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FLAT FOOT
DR.SHIEKH GOLAM MAHBUB D-ORTHO STUDENT DEPARTMENT OF ORTHOPAEDICS BSMMU
WHAT IS FLAT FOOT ?Also known as Pes planus or Fallen arches.Medial border of the foot is abnormally in contact with the floor during weight bearing.Low or absent medial longitudinal arch.When associated with deformities of the hind, mid and fore foot – pes plano valgus
DIVISION OF FOOTForefootMidfootRearfoot/Hindfoot
Forefoot 5 MT’s
– Proximally 1-3 articulate with cuneiforms– Proximally 4-5 articulate with cuboid– Bases articulate with:
Phalanges Midfoot
– Navicular – 3 Cuneiforms– Cuboid
Hindfoot (Rearfoot)• Subtalor Joint
– Talus and calcaneus articulation– Individual Bone Formation
• Calcaneus– Calcaneal Tuberosity– Sustentaculum Tali
• Inferior Talus– Three facets– Five functional articulation
ARCHES OF THE FOOTMedial Longitudinal Arch
Lateral Longitudinal Arch
Transverse Arch
Medial Longitudinal ArchCalcaneusTalusNavicular1-3 cuneiforms1-3 MT’s
• Ligament SupportPlantar CalcaneonavicularLong Plantar LigamentDeltoidPlantar fascia
• Muscular SupportIntrinsic Abductor Hallucis Flexor Digitorum BrevisExtrinsic Tibialis Posterior Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Anterior Flexor Digitorm Longus
Lateral longitudinal Arch• Composed of
CalcaneusCuboid4-5th MT’s
• Ligament SupportLong & Short PlantarPlantar Fascia
Transverse Arch• Formed By:
Ligament SupportIntermetatarsal LigamentsPlantar Fascia
Muscle SupportAll intrinsic musclesExtrinisicTibialis PosteriorTibialis AnteriorPeroneus Longus
FLAT FOOT
Loss of normal medial longitudinal arch. Is a rather common problem affecting pediatric, adults, and geriatrics. The foot is misaligned There is displacement of the hindfoot bones forcing a lowering of the natural arch of the foot.
Normal
ASSOCIATED ABNORMALITY Heel valgus Mild subluxation of subtalar joint Eversion of calcaneus Lateral angulation at the midtarsal joint Supination of forefoot Shortened Achilles tendon
TYPESCongenital Flexible flat foot Rigid flat footAcquired Osseus (# talus or calcaneous) Ligamentous Postural or static Arthritic
FLEXIBLE FLAT FOOT
There is an arch with no pressure on the foot. Upon standing there is a loss of the height of the arc. The foot can be put back into its “normal” position during not weight bearing. Jack’s test: Restored arch by dorsiflexing great toe.
No Weight
Weight
FLEXIBLE FLAT FOOT
Normal in toddlers Hereditary Ligamentous laxity Joint hypermobility
RIGID/STIFF FLAT FOOT
The foot has no arch on or off the ground. Cannot be manually forced back into it’s normal position. Causes- Congenital vertical talus Tarsal coalition Inflammatory joint disorder Neurological disorder
CLINICAL ASSESMENT
• History-Neonatal problems, family history• Heel position• Tiptoe test• Gait• Jack’s test• Sign of arthritis• Spine,hip & knee
RADIOLOGICAL FEATURESX-ray: AP, Lateral & oblique-
Medial displacement of talusBeaking of head of talusNarrowing of TC jointCN bars-C signFlattening of arc
Meary’s angle - between long axis of talus and long axis of first metatarsal on a standing lateral Xray 0 degrees – normal 0 – 15 degrees – mild 15 – 30 degrees – moderate > 30 degrees – severe
Calcaneal pitch - angle between the plantar surface of the calcaneum and horizontal on a lateral x-ray
Normal 15 degrees , in flat foot is decreased
May be 0 or negative in case of tightened TA
The talocalcaneal angle on an AP view is a marker of hind foot valgus Talus much more vertical than normal
WHAT IS HAPPENING?
The talus (ankle bone) is displaced from itsnormal position on the hindfoot or tarsal bones.It falls off its normal alignment with the hindfoot bones.
The talus turns inward and the foot turns outward.
Normal Alignment• Talus is sitting on
top of the hind foot bones.
• Sinus tarsi (natural spaced between the ankle & heel bone ) is in an “open” position.
Abnormal Alignment• Talus is not sitting
where it is supposed to be on the heel bone.
• This partially collapses the sinus tarsi.
• Partial talotarsal joint dislocation is present.
• Excessively abnormal forces are acting on the foot.
Calcaneus
Talus Talus
Calcaneus
TREATMENT
It depends on the type of “flat” foot Flexible
Rigid
TREATMENT PLANUpto 2 years- no treatment2 to 3 years-
Orthopaedic shoes with Thomas heels, medial heel wedges (1/8 to 3/16 inch), and navicular pads
3 to 9 years- Asymtomatic –Parent educationSymtomtic- Orthopaedics shoes, Custom prosthesis
10 to 14 years-Asymtomatic –No treatmentSymtomtic- molded orthroses
FLEXIBLE FLAT FOOTExercise- strengthen muscles“Special” ShoesArch Supports/Orthotics-Extra-Osseous TaloTarsal Stabilization (EOTTS)Reconstructive Hindfoot Surgery
SURGICAL OPTIONS• Miller’s procedure• Modified Hoke Miller procedure• Durham pes planus plasty • Tripple arthrodesis• Post. displacement osteotomy of calcaneum• Anterior calcaneal lengthening-distraction wedge osteotomy• Kidner’s operation(Accessory navicular)
DURHAM PLASTY FOR PES PLANUS
A, Incision. B, Elevation of posterior tibial tendon. C, Elevation of osteoperiosteal flap from proximal to distal. D, Arthrodesis of navicular–first cuneiform joint. E, Extent of arthrodesis resection through midfoot. F, Internal fixation of navicular–first cuneiform joint.
•
pull the posterior tibial tendon taut into its prepared bed on the plantar surface of the waist of the navicular, and tie the suture dorsally
RIGID FLAT FOOT• Conservative- Plaster 6wks; splintage( iron+ T strap)- 3-6 months• Surgery-Before puberty Resection of bar and fill the gap by fat or muscle Resection of middle facet• After puberty Tripple arthrodesis
TRIPLE ARTHRODESIS• A, Lateral skin incision over
sinus tarsi.• B, Suggested plane of
arthrodesis of calcaneocuboid and talonavicular joints.
• C, Suggested plane of removal of talocalcaneal joint–posterior facet.
• D, Medial skin incision.• E, Medial aspect of
talonavicular joint and suggested planes of osteotomy.
• F, Final position of talonavicular, calcaneocuboid, and talocalcaneal joints and internal fixation with Steinmann pins.
TAKE HOME MESSAGE Correction of flexible pes planus for disabling pain and after failure of
conservative management, not for cosmetic reasons only.
Loss of inversion and eversion of the foot.
Arthrodeses for relieving painful pes planus have been most successful.
Sinus tarsi implants are at medical crossroads. Surgeons are studying their results and modifying operative techniques and implant design.
“Our feet are no more alike than our faces” British Medical Journal
THANK YOU