus tarsi and I have actually come up with one, which I think is most effective because metal has been problematic, but we will be coming out with that shortly. Contraindications to arthroereisis, rigid flatfoot. Except if I am going a CN bar and I resected and the foot comes back into a better position, I will put a plug in the sinus tarsi. The other tarsal coalitions, not effective. If you have degenerative joint disease as we see in an older population, not the perfect procedure to use and certainly if there is perineal spasticity, which immediately when I see that is usually associated with a tarsal coalition.

    [20:01]

    You can over correct by the way or underestimate the amount of correction. When you look at dorsal plantar view, when you see adductus of the forefoot on the rear foot even with the foot hyperpronated, can you imagine what is going to happen when you re-position the relationship of forefoot to rear foot? It's going to adduct more. Supination has a component of adduction. So you can put a plug in the sinus tarsi, improve the shape of the arch in a position and now the kid would toes in dramatically, not good. That you should evaluate preoperatively with your dorsal plantar view and I often take the foot and put it in a neutral position and shoot the dorsal plantar view and compare it until fully compensated position to make sure I don't have an underlying adductus even if it's borderline. On our long-term results, perceptible change in the arch, reduction of forefoot lateral transposition, reduction of supinatus, improvement in posture, reduction or elimination of postoperative control and maintain tension and stretch on lengthened Achilles by increasing the height of the arch. These are avoidable complications. Adducted gait that foot that wants to toe in. Supinated foot, you have used too large of a piece in the canal. Unstable gait, you could over lengthen in Achilles tendon or the rigid foot. Extra-articular procedures are next step, more advanced approach in a treatment of flatfoot, still in the uncontrollable hypermobile state where we look at now at Evans procedures, Kidner's.

    [22:03]

    The arthroereisis without or without Achilles lengthening, Cotton, calcaneal displacement osteotomies. So when I now look at functional flatfoot surgery, it's still extra-articular. That's important to me. I try to avoid fusing joints and the ones that I have used most effectively are the Evans Cotton with a TAL and then Koutsogiannis, which is calcaneal displacement osteotomy. So interestingly, a lot of your preoperative criteria are the same but it's more advanced deformity that you are seeing. Still no DJD of the adjacent joints. Ideal age 8 to 14 for these procedures. Pretty severe flattening of these feet, one on your left is obviously significantly hypermobile with what appears to be a lot of calcaneal eversion. There'd still be a component, however, of transverse plane position, forefoot abducted. Your x-rays often look similar to what we saw before but now the child is a little older. So with little bit more advance of age and depending upon the extent of deformity, you are now looking at osseous procedures. Here is that abduction of the cuboid relative to the calcaneus suggestive of significant lateral displacement. That’s not going to swing back into position by just simply putting a plug in the sinus tarsi.

    [24:00]

    So we are seeing all of the poor effect of hyperpronation. So when we look at planal dominance because you as a surgeon needs to determine what planes do you necessarily have to address. Sagittal plane considering Cotton osteotomies, so open osteotomy of the medial cuneiform to drop down the first ray so you can get a retrograde effect on the rear foot. TAL arthroereisis. In the transverse plane, we are looking at Evans osteotomies. Evans is a powerful procedure. You just have to be careful how you perform it in the structures that are passing right over the site where you are going to perform this osteotomy. So here we are. The cut is by the lateral calcaneal wall down to the CC joint. Do not open the CC joint. You don't want any dislocation component of the distal portion of the calcaneus. It's almost an area the sinus tarsi, a centimeter, a centimeter and half proximal to the CC joint is usually where you are making this cut and you make this cut straight up and down. Do not take off excessive soft tissue. Do not take off the extensor brevis muscle. You make a cut and we open the osteotomy and now you could see what you are doing is lengthening the lateral column. By lengthening the lateral column, it's shifting the forefoot over medially to cover more of the talar head on the medial side. You can put a wedge in or you could just put a block of bone in and there is also titanium pieces that can be put into the area.

    [26:02]

    Again, do not overcorrect. Once that's in place by the way, you could put a plate over it, you could put a pins through it because there is a little tendency for that to shift postoperatively. The Cotton as I mentioned the medial cuneiform osteotomy, you just make the cut, you put a piece of bone that you carve into shape or you can bone-bank bone now that is wedge shaped and you put it right into the cuneiform. That drops down the first ray. You could see here in this position on this x-ray where the Cotton osteotomy was in fact performed, where the plug of bone is sitting right here in addition to whatever else you are doing. Cotton could be done in conjunction with arthroereisis by the way to drop down the first ray and de-rotate the column. So you could see here where we are getting significant hyperpronation with talar escape, cuboid abduction and how we have realigned this relationship. This foot now becomes functional. Now, take a look here. Here is one of the problems with the Evans. If you are not careful, you can actually dislocate dorsally the distal part of the calcaneus along with your bone graft. So to avoid that once this is in place where it should be you could put a plate over it or pin over it holding it in place. This almost is transposed this into an arthroereisis by the way with an osseous block.

    [28:03]

    Alright, so we have got beautiful relocation. Here is why we are using a simple pin, Kirschner wire or small Steinman pin to hold that bone graft in place by the Evans and then back into an orthotic for control. Koutsogiannis, very powerful procedure, if you identify that the calcaneus is actually abducted. It's not sitting under the talus and both sitting under the tibia. So you have no support. So we take the calcaneus and we are actually going to transpose it. Little bit more involved, I have even done this procedure in addition to an Evans. You make your cut pretty much parallel to the peroneal tendons by the calcaneus. You go right down to the calcaneus and you are going to actually cut across to displace it and you are displacing it more medially after its cut, so it's going to be shifted over. There are plates that are available by some of the companies so that it holds the position. You are usually displacing it a good number of millimeters, probably 8 to 10 be effective. Then you are holding in place with screw fixation. You can use all other kind of things to assist in the healing of these bony osteotomies and processes. You are in cancellous bone. That's the beauty of doing these types of osteotomies. They heal very quickly without any effect on the joints surrounding them. So we can go on and on with these cases and see the beautiful effective performing these types of osteotomies, combination, size of the grafting, all in what you are comfortable in performing.

    [30:09]

    There is a Koutsogiannis again associated with a Cotton. So what I have shared with you pretty much on time by the way is an approach, a thought process of do not allow that patient to walk around with an uncontrollable hypermobile flatfoot and think they are not going to develop problems as they mature and those problems don't only have to be in the foot. Leg cramps, knee pain, development of genu valgum in the adult, low back pain, all related to the foundation of the body, which is called the foot and thank god we know what to do with it. Thank you for your time.



    TAPE ENDS - [31:03]