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