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POSNA REVIEW ARTICLE

What’s New in Pediatric Flatfoot?


Kathryn Bauer, MD,* Vincent S. Mosca, MD,w and Lewis E. Zionts, MD*

Background: Children with flatfeet are frequently referred to


pediatric orthopaedic clinics. Most of these patients are
C hildren are commonly referred to an orthopaedic
surgeon for evaluation and management of a flatfoot
deformity. We performed a review of the recent literature
asymptomatic and require no treatment. Care must be taken to regarding evaluation and management of pediatric flat-
differentiate patients with flexible flatfeet from those with rigid feet to discuss new findings and suggest areas where fur-
deformity that may have underlying pathology and have need of ther research is needed.
treatment. Rigid flatfeet in infants may be attributable to a
congenital vertical talus (CVT); whereas those in older children
and adolescents may be due to an underlying tarsal coalition. METHODS
We performed a review of the recent literature regarding eval- We searched the PubMed database using the fol-
uation and management of pediatric flatfeet to discuss new lowing terms: pediatric flatfoot, tarsal coalition, and
findings and suggest areas where further research is needed. congenital vertical talus (CVT). We reviewed only papers
Methods: We searched the PubMed database for all papers re- published in English from January 1, 2011 to December
lated to the treatment of pediatric flatfoot, tarsal coalition, and 31, 2014.
CVT published from January 1, 2011 to December 31, 2014,
yielding 85 English language papers. RESULTS
Results: A total of 18 papers contributed new or interesting Eighty-five papers were found. The authors identi-
findings. fied 19 of these papers as having contributed important
Conclusions: The pediatric flexible flatfoot (FFF) remains poorly new findings.
defined, making the understanding, study, and treatment of the
condition extremely difficult. Pediatric FFF is often un-
necessarily treated. There is very little evidence for the efficacy of DISCUSSION
nonsurgical intervention to affect the shape of the foot or to Flexible Flatfoot (FFF)
influence potential long-term disability for children with FFF. For a condition that has been determined to ac-
The treatment of tarsal coalition remains challenging, but short- count for more consultations to pediatric orthopaedic
term and intermediate-term outcome studies are satisfactory, clinics than any other, the pediatric FFF remains poorly
whereas long-term outcome studies are lacking. Management of defined, making the understanding, study, and treatment
the associated flatfoot deformity may be as important as man- of the condition extremely difficult.
agement of the coalition itself. The management of CVT is still In a Cochrane Review, Evans and Rome1 scruti-
evolving; however, early results of less invasive treatment nized the literature on FFF in children in regard to the
methods seem promising. epidemiology, foot development, etiology and associated
Level of Evidence: Level 4—literature review. issues, diagnosis, nonsurgical management, and surgical
Key Words: review, pes planus, flatfoot, tarsal coalition, con- interventions. They concluded that the very definition of a
genital vertical talus flatfoot is debatable. The available prevalence estimates
are limited by variable sampling, assessment measures,
(J Pediatr Orthop 2015;00:000–000) and age groups and, therefore, result in disparate findings.
The authors noted that the literature suggests that the
FFF reduces with age, and that most affected children and
adults are asymptomatic. Joint hypermobility and in-
creased body weight may increase flatfoot prevalence, in-
dependently of age. Furthermore, the review suggested
From the *Department of Orthopaedics, David Geffen School of that the pediatric FFF is often unnecessarily treated, and
Medicine at UCLA, Orthopaedic Institute for Children, Los
Angeles, CA; and wDepartment of Orthopaedics and Sports Medi-
that there is very little evidence for the efficacy of non-
cine, Seattle Children’s Hospital, University of Washington School surgical intervention to affect the shape of the foot or to
of Medicine, Seattle, WA. influence potential long-term disability for children with
None of the authors have received financial support for this study. FFF. The authors note that inexpensive, generic foot
The authors declare no conflicts of interest. orthoses can provide good positional support and relieve
Reprints: Lewis E. Zionts, MD, Orthopaedic Institute for Children, 403
West Adams Boulevard, Los Angeles, CA 90007-2664. E-mail: symptoms in those feet with activity-related pain. Cus-
LZionts@mednet.ucla.edu. tomized foot orthoses should be reserved for children with
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. foot arthritis, unusual foot morphology, or unresponsive

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Bauer et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2015

cases. There is no evidence that supports the use of sur- tarsi to correct alignment of the subtalar joint in children
gical correction of the typically asymptomatic and FFF in with FFF. As reported in the previously highlighted re-
children. Surgery is only indicated at the failure of thor- view by Evans and Rome,1 the indication for this proce-
ough conservative management. dure remains controversial.
A related critical review article from the same in- De Pellegrin et al5 reported an uncontrolled, retro-
stitution2 confirmed that there is very little evidence for spective study of 732 subtalar extra-articular screw ar-
the effectiveness of nonsurgical intervention for pediatric throereisis procedures performed in 485 children between
FFF. All articles reviewed were assessed using the Quality the ages of 5 and 18 years. Only 11% of the patients
Index score, which uses a structured checklist to access reported pain preoperatively. The justification for surgery
the validity of clinical trials. They found only 13 articles, in this study seemed to be the foot shape itself, and the
among the 429 published between 1970 and 2011 on the ease of performing the minimally invasive procedure. Of
efficacy of nonsurgical interventions for pediatric FFF, note is that 2% of the patients reported pain post-
that met the criteria for quality evaluation; and the mean operatively. It is not clear from the manuscript how many
Quality Index score was only 35%. The authors listed a of those patients had pain preoperatively.
number of methodological limitations of the studies, in- Perhaps the most commonly used procedures to
cluding the lack of a control group, inconsistent methods correct an intractably symptomatic FFF are the anterior
of diagnosis, small sample sizes, variable recruitment and posterior calcaneal osteotomies. Moraleda et al6
ages, failure to use valid and reliable outcome measures, compared the calcaneo-cuboid-cuneiform (triple C) os-
and dissimilar follow-up periods. In addition to address- teotomies procedure that was developed at the authors’
ing these shortcomings, the authors recommended that institution, with the calcaneal lengthening osteotomy
future research efforts include longer, prospective follow- (CLO) for the treatment of symptomatic FFF. The study
up studies to allow identification of effective inter- compared 30 feet (21 patients) in the triple C group to 33
ventions. feet (21 patients) in the CLO group. The average follow-
Historically, several authors have reported a greater up for the CLO group was nearly twice that of the triple C
body mass index (BMI) in subjects with FFF. Tenenbaum group (5.3 vs. 2.7 y). The necessary additional osseous
et al3 looked at the relationship between FFF and BMI, and soft tissue procedures of the CLO (CC joint fixation,
body height, and sex in 825,964 generally healthy 16 to medial soft tissue reefing, peroneus brevis lengthening,
19-year-old Israelis who presented to a military recruiting tendo-Achilles lengthening) were only performed between
center for a mandatory comprehensive medical evaluation 18% and 38% of the time. That said, the authors found
since 1998. Acknowledging that the diagnosis of mild and no difference in subjective or objective clinical outcomes
severe pes planus in their study was subjective, they found between the study groups, and the CLO group achieved
a greater prevalence of FFF in males than females. FFF significantly better alignment at the talonavicular joint
was associated with increased BMI and shorter body than the triple C group. The authors acknowledged that
height for all grades of severity and in both sexes. CC joint subluxation could have been a surgical mistake
instead of a fault of the CLO technique and that the
Imaging subluxation did not affect the outcome.
Not all flatfeet are the same. Bourdet et al4 identi-
fied 4 patterns of pes planovalgus in a study of 65 Tarsal Coalition
standing AP and lateral foot radiographs in 35 children A tarsal coalition is often the cause of foot pain in
aged 7 to18 years who were diagnosed with idiopathic or children and adolescents who present with a rigid flatfoot
neurological flatfoot. Subtalar pes planus is characterized deformity. Talocalcaneal (TC) and calcaneonavicular
by marked subtalar valgus and longitudinal sag pre- (CN) are the most common types. These patients are
dominantly at the talonavicular joint. Midtarsal pes typically asymptomatic in early childhood, and generally
planus has marked midtarsal abduction and sag pre- present with activity-related hindfoot and midfoot pain in
dominantly at the cuneonavicular joint without subtalar early adolescence. When the patient is not responsive to
valgus. Mixed pes planus, the most common pattern, nonoperative treatment, surgery may be considered.
combines subtalar valgus, midtarsal abduction, and sag at
both the talonavicular and cuneonavicular joints. Pes Clinical Outcome
planocavus manifests as sag of the medial arch and cavus The long-term outcome of surgically resected coa-
deformity of the lateral arch. The authors concluded that litions is not well established in the literature. Outcomes
their classification system is helpful for the accurate as- are thought to vary with the type and extent of the bar as
sessment of the site(s) of deformity that can be used to well as the amount of subtalar valgus deformity present.
determine the best surgical technique for a symptomatic Mahan et al7 mailed outcome questionnaires to patients
flatfoot, although they have not validated their treatment who had undergone surgical excision of a tarsal coalition.
algorithm. Sixty-three of 101 patients (63.4%) responded at an
average of 4.6 years after surgery. TC coalitions were
Surgical Techniques present in 20 patients; CN coalitions were present in the
The technique of arthroereisis involves the insertion other 43 patients. Five patients (5%) required additional
of a metallic or synthetic implant in the region of the sinus surgery after initial coalition resection. No limitation of

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015 Pediatric Flatfoot

activity due to foot pain was reported by 46 patients review of lateral radiographs of 88 feet in patients with a
(73%). The authors found no difference in the self-re- TC coalition confirmed by CT scan, and 260 patients with
ported outcomes between those treated for a TC and FFF. The authors found that a “true” C-sign (defined as
those treated for a CN coalition. As well, in patients with complete, or having a linear interruption with rarefaction
TC coalitions there was no difference in outcomes be- of the edges) had a prevalence of 41% in cases of TC
tween those with <50% of the posterior facet involved coalition versus only 0.4% of flatfeet. They concluded
compared with those where >50% was involved. that a “true” C-sign indicates the presence of a coalition,
Longer term follow-up was reported by Khoshbin whereas the other types of interrupted C-signs were much
et al8 who retrospectively evaluated 32 tarsal coalition more likely to be related to flatfoot deformity than to a
resections in 24 patients using clinical examination and coalition.
self-reported functional outcome questionnaires. Con-
comitant calcaneal osteotomies were performed in 2 feet. Surgical Techniques
The patients were followed for a mean of 14.4 years after Assessing the adequacy of a TC coalition resection
surgery. The authors reported that the patients had little while in the operating room can be difficult. Kemppainen
pain and few functional limitations. Patients with resected et al11 compared coalition resection in 14 feet using in-
CN and TC coalitions reported similar function and pain traoperative CT scan with 12 feet in which this imaging
on self-reported outcome questionnaires. In contrast to modality was not used. The quality of resection was de-
earlier studies, excellent long-term functional outcomes termined by 2 pediatric orthopaedic surgeons, who were
were found in patients who had TC coalitions involving blinded as to how the coalition resection was performed,
greater than 50% of the posterior facet. As well, patients by comparing preoperative and postoperative CT scans.
in the TC group with >16 degrees of hindfoot valgus and The resection quality was deemed better in the intra-
those with <16 degrees had similar outcomes scores. operative CT group. As well, the use of intraoperative CT
altered surgical decision making in 3 feet (21%). Both
groups showed similar improvement in pain at last fol-
Imaging low-up. Larger, prospective studies would be useful to
As a tarsal coalition can sometimes be cartilaginous show whether improved clinical outcomes can justify the
or fibrous, plain radiographs and computed tomography increased cost and radiation exposure using this imaging
(CT) may not always be definitive. Guignand et al9 de- modality.
scribed a series of 19 feet with a CN coalition in 14 Mosca and Bevan12 retrospectively evaluated 13
children. The authors reported that plain radiographs painful TC coalitions in 8 patients who had undergone a
were not conclusive in 10 feet (53%), and these patients CLO with gastrocnemius or Achilles tendon lengthening
underwent further imaging including either bone scan, for correction of deformity with or without resection of
CT, or magnetic resonance imaging (MRI). The authors the coalition. Five patients underwent isolated CLO due
claimed that bone scan missed the diagnosis in 3 of 7 feet; to large coalitions averaging 89% of the posterior facet.
CT missed the diagnosis in 4 of 11 feet. Twelve feet were One patient with bilateral large coalitions underwent
assessed by MRI that confirmed the diagnosis in all in- concomitant coalition resection and CLO. Two other
stances. The authors concluded that MRI was the most patients had undergone earlier coalition resection and
effective imaging modality to assess CN coalitions. underwent CLO later when pain recurred. The clinical
A C-sign of Lateur may be present on a lateral ra- outcome scores improved in all cases. The authors con-
diograph of the foot in patients who have a TC coalition. cluded that restoring the hindfoot alignment can improve
The C-sign is formed by the medial outline of the talar symptoms in cases of resectable as well as nonresectable
dome, and the posteroinferior outline of the sustentac- TC coalitions with preoperative hindfoot valgus >16
ulum tali (Fig. 1). This line may seem continuous or in- degrees, and that resection of the coalition is not man-
terrupted. Moraleda et al10 performed a retrospective datory to have good results with CLO.
Less invasive methods of coalition resection have
been proposed, including percutaneous and arthroscopic
resection techniques. El Shazly and Abou El Ela13 used a
percutaneous method to resect CN coalitions involving 12
feet in 9 patients. Under C-arm guidance, they used a 4.5-
cannulated drill bit followed by a burr to resect the bar,
followed by placing a rolled Teflon sheet as interposition
material. The patients were followed for a mean of 26.4
months, and showed improved functional outcome. The
authors reported no complications or recurrences at latest
evaluation. Knorr et al14 reported arthroscopic resection
FIGURE 1. The C-sign of Lateur. The sign is a C-shaped line of CN coalitions in 3 children. Two portals were estab-
formed by the medial outline of the talar dome and the in- lished, a viewing portal that is posterior to the antero-
ferior outline of the sustentaculum tali (arrows). Its presence lateral process of the calcaneus and dorsal to the angle of
suggests the presence of a tarsal coalition tarsal coalition. Gissane, and a working portal distal to the calcaneal

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Bauer et al J Pediatr Orthop  Volume 00, Number 00, ’’ 2015

process and lateral to the extensor digitorum longus. yield acceptable results with fewer complications than
They did not clearly state whether any interposition ma- have been reported in the past.
terial was used. Clinical outcome scores for the 3 patients
improved from 58 to 91, and there were no recurrences at
1 year. Quicker recovery and a smaller scar are cited as Cast and Minimally Invasive Surgical Treatment
advantages. Chalayon et al16 reported management of 15 pa-
tients (25 feet) with nonisolated CVT (associated with
Congenital Vertical Talus spina bifida, distal arthrogryposis, and other genetic dis-
A CVT is a rigid flatfoot deformity that presents at orders) who were followed for a minimum of 2 years. The
birth that is characterized by a fixed dorsal dislocation of feet underwent an average of 5 manipulations and casts.
the navicular on the head of the talus. Traditionally, this Talonavicular pinning was performed through a small
deformity was managed by cast applications followed by incision in the talonavicular joint in 5 feet. Selective
extensive soft tissue release. More recently, minimally capsulotomies of the talonavicular joint and anterior
invasive approaches, known as the “Reverse Ponseti” or subtalar joint were performed in 20 feet. All patients had
“Dobbs” technique, have been described (Fig. 2). a percutaneous Achilles tenotomy. Relapse was noted in 5
feet (20%) that required further treatment. No subtalar
Open Surgical Treatment stiffness was noted at latest follow-up evaluation.
Ramanoudjame et al15 evaluated the results of Wright and colleagues17 reported management of 13
midtarsal release and open reduction to manage 22 pa- patients (21 feet) with CVT who were followed for a mean
tients with 31 CVT followed for a mean of 11 years of 36 months (range, 8 to 57 mo). Six of the patients (9
(range, 2 to 21 y). In 9 patients (15 feet) the deformity was feet) had teratologic CVT. They reported a median of 8
isolated. Surgery was performed at a mean age of 33 manipulations and casts to adequately improve the
months (range, 10 to 120 mo). The patients generally alignment of the talonavicular joint. In 7 feet (33%) a
showed good functional results. The authors noted that limited capsulotomy was needed to achieve final reduc-
subtalar motion was reduced, and the medial longitudinal tion. Initial correction was obtained in all. Overall, re-
arch was flat in every case. However, all patients were lapse was seen in 10 feet (48%): 4 of 12 feet (33%) in the
able to wear ordinary shoes. Only 6 feet (19%) showed idiopathic group. None of those with relapse had limited
persistent talonavicular subluxation. Five feet (16%) re- capsulotomy and open reduction. The authors postulated
quired further surgery. No talar avascular necrosis was that including a limited capsulotomy at the initial oper-
seen. This article suggests that surgical management, ation may reduce the risk of relapse.
which may be needed in older patients with CVT or those The upper age limit for successful management of
patients who fail minimally invasive approaches, may CVT using techniques involving minimal surgery is not

FIGURE 2. Minimally-invasive treatment of congenital vertical talus (CVT). A, Lateral radiograph in neutral position. B, Forced
plantarflexion radiograph showing the long axis of the talus does not align with the first metatarsal indicating the presence of a
CVT. C, Force plantarflexion radiograph after 6 manipulations and cast applications. D and E, Appearance after percutaneous
pinning of talonavicular joint. F and G, AP and lateral radiographs taken at age 2 years.

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J Pediatr Orthop  Volume 00, Number 00, ’’ 2015 Pediatric Flatfoot

well established. Aslani et al18 treated 15 feet with CVT in 2. MacKenzie AJ, Rome K, Evans AM. The efficacy of nonsurgical
10 patients whose age ranged from 1 month to 9 years of interventions for pediatric flexible flat foot: a critical review.
J Pediatric Orthop. 2012;32:830–834.
age. Half of the patients had teratologic CVT. They used a 3. Tenenbaum S, Hershkovich O, Gordon B, et al. Flexible pes planus
minimally invasive approach that included serial manipu- in adolescents: body mass index, body height, and gender—an
lation and cast application, limited open reduction of the epidemiological study. Foot Ankle Int. 2013;34:811–817.
talonavicular joint, and Achilles tenotomy. After a mean of 4. Bourdet C, Seringe R, Adamsbaum C, et al. Flatfoot in children and
2 years (18 to 36 mo) they reported pain-free, flexible, and adolescents. Analysis of imaging findings and therapeutic implica-
tions. Orthop Traumatol Surg Res. 2013;99:80–87.
plantigrade feet in all cases, including the feet of 4 patients 5. De Pellegrin M, Moharamzadeh D, Strobl WM, et al. Subtalar
aged 5 to 9 years. Although the follow-up was short, the extra-articular screw arthroereisis (SESA) for the treatment of
authors suggested that older patients with CVT can be flexible flatfoot in children. J Child Orthop. 2014;8:479–487.
managed with a minimally invasive technique. 6. Moraleda L, Salcedo M, Bastrom TP, et al. Comparison of the
calcaneo-cuboid-cuneiform osteotomies and the calcaneal length-
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It is important to differentiate CVT from a marked 7. Mahan ST, Spencer SA, Vezeridis PS, et al. Patient-reported
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Supakul et al19 suggested that there are limitations in J Pediatr Orthop. 2014; [Epub ahead of print].
8. Khoshbin A, Law PW, Caspi L, et al. Long-term functional
interpreting plain radiographs of the foot in infants due to outcomes of resected tarsal coalitions. Foot Ankle Int. 2013;34:
variable ossification patterns of the talus. They described 1370–1375.
the use of ultrasound to help differentiate CVT from 9. Guignand D, Journeau P, Mainard-Simard L, et al. Child
flexible flatfeet in 13 infants below 6 months of age. On calcaneonavicular coalitions: MRI diagnostic value in a 19-case
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10. Moraleda L, Gantsoudes GD, Mubarak SJ. C sign: talocalcaneal
surgery. Advantages of this modality are that it directly coalition or flatfoot deformity? J Pediatr Orthop. 2014;34:
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portable CT scanner for the intraoperative assessment of talocalca-
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The pediatric FFF remains poorly defined, making 12. Mosca VS, Bevan WP. Talocalcaneal tarsal coalitions and the
calcaneal lengthening osteotomy: the role of deformity correction.
the understanding, study, and treatment of the condition J Bone Joint Surg. 2012;94:1584–1594.
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intervention can affect the shape of the foot or influence (Edinb). 2011;21:138–141.
14. Knorr J, Accadbled F, Abid A, et al. Arthroscopic treatment of
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Longer term outcome studies are needed to help confirm
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