Transcript Pediatric Disorders of the Foot”

“Pediatric Disorders of the Foot”
Dr. Donald Kucharzyk
Pediatric Orthopedic Surgeon
The Orthopaedic, Pediatric &
Spine Institute
“Pediatric Disorders of the Foot”
The Ossific Development of the Foot
 Begins in utero
 At birth talus, calcaneus, cuboid,
metatarsals and phalanges are ossified
 The navicular and cunieforms are
cartilaginous
 The cuneiform ossifies between 4 and 20
months
“Pediatric Disorders of the Foot”
The lateral cuneiform ossifies between 4
and 20 months
 The medial cuneiform ossifies at 24
months
 The intermedial cuneiform ossifies at 36
months
 The navicular ossifies between the
second and fifth years of life

“Pediatric Disorders of the Foot”
Standard Radiography
 Radiographs should be obtained
weightbearing or those that can’t
simulated weightbearing
 Initial radiographs include AP and
Lateral
 Forced Dorsiflexion Lateral for talocalcaneo alignment: divergent/convergent
“Pediatric Disorders of the Foot”
Normal Alignment
 Usual angles measured include the AP and
Lateral talocalcaneal angles
 AP angle is 42 degrees (range 27-56) in a
newborn and decreases to 34 degrees by
4 years of age
 Lateral angle decrease from a mean 45
degrees at birth to an average of 33
degrees at 4 years of age
“Pediatric Disorders of the Foot”
Normal Variations
 Many variations of “normal” are seen
especially in the newborn
 Especially when dealing with accessory
bones of the foot
 More than 20% of children have one or
more accessory bones
“Pediatric Disorders of the Foot”
“Os Trigonum”
 Formed from the lateral projection of
the groove in the posterior talus
 The flexor hallucis longus pases through
this groove
 Between 8 and 11 years of age it is two
centers that fuse with the talus in a
year
“Pediatric Disorders of the Foot”
Injury is seen in with forced plantar
flexion
 Sports that require extreme plantar
flexion can predispose patients to injury
 Dancers especially Ballet are prone to
injury to this area
 Treatment includes rest, cast
immobilization and surgical excision of
the ossicle

“Pediatric Disorders of the Foot”
“Accessory Navicular”
 ‘Bauhin’ in 1605 described this condition
 Prevalence is between 14 and 26 percent
 Three types exist: Type I is a small
ossicle, Type II is a 8-12mm ossicle
that extends from the navicular, Type
III is a cornuate navicular remaining
after fusion
“Pediatric Disorders of the Foot”
Pain over an enlarged area at the medial
aspect of the navicular
 Area may be reddened or callused
 Pain aggravated by tight fitting shoes
 Treatment involves soft pads over the
navicular ‘navicular cookie’, UCBL inserts
of associated with pes planovalgus, and
surgical excision…simple excision to
Kidner procedure

“Pediatric Disorders of the Foot”
“Osteochondroses”
Kohler’s Disease
 Osteochodrosis of the tarsal navicular
 Pain about the midfoot with tenderness
and swelling with radiographic changes of
sclerosis, flattening and irregular
lucency of the tarsal navicular
“Pediatric Disorders of the Foot”
Age distribution is between 2 an 7 years
 Treatment involves walking cast
immobilization
 Kohler’s is a self limiting disorder that
in all cases resolves over time

“Pediatric Disorders of the Foot”
Freiberg’s Infarction
 Destructive changes of the second
metatarsal head
 Etiology is thought to be AVN of the
metatarsal head
 Age commonly seen after 13 years of age
 Pain under the second metatarsal head
with limping and decreased activity seen
“Pediatric Disorders of the Foot”
Radiographs reveal a lucency and
collapse with flattening and loss of the
normal shape of the condyles; bone scan
will show increased uptake
 Treatment includes a hard-soled shoe or
short leg walking cast and then a
metatarsal pad
 Surgical excision, curettage and bone
grafting, dorsiflexion osteotomy and
MTP joint debridement have been used

“Pediatric Disorders of the Foot”
“Metatarsus Adductus”
 Forefoot deviation inward relative to the
hindfoot
 Spontaneous active medial deviation of
the foot
 Concave medial border
 Bean shaped appearance of the sole of
the foot
 Separation of the first and second toes
“Pediatric Disorders of the Foot”
Etiology is intrauterine compression
 Associated with torticollis and DDH
 Incidence Wynne-Davies was 1 in 1000
births
 Clinical types: Type I: passive and active
correction fully, Type II: passive
correct limited active correction, Type
III: passive and active correction
limited

“Pediatric Disorders of the Foot”
Treatment involves simple observation in
those that are Type I
 Type II requires stretching exercises by
the parents and perhaps a brace at
night
 Type III requires either serial casting
or a brace full-time and if refractory,
release of the abductor hallucis and
capsulotomy and over the age of 3,
metatarsal osteotomy

“Pediatric Disorders of the Foot”
“Talipes Calcaneovalgus”
 Postural deformity due to intrauterine
compression
 Foot appears hyper-dorsiflexed against
the tibia
 External rotation attitude of the tibia
 Associated with metatarsus adductus on
the opposite side, DDH, and
posteromedial bowing of the tibia
“Pediatric Disorders of the Foot”
Incidence as high as 30 to 50 percent
 Treatment involves gentle stretching
exercises by the parents with
normalization within 3 to 6 months,
resistant feet require serial casting and
AFO braces
 Residual pes planovalgus can be seen in
the older child

“Pediatric Disorders of the Foot”
“Flexible Pes Planovalgus”
 No specific incidence of flatfoot exists
but it is the most common deformity
seen by pediatric orthopaedists
 No clinical or radiographic definition of a
flatfoot
 Reflection of generalized ligamentous
laxity in the foot
“Pediatric Disorders of the Foot”
Radiographic evaluation of the lateral
talo-first metatarsal angle ‘Meary’s’ will
be angled apex plantarward: “Plantar
Sag Sign”
 Differential Diagnosis: tarsal coalition,
congenital vertical talus, talipes
calcaneovalgus, accessory navicular, and
inflammatory conditions

“Pediatric Disorders of the Foot”
Clinically the foot will have an arch with
the foot suspended and collapsed with
weightbearing and hindfoot valgus
 Inversion of the heel will reconstitute
the arch seen during tip-toe standing
 Arch difficult to see during the early
years due to the presence of
subcutaneous fat

“Pediatric Disorders of the Foot”
Treatment is supportive when the foot is
asymptomatic
 Symptomatic patients may require the
use of arch supports or if tight Tendo
Achilles seen then stretching exercises
needed
 Recalcitant cases may require the use of
UCBL inserts and Achilles Tendon
Lengthening

“Pediatric Disorders of the Foot”
Surgery is reserved for severe painful
flat feet and importantly joint-sparing
 Arthroereisis of the subtalar joint via
Stay-Peg or Staple
 Lateral Column lengthening of the
calcaneus with bone grafting BEST
 Medial Column shortening with calcaneal
sliding osteotomy and medial soft tissue
imbrication

“Pediatric Disorders of the Foot”
“Congenital Talipes Equinovarus”
 Clubfoot is most common congenital
deformity seen; 1.24 times per 1000
births; boys two times greater than
girls; bilateral in 50% of cases
 Represents a congenital dysplasia of all
musculoskeletal tissues distal to the
knee with the extremity never being
“normal”
“Pediatric Disorders of the Foot”
Etiology has been proposed from arrest
in embryonic development to a reactive
fibrotic response to a primary germ
plasm defect in the cartilaginous talus
producing a dysmorphic neck and
navicular subluxation MOST ACCEPTED
 Etiology is therefore multifactoral and
modulated by developmental aberrations
early in limb bud development

“Pediatric Disorders of the Foot”
‘Pathoanatomy’
 Scarpa reported the medial and plantar
displacement of the navicular, cuboid and
calcaneus around the talus
 Contracture of the soft tissue maintains
this pathologic malalignment of the joints
 Midtarsal subluxation: navicular and
cuboid displaced medially with plantar and
medial rotation of the calcaneus
“Pediatric Disorders of the Foot”
Deformity of the talus observed with
medial and plantar deviation of the
anterior end, short talar neck, and
dysmorphic small talar body
 Delayed appearance of the ossification
center of the talus
 Underdevelopment of the sustentaculum
talus
 Talar neck rotated internally relative to
the ankle mortise 45 degrees

“Pediatric Disorders of the Foot”
Calcaneus internally rotated 22 degrees
 Body of talus externally rotated within
the mortise
 Navicular displaced medially and
plantarward on the talar head
 Cuboid displaced medially on the anterior
end of the calcaneus producing midfoot
varus and adductus
 Contracture of the periarticular soft
tissue

“Pediatric Disorders of the Foot”
“Associated pathologic conditions”
 Downs or Larsen’s Syndrome
 Arthrogryposis
 Diastrophic Dysplasia
 Spina bifida and dysraphism
 Fetal Alcohol Syndrome
 Streeter’s Dysplasia
“Pediatric Disorders of the Foot”
Type
 Type
 Type
 Type

“Classification”
I: benign
Frequency 20%
II: moderate
Frequency 33%
III: severe
Frequency 35%
IV: very severe Frequency 12%
“Pediatric Disorders of the Foot”
“Treatment”
 Initial treatment is manipulation and
serial casting
 Kite et al: the earlier treatment begun
the greater the chance for success
 Sequential correction of each deformity:
forefoot adduction first then hindfoot
varus next and finally correction of the
equinus…… Kite et al 1964
“Pediatric Disorders of the Foot”
Ponsetti et al confirmed the need to
correct all aspects of the deformity but
not individually but simultaneously
 Ponsetti’s correction included a
percutaneous achilles tendon release…78%
success
 Crawford, Kucharzyk et al……85% success
 Dimeglio et al reported results with a
clubfoot CPM…….success rates of 72%

“Pediatric Disorders of the Foot”
Surgical correction for those resistant
to corrective casting and Achilles
tenotomy
 Performed as early as 3 months and as
late as 12 months
 Surgical release must address all of the
pathoanatomic structures including the
hindfoot and midfoot

“Pediatric Disorders of the Foot”
Turco described the first one-stage
posteromedial release with two incisions
 Carroll emphasized the plantar fascial
release and capsulotomy of the
calcaneocuboid joint with two incisions
 McKay and Simmons most extensive
release performed and features a “cable
cast” through single incision
 Cincinnatti Incision most commonly used
approach now

“Pediatric Disorders of the Foot”
“Postoperative Complications”
 Loss of Correction
 Dorsal Subluxation of the Navicular
 Valgus Overcorrection
 Dorsal Bunion
“Pediatric Disorders of the Foot”
“Revision and Secondary Procedures”
 Prevalance of repeat surgery…….10%
 Not all feet with residual deformity or
muscle imbalance undergo additional
surgery
 Additional stiffness and muscle weakness
can occur as a result of repeat surgery
and immobilization
 Surgery should address a specific problem
and address a functional problem and pain
“Pediatric Disorders of the Foot”
“Functional Problems”
 Poor foot position: supination/inversion
 Excessive internal foot progression
angle: painful lateral ray weightbearing
 Muscle imbalance/weakness: triceps
incompetence calcaneus gait and calf
pain
“Pediatric Disorders of the Foot”
“Surgical Procedures”
 Anterior Tibial Tendon Transfer
 Transfer for Insufficent Triceps
 Lateral Column Shortening
 Calcaneal Osteotomy
 Supramalleolar Osteotomy
 Tibial Osteotomy
“Pediatric Disorders of the Foot”
“Congenital Vertical Talus”
 Condition producing ‘rocker-bottom’
deformity with fixed equinus of the
calcaneus and dorsal dislocation of the
navicular on the talus
 Seen in association with
myelomeningocele, arthrogryposis, spinal
muscular atrophy, neurofibromatosis,
DDH, trisomy 13-15-18
“Pediatric Disorders of the Foot”

Clinical appearance reveals a foot with a
convex plantar surface apex at the talar
head, calcaneus is fixed in equinus,
Achilles tendon contracted, peroneal and
anterior tibialis tendons are taught,
navicular palpable on the talar neck, and
no passive correction of the deformity
“Pediatric Disorders of the Foot”
Etiology is unknown
 Pathoanatomy reveals the navicular to
articulate with the dorsal aspect of the
nec of the talus, head of talus is
flattened, calcaneus is displaced
posterolaterally and in equinus, subtalar
joint is abnormal, elongation of the
medial column and shortening of the
lateral column, contractures of the
ligaments

“Pediatric Disorders of the Foot”
Radiographic reveals talus in vertical
position parallel to the talus, calcaneus
is in equinus, navicular dislocated
dorsally on the talus,
 Differential Diagnosis include: infantile
calcaneovalgus, oblique talus, and
flatfoot with heel cord contracture
 Treatment begins with serial casting to
stretch out the soft tissue

“Pediatric Disorders of the Foot”
Surgical correction is the mainstay of
treatment
 Single stage release performed at one
year of age recommended
 Four components of release: reduction of
navicular, lengthening of toe extensors
and peroneals for forefoot reduction,
release equinus contracture, transfer
anterior tibialis tendon to talus to
stabilize the correction

“Pediatric Disorders of the Foot”
“Tarsal Coalition”
 Peroneal spastic flatfoot
 Abnormal connection between two or
more of the bones of the foot producing
pain and limitation of motion of the foot
 Etiology is unknown with the most likely
cause being failure of segmentation of
the fetal tarsal bones
“Pediatric Disorders of the Foot”
Clinically present between 12 and 16
years
 Pain is the usual presenting complaint
 Abduction of the forefoot
 Stiffness of the hindfoot with
restricted subtalar joint
 Hindfoot valgus deformity
 Tightness of the peroneal tendons

“Pediatric Disorders of the Foot”
Radiographics include AP, lateral,
oblique, and Harris view
 Standing Oblique…….calcaneonavicular
 Harris view…….talocalaneal
 Anteater Sign……elongation of the
calcaneus and seen with
calcaneonavicular
 CT Scan of the hindfoot best for
assessing tarsal caolitions if xray’s
questionable

“Pediatric Disorders of the Foot”
Frequency of the various types of the
tarsal caolitions
 Calcaneonavicular: most common
 Medial Talocalcaneal: second most
common
 Calcaneocuboid: Third most common
 Significant incidence of a second
coalition in a foot in which one coalition
has been identified has ben seen

“Pediatric Disorders of the Foot”
Treatment: Intially conservative with
the use of a firm orthosis flattened on
the bottom to reduce inversion and
eversion stresses on the foot…….UCBL
 Refractory to conservative care require
surgical excision of the coalition with
interposition of muscle
 Long Term results reveal that these
patients will require subtalar fusions or
triple arthrodesis

“Pediatric Disorders of the Foot”
“Pes Cavus Foot”
 Abnormal elevation of the longitudinal
arch of the foot
 Complex deformity consisting of forefoot
equinus and varus or calcaneus of the
hindfoot
 Etiology is Neuropathic
“Pediatric Disorders of the Foot”

Associated conditions: cerebral palsy,
poliomyelitis, Friedreich’s ataxia,
myelomeningocele, tethered cord,
lipomeningocele, diastematomyelia,
Charcot-Marie-Tooth disease, Peripheral
Sensory Motor Neuropathies, tumor
“Pediatric Disorders of the Foot”
Common pathologic finding: Muscle Imbalance
 Posterior tibialis and peroneus longus remain
strong and invert the hindfoot with depression
of the first metatarsus
 Tibialis anterior and peroneus brevis are weak
and cannot dorsiflex the ankle or evert foot
 This combination produces hindfoot varus,
forefoot equinus, and pronation deformity

“Pediatric Disorders of the Foot”
Clawing of the toes seen
 Atrophy of the calf musculatures
 Coleman ‘Block Test’ allows one to
evaluate the varus component of the
deformity to determine flexibilty and if
any fixed bony deformity exists
 Radiographic studies include AP and
Lateral xrays; Meary’s angle increased

“Pediatric Disorders of the Foot”
MRI of the Brain and spinal cord to
evaluate for cerebral palsy or spinal
cord abnormalities
 EMG’s reveal a neuropathic pattern
 NCV reveal velocities to be slowed as
seen in CMT syndrome
 DNA studies to look for mutations
associated with peripheral neuropathies
and Friedreich’s Ataxia

“Pediatric Disorders of the Foot”
“Treatment”
 Conservative care has little role
 Surgical correction the staple of care
 Decision making determined by: apex of the
deformity, type of pes cavus, position of
hindfoot, presence of claw toe deformity,
presence of skin changes on sole of foot,
abnormal shoe wear, rigidity of the deformity,
strength of the muscles, stability of the
neurologic disease, and age of the patient
“Pediatric Disorders of the Foot”
Surgical Procedures divided into soft
tissue, osteotomies, and triple
arthrodesis
 Soft Tissue: plantar releases, peroneal
longus to brevis transfer, anterior
transfer of the posterior tibialis tendon,
transfer of the toe extensors to the
metatarsal heads

“Pediatric Disorders of the Foot”
Bony surgery: Metatarsal osteotomies,
calcaneal osteotomies (Dwyer), midfoot
osteotomies (Cole dorsal closing wedge),
triple arthrodesis (Lambrinudi or Hoke)
 Recommendation: calcaneal osteotomy for
hindfoot varus correctable with plantar
release, midfoot osteotomy when rigid
cavus but hindfoot not severe, inflexible
hindfoot varus and stiff cavus deformity
triple arthrodesis

“Pediatric Disorders of the Foot”
Thank You