What's New in Pediatric Flatfoot?

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit

PURPOSE

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.

METHODS

A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.

RESULTS

The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.

CONCLUSION

Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Dynamic Gait Analysis in Paediatric Flatfeet: Unveiling Biomechanical Insights for Diagnosis and Treatment

BACKGROUND

Flatfeet in children are common, causing concern for parents due to potential symptoms. Technological advances, like 3D foot kinematic analysis, have revolutionized assessment. This review examined 3D assessments in paediatric idiopathic flexible flat feet (FFF).

METHODS

Searches focused on paediatric idiopathic FFF in PubMed, Web of Science, and SCOPUS. Inclusion criteria required 3D kinematic and/or kinetic analysis during posture or locomotion, excluding non-idiopathic cases, adult feet, and studies solely on pedobarography or radiographs.

RESULTS

Twenty-four studies met the criteria. Kinematic and kinetic differences between FFF and typical feet during gait were outlined, with frontal plane deviations like hindfoot eversion and forefoot supination, alongside decreased second peak vertical GRF. Dynamic foot classification surpassed static assessments, revealing varied movement patterns within FFF. Associations between gait characteristics and clinical measures like pain symptoms and quality of life were explored. Interventions varied, with orthoses reducing ankle eversion and knee and hip abductor moments during gait, while arthroereisis normalized calcaneal alignment and hindfoot eversion.

CONCLUSIONS

This review synthesises research on 3D kinematics and kinetics in paediatric idiopathic FFF, offering insights for intervention strategies and further research.

Efficacy of Personalized Foot Orthoses in Children with Flexible Flat Foot: Protocol for a Randomized Controlled Trial

Pediatric flat foot (PFF) is a very frequent entity and a common concern for parents and health professionals. There is no established definition, diagnostic method, or clear treatment approach. There are multiple conservative and surgical treatments, the implantation of foot orthoses (FO) being the most used treatment. The evidence supporting FO is very thin. It is not clearly known what the effect of these is, nor when it is convenient to recommend them. The main objective of this protocol is to design a randomized controlled trial to determine if personalized FO, together with a specific exercise regimen, produce the same or better results regarding the signs and symptoms of PFF, compared to only specific exercises. In order to respond to the stated objectives, we have proposed a randomized controlled clinical trial, in which we intend to evaluate the efficacy of FO together with strengthening exercises, compared to a control group in which placebos will be implanted as FO treatment along with the same exercises as the experimental group. For this, four measurements will be taken throughout 18 months (pre-treatment, two during treatment and finally another post-treatment measurement). The combination of FO plus exercise is expected to improve the signs and symptoms (if present) of PFF compared to exercise alone and the placebo FO group. In addition, it is expected that in both conditions the biomechanics of the foot will improve compared to the initial measurements.

Pediatric Flatfoot: Is There a Need for Surgical Referral?

Pediatric foot deformities are a common finding, concerning up to 44% of preschool aged children. The absence of accepted international guidelines, as well as heterogeneity in definitions and measurements, makes management of pediatric flatfoot a challenge, and decisions surrounding specialized care referral confusing and biased. The objective of this narrative review is to provide guidance to primary care physicians treating these patients. A non-systematic review of the literature regarding the development, etiology, and clinical and radiographic assessment of flatfeet using the PubMed and Cochrane Library databases was performed. The exclusion criteria for the review were adult populations, papers detailing the outcome of a specific surgical procedure, and publications prior to 2001. The included articles showed great heterogeneity in definition and proposed management, which makes the study of pediatric flatfoot challenging. Flatfoot is a common finding in children under 10 years old, and should not be considered pathological unless stiffness or functional limitation are present. Surgical referral should be reserved to children with stiff or painful flatfoot, while simple observation is indicated for flexible, asymptomatic flatfeet.

Ankle and Foot Deformities in Children

Ankle and foot deformity is one of the most common musculoskeletal disorders in children and a leading cause of functional impairment and diminished quality of life when not treated. A spectrum of conditions may produce foot and ankle deformities, with congenital disorders the most frequent cause, followed by acquired conditions. Congenital disorders include congenital talipes equinovarus or congenital clubfoot, metatarsus adductus, skewfoot, congenital vertical talus, and tarsal coalition.Some of these deformities are frequent and easily diagnosed based on clinical features, but clinical overlap between pathologies can be challenging. Thus imaging plays a paramount role in evaluating these patients. Radiographs are the first imaging modality of choice, but they may not be sufficient in infants due to the lack of ossification of the tarsal bones. Ultrasonography allows not only a detailed visualization of the cartilaginous structures but also permits a dynamic study of the foot and ankle. Computed tomography may be necessary in certain conditions such as tarsal coalitions.

The Rehabilitation Program Improves Balance Control in Children with Excessive Body Weight and Flat Feet by Activating the Intrinsic Muscles of the Foot: A Preliminary Study

BACKGROUND

determining the appropriate rehabilitation protocol is essential to influence the correction of flat feet, e.g., by activating the intrinsic muscles of the foot. Therefore, this study aimed to determine the impact of the exercises activating the intrinsic foot muscles for postural control in children with flat feet, with normal and excessive body weight.

METHODS

Fifty-four children aged 7 to 12 were enrolled in the research. Forty-five children were qualified for the final evaluation. Each child in the experimental group was demonstrated an appropriate technique for performing a short foot exercise without compensation by extrinsic muscle. The participants then performed a supervised short foot training session once a week and on other days of the week under the supervision of caregivers for 6 weeks. Flat feet were scored on the foot posture index scale. A postural test was evaluated with a Biodex balance system SD. Statistical significance in the foot posture index scale and postural test were evaluated using an analysis of variance (ANOVA) with Tukey's post-hoc test.

RESULTS

according to the six indices of the foot posture index scale, five indicators showed statistically significant improvement after rehabilitation. At the 8-12 platform mobility level, it was revealed that the excessive body weight group had significant improvements in the overall stability index and medio-lateral stability index, with eyes closed.

CONCLUSION

our results indicate that a 6-week rehabilitation program based on the activation of the intrinsic muscles of the foot resulted in an improvement in the foot position. This, in turn, affected balance control, especially in children with excess body weight in conditions of closed eyes.

Clinical, Radiographic and Gait Parameters Associated with Medial Arch Pain in the Flexible Pediatric Flatfoot

Pain in the flexible flatfoot is a common complaint, if present it is important to find its exact location and causes Therefore, the study aimed to find differences between children with and without medial arch pain and relate them to the reduction of pain following surgical treatment. Children with idiopathic flexible flatfeet were retrospectively included in the study. All children underwent a clinical, radiographic, and gait examination. The feet were subdivided into 2 groups: asymptomatic and those with medial arch pain. Factors associated with medial arch pain were identified via t test. Significant radiological and gait parameters were correlated to the change in medial arch pain score following surgery. Included were 322 feet belonging to 177 children, with the mean age of 11.8 (SD = 2.2) years. The pain was perceived in 52% of the feet, of these, 74% in the medial arch. In the group with pain, 31 feet received a gait analysis following surgery. The radiological parameters, talus-1 and -2 metatarsal angles and the gait parameter, calcaneal lateral shift during walking showed a significant difference (p ≤ .004) between the no pain and pain groups and were associated (R² ≥0.14, p ≤ .04) with the reduction in pain following surgery. The increased talus-1 and -2 metatarsal angles and the calcaneal lateral shift may cause increased tension on the soft-tissues along the medial side of the foot and may produce pain. Therapies aiming at improving the medial arch pain should be directed to normalize the talus-1 or -2 metatarsal angles and the calcaneal lateral shift.

Foot morphology and correlation with lower extremity pain in Japanese children: A cross-sectional study of the foot posture Index-6

BACKGROUND

Abnormal foot morphology in children and adolescents is a possible risk factor for lower extremity pain. Foot posture index-6 (FPI-6) is a valid and reliable tool to assess foot morphology. However, the normative data on the age distribution for FPI-6 in Asian children and adolescents are still minimal. Further, the correlation of FPI-6 with lower extremity pain is poorly understood. We aimed to investigate the normative distribution for FPI-6 and the relationship between FPI-6 scores and knee and heel pain in Japanese children.

METHODS

We included 2569 Japanese children, aged 9-15 years, at a single school from 2016 to 2018. We summarized the age distribution of children and their mean bilateral FPI-6 scores. Additionally, we assessed the tenderness at the apophysis or tendon insertions at the knee and heel. We performed a cross-sectional analysis to investigate the correlations between FPI-6 scores and sex, age, and knee and heel pain for the data obtained each year.

RESULTS

The mean FPI-6 score was 3.1 ± 2.4, 3.4 ± 2.0, and 3.2 ± 1.9 for the left foot and 3.0 ± 2.4, 3.2 ± 1.9, and 3.1 ± 1.9 for the right foot in 2016, 2017, and 2018, respectively. Boys tended to have higher scores than girls, and the FPI-6 score of the left foot was significantly higher than that of the right foot (p < 0.05). There was no correlation between FPI-6 scores and knee and heel pain.

CONCLUSION

Children and adolescents between 9 and 15 years of age have neutral to slightly pronated foot morphology and an average FPI-6 score of 3.0-3.4. In addition, there was no relationship between foot morphology and knee and heel pain. This normative distribution for FPI-6 in Japanese children could serve as a reference value for future research and clinical evaluation.

Radiographic foot alignment and morphological features of deltoid ligament in pediatric patients with medial osteochondral lesions of the talus

The cause of osteochondral lesions of the talus (OLT) in patients without a history of trauma remains unclear, and almost all nontraumatic lesions appear to involve the medial talar dome. This study aimed to investigate the relationship between foot alignment, deltoid morphology, and medial OLT in pediatric patients. In total, 28 patients (31 feet) with medial OLT (17 boys, 11 girls, mean age: 14.9 years), and 50 patients without OLT (50 feet, 31 boys, 19 girls, mean age: 14.5 years) were included in this study. The OLT patients were subdivided into traumatic and nontraumatic groups. Radiographic parameters of the foot arch were measured on weight-bearing lateral images. The extent of the OLT was measured on computed tomographic images. The ratio of deep deltoid attachment length of the talus to talar height was examined as deltoid ligament position index (DPI) on coronal magnetic resonance imaging. Nontraumatic medial lesions were frequently observed in pediatric patients (54.8%) compared to traumatic lesions. The depression of the foot arch was commonly identified in pediatric patients with resistant medial lesions. The lesion size was moderately correlated with DPI (rho = 0.48; P = 0.0086). The attachment of the deep deltoid ligament to the medial talar dome was located more proximally in nontraumatic lesions than in traumatic lesions and the control group. Our findings suggest that a combination of foot alignment and the anatomic variations in the attachment of the deep deltoid ligament contributes to the incidence of nontraumatic medial OLT in the pediatric population. Level of evidence: level IV.

Postsurgical Evaluation of the Pediatric Foot and Ankle

This article reviews situations in which surgical treatment is required in the context of different types of pathology in the foot and ankle of children, focusing on the role of imaging in surgical planning and postsurgical assessment. The types of pathology analyzed from this perspective are congenital pathology, neuromuscular disorders, osteochondral lesions, fractures and infection, ligament injuries, and tumors.We address the most common pitfalls of postsurgical imaging of the ankle and foot in children. With some exceptions, postsurgical follow-up focuses on clinical assessment, with imaging follow-up only needed in patients where complications are suspected or symptoms recur. Postoperative assessment of the foot and ankle in children and adolescents requires knowing the indications for surgery and the most common types of interventions, along with their imaging characteristics. The radiologist needs to be aware of the normal sequence of development of structures and how to select adequate imaging techniques to assess anatomy at various stages or in different postsurgical scenarios.

Weight-Bearing Computed Tomography of the Foot and Ankle in the Pediatric Population

BACKGROUND

Newer cone-beam computed tomography (CT) technology has grown in popularity for evaluation of foot and ankle pathology in the weight-bearing (WB) position. Many studies have demonstrated its benefits within the adult population, but there is a paucity of its use within the pediatric literature. The purpose of this study was to describe the indications and clinical findings of WBCT within a pediatric population.

METHODS

A retrospective cohort of 68 patients (86 extremities) who underwent WBCT for a variety of conditions were compared with 48 patients (59 extremities) who underwent traditional supine nonweight-bearing (NWB) CTs. Clinical indications, demographic data, radiation doses, and cost were obtained from the medical record. WBCTs were obtained in a private outpatient orthopaedic clinic, and the conventional NWBCTs were obtained within a hospital-based system.

RESULTS

The most common indications for obtaining a WBCT and NWBCT in our study were fracture, tarsal coalition, and Lisfranc injury. The average WBCT radiation dose was 0.63 mGy for patients <100 lbs and 1.1 mGy for patients >100 lbs undergoing WBCT. For NWBCTs, the average radiation dose was 7.92 mGy for patients <100 lbs and 10.37 mGy for patients greater than 100 lbs. There was a significant reduction in radiation dose for all patients who underwent WBCT (P<0.0001 vs. 0.002). The average reimbursement for NWBCTs was $505 for unilateral studies and $1451 for bilateral studies. The average reimbursement for the WBCTs was $345 for unilateral studies and $635 for bilateral studies.

CONCLUSIONS

WBCT offers a new modality for studying complex foot and ankle pathoanatomy in the pediatric population at a reduced radiation exposure and reduced cost.

LEVEL OF EVIDENCE

Level III-a retrospective comparative study.

The Role of Arthroereisis in Improving Sports Performance, Foot Aesthetics and Quality of Life in Children and Adolescents with Flexible Flatfoot

Flexible flatfoot represents one of the most common deformities of the lower limb, affecting children and adolescents. Aesthetic aspect, abnormal gait, pain and fatigue are by far the most important symptoms which determine parents to bring their children to the orthopedist. We set out to conduct a prospective study, case-controlled, including patients with symptomatic flexible flatfeet operated on by arthroereisis surgery and comparing them to a normal feet group of children age- and sex-matched (control group). Minimum follow-up time was 2 years. In total, 33 patients with bilateral arthroereisis were included and 36 patients formed the control group (12.12 +/− 1.85 years vs. 11.81 ± 2.40 years, p = 0.54). Quality of life improved postoperatively (p = 0.18) and was not different from the control group. Median running time improved postoperatively by 2.25 s (p < 0.0001) and got closer to the median running time from the control group (22.30 s compared to 20.94 s, p = 0.01). All radiological angles improved (p < 0.0001), but quality of life improvement was correlated with talonavicular coverage angle and Meary angle measurements. Flatfoot in children and adolescents may be a condition in which the quality of life and sports performance are decreased, compared to healthy children. Arthroereisis is a minimally invasive surgical procedure with a short recovery time and a short period before resumption of sport activities, which can be useful in certain types of flexible flatfoot due to its effectiveness on symptom reduction.

Trends in hospitalization for paediatric flatfoot: an Italian nationwide study from 2001 to 2016

Background

Flatfoot is a common condition in young patients, but usually resolves by adolescence. This study aimed to estimate annual trend hospitalizations for flatfoot in Italian paediatric population from 2001 to 2016.

Methods

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper (2001–2016). The yearly number of hospital admission for flatfoot, the percentage of males and females, the average age, the average days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses.

Results

109,300 hospitalizations for flatfoot of young patients were performed during this period. 59.3% of patients were male and 40.7% female of the 10–14 years-old age class. The average days of hospitalization stay were 1.73 ± 1.27 days. The data highlights that the burden of flatfoot surgery is growing and affecting the healthcare system. The mean rate of hospital admissions in Italy for flatfoot in the young population was 82.14 for 100,000 inhabitants of the same age class.

Conclusions

The data highlights that the cases of flatfoot surgery increased from 2001 to 2016. The most common treatment was the “Internal Fixation Of Bone Without Fracture Reduction, Tarsals And Metatarsals followed by Subtalar Fusion and Arthroereisis. Further prospective studies on this topic may be conducted to improve the evidence of the results.

Foot orthoses for treating paediatric flat feet

BACKGROUND

Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet.

OBJECTIVES

To assess the benefits and harms of foot orthoses for treating paediatric flat feet.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020.

SELECTION CRITERIA

We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs).

DATA COLLECTION AND ANALYSIS

We followed standard methods recommended by Cochrane.

MAIN RESULTS

We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFOs (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to 10 scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8).

AUTHORS' CONCLUSIONS

Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions.

Foot orthoses for treating paediatric flat feet

BACKGROUND

Paediatric flat feet are a common presentation in primary care; reported prevalence approximates 15%. A minority of flat feet can hurt and limit gait. There is no optimal strategy, nor consensus, for using foot orthoses (FOs) to treat paediatric flat feet.

OBJECTIVES

To assess the benefits and harms of foot orthoses for treating paediatric flat feet.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase to 01 September 2021, and two clinical trials registers on 07 August 2020.

SELECTION CRITERIA

We identified all randomised controlled trials (RCTs) of FOs as an intervention for paediatric flat feet. The outcomes included in this review were pain, function, quality of life, treatment success, and adverse events. Intended comparisons were: any FOs versus sham, any FOs versus shoes, customised FOs (CFOs) versus prefabricated FOs (PFOs).

DATA COLLECTION AND ANALYSIS

We followed standard methods recommended by Cochrane.

MAIN RESULTS

We included 16 trials with 1058 children, aged 11 months to 19 years, with flexible flat feet. Distinct flat foot presentations included asymptomatic, juvenile idiopathic arthritis (JIA), symptomatic and developmental co-ordination disorder (DCD). The trial interventions were FOs, footwear, foot and rehabilitative exercises, and neuromuscular electrical stimulation (NMES). Due to heterogeneity, we did not pool the data. Most trials had potential for selection, performance, detection, and selective reporting bias. No trial blinded participants. We present the results separately for asymptomatic (healthy children) and symptomatic (children with JIA) flat feet. The certainty of evidence was very low to low, downgraded for bias, imprecision, and indirectness. Three comparisons were evaluated across trials: CFO versus shoes; PFO versus shoes; CFO versus PFO. Asymptomatic flat feet 1. CFOs versus shoes (1 trial, 106 participants): low-quality evidence showed that CFOs result in little or no difference in the proportion without pain (10-point visual analogue scale (VAS)) at one year (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.67 to 1.07); absolute decrease (11.8%, 95% CI 4.7% fewer to 15.8% more); or on withdrawals due to adverse events (RR 1.05, 95% CI 0.94 to 1.19); absolute effect (3.4% more, 95% CI 4.1% fewer to 13.1% more). 2. PFOs versus shoes (1 trial, 106 participants): low to very-low quality evidence showed that PFOs result in little or no difference in the proportion without pain (10-point VAS) at one year (RR 0.94, 95% CI 0.76 to 1.16); absolute effect (4.7% fewer, 95% CI 18.9% fewer to 12.6% more); or on withdrawals due to adverse events (RR 0.99, 95% CI 0.79 to 1.23). 3. CFOs versus PFOs (1 trial, 108 participants): low-quality evidence found no difference in the proportion without pain at one year (RR 0.93, 95% CI 0.73 to 1.18); absolute effect (7.4% fewer, 95% CI 22.2% fewer to 11.1% more); or on withdrawal due to adverse events (RR 1.00, 95% CI 0.90 to 1.12). Function and quality of life (QoL) were not assessed. Symptomatic (JIA) flat feet 1. CFOs versus shoes (1 trial, 28 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain (0 to 10 scale, 0 no pain) between groups (MD -1.5, 95% CI -2.78 to -0.22). Low-quality evidence showed improvements in function with CFOs (Foot Function Index - FFI disability, 0 to 100, 0 best function; MD -18.55, 95% CI -34.42 to -2.68), child-rated QoL (PedsQL, 0 to 100, 100 best quality; MD 12.1, 95% CI -1.6 to 25.8) and parent-rated QoL (PedsQL MD 9, 95% CI -4.1 to 22.1) and little or no difference between groups in treatment success (timed walking; MD -1.33 seconds, 95% CI -2.77 to 0.11), or withdrawals due to adverse events (RR 0.58, 95% CI 0.11 to 2.94); absolute difference (9.7% fewer, 20.5 % fewer to 44.8% more). 2. PFOs versus shoes (1 trial, 25 participants, 3-month follow-up): very low-quality evidence showed little or no difference in pain between groups (MD 0.02, 95% CI -1.94 to 1.98). Low-quality evidence showed no difference between groups in function (FFI-disability MD -4.17, 95% CI -24.4 to 16.06), child-rated QoL (PedsQL MD -3.84, 95% CI -19 to 11.33), or parent-rated QoL (PedsQL MD -0.64, 95% CI -13.22 to 11.94). 3. CFOs versus PFsO (2 trials, 87 participants): low-quality evidence showed little or no difference between groups in pain (0 to scale, 0 no pain) at 3 months (MD -1.48, 95% CI -3.23 to 0.26), function (FFI-disability MD -7.28, 95% CI -15.47 to 0.92), child-rated QoL (PedsQL MD 8.6, 95% CI -3.9 to 21.2), or parent-rated QoL (PedsQL MD 2.9, 95% CI -11 to 16.8).

AUTHORS' CONCLUSIONS

Low to very low-certainty evidence shows that the effect of CFOs (high cost) or PFOs (low cost) versus shoes, and CFOs versus PFOs on pain, function and HRQoL is uncertain. This is pertinent for clinical practice, given the economic disparity between CFOs and PFOs. FOs may improve pain and function, versus shoes in children with JIA, with minimal delineation between costly CFOs and generic PFOs. This review updates that from 2010, confirming that in the absence of pain, the use of high-cost CFOs for healthy children with flexible flat feet has no supporting evidence, and draws very limited conclusions about FOs for treating paediatric flat feet. The availability of normative and prospective foot development data, dismisses most flat foot concerns, and negates continued attention to this topic. Attention should be re-directed to relevant paediatric foot conditions, which cause pain, limit function, or reduce quality of life. The agenda for researching asymptomatic flat feet in healthy children must be relegated to history, and replaced by a targeted research rationale, addressing children with indisputable foot pathology from discrete diagnoses, namely JIA, cerebral palsy, congenital talipes equino varus, trisomy 21 and Charcot Marie Tooth. Whether research resources should continue to be wasted on studying flat feet in healthy children that do not hurt, is questionable. Future updates of this review will address only relevant paediatric foot conditions.

Results of the Italian Pediatric Orthopedics Society juvenile flexible flatfoot survey: diagnosis and treatment options

The objectives of this study were to collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

Subtalar Arthroereisis for Surgical Treatment of Flexible Flatfoot

Various surgical techniques are known for the treatment of flexible flatfoot in children after failure of nonsurgical attempts. Data collected in a review of the last 10-year period (2010-2020) show that among the 691 feet undergoing subtalar arthroereisis with endorthesis, average age at surgery was 11.40 years and in the 1856 feet that underwent subtalar arthroereisis with calcaneo-stop 11.69 years, while the complications rate was 9.00% and 6.38%, respectively. These data confirm that subtalar arthroereisis with calcaneo-stop may have an advantage over subtalar arthroereisis with endorthesis as the screw is not placed across the subtalar joint but instead into the calcaneus.

Diagnosis and treatment of flexible flatfoot: results of 2019 flexible flatfoot survey from the European Paediatric Orthopedic Society

The aim of the study was to evaluate flexible flatfoot (FFF) diagnostic and current therapeutic modalities, as well as treatment expectations, among members of the European Paediatric Orthopaedic Society (EPOS). A 59-questions survey on FFF diagnosis and treatment preferences was distributed to EPOS members. The survey consisted of six sections (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; and (6) management options. Descriptive statistics were performed. A total of 93 responses were analysed. In general, clinical parameters, age (91.4% of cases), laxity (81.7%), diffuse pain (84.9%), and pain at the ankle joint (81.7%) were rated as 'average' and 'crucial importance' by the vast majority of respondents. Meary's angle (47.3% of cases), talonavicular coverage (35.5%), and lateral talocalcaneal angle (35.5%) were assessed as main radiological tools in the FFF evaluation. Among respondents, 61.3% rated 'improved ability to walk longer without symptoms' as of 'crucial importance'. Eighty-two percent of the respondents felt less than 10% of patients with FFF are candidates for corrective surgery. Arthroereisis (29.3%) was the most common surgical procedure (16.4% for subtalar and 12.9% for extra-articular arthroereisis, respectively), followed by lateral column lengthening (17.9%) and medializing calcaneal osteotomy (12.3%). There is great variation among respondents in diagnostic and treatment preferences in the management of children with FFF. The results of the EPOS 2019 FFF survey clearly show that large-scale, multicentric, international studies are necessary to elucidate which diagnostic and treatment practices lead to the best outcomes.

The diagnosis and management of common childhood orthopedic disorders: An update

Musculoskeletal illness represents a significant portion of office visits to primary and urgent care clinicians. Despite this, little emphasis is placed on learning pediatric orthopaedics during medical school or residency. The focus of this paper is to provide a systematic approach to this general musculoskeletal physical exam and to assist in the recognition of what conditions are normal development and what conditions require observation, workup and referral to an experienced pediatric orthopaedist.

Flexibility does not affect the dorsiflexion of foot and the popliteal angle in young adults

BACKGROUND

The aim of the study was to assess how flexibility affects the dorsiflexion of foot and the popliteal angle test results in junior high school students.

METHODS

The subjects were 142 students from the 2nd, and 3rd year of Poznań junior high schools (age between 13 and 15). Each subject was examined 6 times: there were 3 raters, a specialist in orthopaedics, a resident doctor and a physical therapy student, and each of them performed 2 measurements. Flexibility was also measured using the Beighton scale (score from 0 to 9).

RESULTS

Since the Beighton scale is ordinal in order to evaluate the relationship between flexibility and the range of motion Spearman's rank correlation coefficient was calculated. The statistical analysis showed no correlation between flexibility measured on the Beighton scale and the range of passive foot dorsiflexion and the popliteal angle.

CONCLUSIONS

The degree of flexibility does not affect the dorsiflexion of the foot and the popliteal angle in junior high students. At this age the range of dorsiflexion is determined by the length of the triceps surae muscle while the popliteal angle depends on the length of the muscles on the back of the thigh.

Is there a correlation between static radiographs and dynamic foot function in pediatric foot deformities?

BACKGROUND

Idiopathic flexible flatfeet, congenital clubfeet and pes cavovarus are the most common foot deformities in children. Accurate assessment to quantify the severity of these deformities by clinical examination alone can be challenging. Radiographs are a valuable adjunct for accurate diagnosis and effective treatment. However, static radiographs during relaxed standing may not reflect the dynamic changes in the foot skeleton during functional activities such as walking. Therefore, the aim of this study is to predict dynamic foot movements during walking from planar standing radiographs to reveal the significance of the radiographic analysis for the assessment of foot function.

METHODS

Patients 8-17 years with flexible flatfeet (FFF, n=217) recurrent clubfeet (RCF n=38) and overcorrected clubfeet (OCCF, n=71) of non-neurogenic or syndromic origin and pes cavovarus due to peripheral neuropathy (PNP, n=48) were retrospectively included. Patients underwent gait analysis with the Oxford Foot Model and radiographic examination in anterior-posterior and lateral view during standing. Multilinear predictor analysis of selected gait parameters was performed based on radiographic measures.

RESULTS

The variance that was explained by radiography was greatest for the transverse plane forefoot abduction with 33% for OCCF, 50% for RCF and 59% for PNP. Flatfeet and foot kinematics in the other planes or between rearfoot and tibia showed little or no relation.

CONCLUSIONS

The static measures of foot deformities by radiography could explain only a small amount of variance in foot kinematics during walking, in particular for FFF. An explanation may be that the forces during weight bearing bear little resemblance to those during gait in terms of neither magnitude nor direction. These findings suggest that foot function cannot be accurately assessed solely from static radiographic observations of the foot, commonly undertaken in clinical practice.

Calcaneal lengthening osteotomy in spastic planovalgus feet

PURPOSE OF STUDY

Planovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.

METHODS

17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.

RESULTS

Improvement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.

CONCLUSION

Calcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.

Discrepancy between true ankle dorsiflexion and gait kinematics and its association with severity of planovalgus foot deformity

Background

In planovalgus deformity with triceps contracture, a midfoot break happens, and ankle dorsiflexion (ADF) occurs at the mid-tarsal joint during gait. Results of standard 3D gait analysis may misinterpret the true ankle dorsiflexion because it recognizes the entire foot as a single rigid segment. We performed this study to investigate whether the severity of planovalgus deformity is associated with the discrepancy between the value of ADF evaluated by physical examination and 3-dimensional (3D) gait analysis. In addition, we aimed to identify the radiographic parameters associated with this discrepancy and their relationships.

Methods

Consecutive 40 patients with 65 limbs (mean age, 11.7 ± 5.5 years) with planovalgus foot deformity and triceps surae contracture were included. All patients underwent 3D gait analysis, and weightbearing anteroposterior (AP) and lateral (LAT) foot radiographs. ADF with knee extension was measured using a goniometer with the patient’s foot in an inverted position.

Results

Twenty-one limbs underwent operation for planovalgus foot deformity, and 56 limbs underwent operation for equinus deformity. The difference between ADF on physical examination and ADF at initial contact on gait analysis was 17.5 ± 8.4°. Differences between ADF on physical examination and ADF at initial contact on gait analysis were significantly associated with the LAT talus-first metatarsal angle (p = 0.008) and calcaneal pitch angle (p = 0.006), but not associated with the AP talus-first metatarsal angle (p = 0.113), talonavicular coverage angle (p = 0.190), talocalcaneal angle (p = 0.946), and naviculocuboid overlap (p = 0.136).

Conclusion

The discrepancy between ADF on physical examination and 3D gait analysis was associated with the severity of planovalgus deformity, which was evaluated on weightbearing LAT foot radiographs. Therefore, physicians should be cautious about interpreting results from 3D gait analysis and perform a careful physical examination to assess the degree of equinus deformity in patients with planovalgus foot deformity.

Pediatric Flatfeet-A Disease Entity That Demands Greater Attention and Treatment

Background: Pediatric flatfoot is a common deformity. Unfortunately, the common opinion has been that most children with this faulty foot structure will simply out-grow it, despite no radiographic evidence to support this claim. Every step on a deformed foot leads to excessive tissue strain and further joint damage. Many forms of conservative and surgical treatments have been offered. This study was aimed at investigating the effectiveness of non-surgical and surgical treatment options. Main Text: faulty-foot structure is the leading cause of many secondary orthopedic deformities. A wide range of treatments for pediatric flatfeet have been recommended from the "do-nothing" approach, observation, to irreversible reconstructive surgery. Most forms of conservative care lack evidence of osseous realignment and stability. A conservative surgical option of extra-osseous talotarsal joint stabilization provides patients an effective form of treatment without the complications associated with other irreversible surgical procedures. Conclusion: Pediatric flatfeet should not be ignored or downplayed. The sooner effective treatment is prescribed, the less damage will occur to other parts of the body. When possible, a more conservative corrective procedure should be performed prior to irreversible, joint destructive options.

Cluster analysis to identify foot motion patterns in children with flexible flatfeet using gait analysis-A statistical approach to detect decompensated pathology?

INTRODUCTION

The paediatric flexible flatfoot constitutes the major cause of clinic visits for orthopaedic foot problems. It shows variations of deformities in different planes and locations of the foot and its indication for treatment have been extensively discussed. Despite its high prevalence there exists no classification of flatfeet during walking as a prerequisite for treatment decision. Therefore, the aim of this study is to classify flexible flatfeet based on 3D foot kinematics during walking.

METHODS

Patients age 7-17 years with flexible flatfeet (N = 129, 255 feet) of non-neurogenic or syndromic origin, were retrospectively included. Patients underwent gait analysis using the Oxford Foot Model after standard clinical examination. A k-means cluster analysis was performed on 3 scores derived from the principal component analysis of the foot kinematic waveforms over the gait cycle. Gait and clinical parameters were then statistically tested between clusters.

RESULTS

Cluster analysis revealed two groups of flexible flatfeet that were discriminated best by the inversion at push-off during walking. Cluster 2, including 110 feet, showed an average eversion instead of an inversion at push-off and a lower number of heel rises in the clinical test. Both was significantly different between clusters (p < 0.001).

DISCUSSION

Based on the findings, the resultant clusters can be interpreted as describing compensated and decompensated feet, with the latter presenting a group that may require surgical interventions, even if they are not yet present with pain. The hindfoot inversion capability at push-off is the most important variable in the 3D gait analysis to classify flexible flat feet.

Diagnosis and management in Pitt-Hopkins syndrome: First international consensus statement

Pitt-Hopkins syndrome (PTHS) is a neurodevelopmental disorder characterized by intellectual disability, specific facial features, and marked autonomic nervous system dysfunction, especially with disturbances of regulating respiration and intestinal mobility. It is caused by variants in the transcription factor TCF4. Heterogeneity in the clinical and molecular diagnostic criteria and care practices has prompted a group of international experts to establish guidelines for diagnostics and care. For issues, for which there was limited information available in international literature, we collaborated with national support groups and the participants of a syndrome specific international conference to obtain further information. Here, we discuss the resultant consensus, including the clinical definition of PTHS and a molecular diagnostic pathway. Recommendations for managing particular health problems such as dysregulated respiration are provided. We emphasize the need for integration of care for physical and behavioral issues. The recommendations as presented here will need to be evaluated for improvements to allow for continued optimization of diagnostics and care.

Calcaneal lateral column lengthening osteotomy for symptomatic flexible flatfoot in children and adolescents: a systematic review

Flexible flatfoot is a common condition in small children, which shows a strong tendency to spontaneously correct with their growth or to become moderate or mild in adults, which will not cause future problems. However, in a small number of cases, this condition is more severe, does not improve spontaneously, which may cause mechanical impairment, deformity, and, eventually, pain. In such cases, surgical treatment should be considered. The aim of this systematic review was to evaluate the literature results on the treatment of the symptomatic flexible flatfoot in children or adolescents through a very frequent procedure: calcaneal lateral column lengthening osteotomy, A systematic electronic search in PubMed, Web of Science, Cochrane, CINAHL, SciELO, SCOPUS and LILACS databases was performed. We searched articles published between March 1975 and September 2016. After applying the eligibility criteria, the selected publications were evaluated in relation to their clinical and radiographic results and complications. We found 341 articles in the mentioned databases, but selected only eight studies, according to the inclusion and exclusion criteria. These studies included a total of 105 patients and 167 treated feet. Only three authors performed prospective studies, but without case-control or randomization. The majority of publications were descriptive studies or case series (level of evidence III or IV), with great methodological variations, but with a high satisfaction rate on the part of both patients and surgeons in relation to the results. However, more prospective and randomized studies are required, with adequate control groups and validated evaluation criteria.

Foot longitudinal arches in obese, overweight and normal weight females who differ in age

Nowadays, excessive body weight is the cause of death of more people than malnutrition. Obesity is a growing health problem worldwide, which also results in a considerable number of movement dysfunctions, including degenerative changes and foot pain. The study aimed to assess the effect of overweight and obesity on the height of foot arches in females aged 10-84 years, as well as to establish which factor - age or BMI - affected the height of medial longitudinal arch (MLA) to a greater extent. Three groups of females (96 pupils, 86 young adults and 88 seniors) were selected to participate in the study. The participants' height and weight were measured, their BMI calculated and their body weight status categorized as normal weight, overweight or obesity. The height of foot arches was assessed using the Arch Index (AI). According to the value of the AI, the foot was defined as high-arched, normal or flat. Differences in participants' AI were determined in their age and weight status groups. Correlations between BMI and AI were calculated for the whole study sample and age groups. The analysis used the Shapiro-Wilk test, the Kruskal-Wallis test and Pearson's linear correlation. Overweight or obesity prevailed in 31% of pupils, 4.7% of young adults and in 77% of seniors. Pupils and young adults had often the high-arched foot. Flat feet were mostly observed in seniors and were common in obese individuals. BMI significantly correlated with the height of the foot arch but their age did not. Excessive body weight contributes to the development of flat feet to a greater extent than age.

Bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot

Flatfoot is a common condition in growing-age patients. Despite its common presentation, nowadays surgical indications and treatments are still debated. Arthroereisis is a widely used technique, and several implants designs have been proposed over time. Despite the good results shown in the literature, the main drawback of these techniques has always been the need for a second surgery for implant removal. Bioabsorbable devices have been introduced to overcome this necessity.Correct approach to the patient, indications and contraindications and available studies on bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot were analyzed in this narrative review. Even if only a few studies have been published in the literature, bioabsorbable implants showed good clinical results comparable to non-absorbable implants and with a rare necessity for implant removal or revision. When correct indications and proper surgical technique are followed, arthroereisis with bioabsorbable implants appears to be an effective solution for the treatment of pediatric flexible flatfoot.