“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 talo-calcaneo 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” “Classification” Type I: benign Frequency 20% Type II: moderate Frequency 33% Type III: severe Frequency 35% Type 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