Flexible Flatfoot

ajkim1's version from 2015-05-08 06:17


Question Answer
One common characteristic in all flatfoot deformitiesPartial or total collapse of arch
Most common type of flatfootFlexible flatfoot
Characteristics of flexible flatfootBegins in childhood and progresses into adulthood, bilateral and progressively worsens (PTTD), foot is flat when WB, arch returns when not standing
6 ligamentous parts of arch stabilityPlantar fascia, long/short plantar, spring, talocalcaneal interosseous, medial talocalcaneal, talonavicular
Muscular supports for arch stabilityPL, TP, FDL, FHL
Biomechanics behind flatfootMaximally pronated STJ in WB, calcaneus and foot everted, talus and leg internally rotated with adduction, MTJ unlocked, unstable, and hypermobile
Causes of flatfootCompensate FF varus, non-rigid or flexible FF valgus, ankle equinus, congenital talipes calcaneovalgus, torsional abnormalities, muscle imbalance, ligamentous laxity, neurotrophic feet
Clinical findings of flatfootEverted/valgus heel RCSP, abduction of FF/RF
Gait exam findings for flatfootIncreased angle of gait, delayed/absent supination of foot, decreased propulsion, genu valgum
Jack testFlexibility of flatfoot type
Jack test procedurePatient WB while hallux dorsiflexed
Positive finding of Jack testArch formation from the flatfoot being flexible
Negative finding of Jack testLack of arch formation from the flatfoot being rigid
Silverskiold testDifferentiates between solid and gastrosoleal equinus or tendoachilles lengthening vs gastric recession
Single heel raise testMuscle strength and tendon function
Double heel raise testReducibility of RF valgus
Flexible flatfootEverted heel, FF abduction, medial column collapse, equinus, flexible and reducible, postural foot and leg fatigue, night cramps, CSP>8 degrees, FF varus>10 degrees, midtarsal fault
DD of flatfootPTTD, tarsal coalition, arthritic/post-trauma, iatrogenic, charcot, neuromuscular
Best view for a tarsal coalitionHarris-beath
FF abduction radiographic viewAP shows TN coverage angle and 1st MT talar angle
Collapse of longitudinal arch radiographic viewLateral shows 1st MT talar angle and calcaneal pitch
Hindfoot valgus radiographic viewLateral and AP show talocalcaneal angle
Best radiographic view for Cyma lineAP and lateral
What increases in AP view of flatfoot?Talocalcaneal angle, cuboid abduction angle, talocuboid angle, lesser tarsus angle
What decreases in AP view of flatfoot?TNJ articulation, talo-1st MT angle, FF adductus angle
What increases in lateral view of flatfoot?Talocalcaneal angle, talar declination angle
What decreases in lateral view of flatfoot?Calcaneal inclination angle
Appearance of Cyma line in lateral viewUnbroken, anterior break
Axial calcaneal viewSustentaculum normal, posterior and middle facets parallel, clear joint spaces
Advanced imaging CTPediatric coalitions
Advanced imaging MRIEvaluate soft tissue pathology (PTTD)
Essential joints in bunionsSTJ and TN
What angles increase in sagittal plane dominanceTalar declination angle, TC angle on lateral
What angle decreases in sagittal plane dominance?Calcaneal inclination angle
What angles increase in transverse plane dominance?TC angle on AP, cuboid abduction angle
What angles decrease in transverse plane dominance?FF adduction angle, TNJ congruency
What angles decrease in frontal plane dominance1st MT declination angle, height of sustentaculum talk
FaultSag or collapse in medial column
Common faultsTNJ, NC, 1st MT-cuneiform joint
Conservative treatment goalCorrect ASAP before arthritis sets is
Treatment for <1yoPlaster casting, Ganley splint
Treatment for 1-3yoGanley splint, heel stabilizers or shoe correction, stretching
Treatment for 3yo-adolescenceNight splinting, orthotic device w/o FF posting, stretching
Treatment for adultOrthotics, shoe therapy
Goal of surgeryStabilize STJ and MTJ and want to to function normally during gait
Surgery for equinusGastrocnemius resection, tendo-achilles lengthening
Anterior osteotomy procedures for flatfootEvans
Posterior osteotomy procedures for flatfootDwyer, Silver, Koutsogiannis
Arthroereisis procedures for flatfootSelf locking, axis altering, impact blocking
Arthrodesis of medial column procedure for flatfootCotton
Soft tissue procedures for flatfootKidner, Young
KidnerPre-hallux or accessory navicular interferes with PT muscle mechanics and produces weakness of longitudinal arch
Kidney procedureResect hypertrophic navicular, remove OTE, TP and spring ligament advancement, adjunct to another bony procedure, helps bring up medial column
YoungTAL, TA re-routes through navicular keyhole, TP reefing (surgically reducing extent of tissue by folding it and securing with sutures), above knee cast 7-8 wks
K-wire size for Young0.062 in
ArthroereisisLifting up joint to prevent abnormal joint motion, prevents valgus motion at STJ, used with Kidner or Young procedure
Goals of arthroeresisPrevent lateral talar process from falling into calcaneal sulcus, increase arch heigh, stabilize STJ by stabilizing PL and medial column, decreasing heel valgus
Self-locking wedge implantElevates STJ axis, screws into STJ, any age, no removal
Axis-altering implantDrilled into calcaneus, 3-12yo, may be removed
Direct impact implantany age, do not remove
Purpose of self-locking and direct impactEliminates excessive STJ motion
Purpose of axis alteringSTJ pronates, front edge of talus glides over implant, motion permitted in only one plane perpendicular to joint axis
Indications for implantsBad RF valgus, 8-10 degree heel eversion, frontal plane deformity, >10 degrees FF varus, MF collapse, ligamentous laxity, PTTD
Relative CI for implantsSkewfoot, equinus, super torsional problems, severe frontal plane knee deformity, less than 3 yo
Absolute CI for implantsRigid flatfoot, structural FF varus, DJD, ankle valgus, prior infection, arthritis
Complications of implantsErosion, lateral process fracture, implant malposition or fracture, calcaneal frature, excessive posterior facet arthroplasty, sinus tarsitis
EvansLengthens calcaneus, reduces in TP
Evans procedureInsert transverse bone graft into distal 1/3 of calcaneus, linear incision over CCJ, reflect EDB and osteotomy 1-1.5 cm proximal to CCJ
DwyerWant to take calcaneus from everted to neutral
Dwyer procedureOpen wedge allows cut in calcaneus, put a graft in there to bring something everted more rectus
KoutsogiannisRealigns valgus heel and shifts function of Achilles medially
Koutsogiannis procedureOblique osteotomy through lateral approach, posterior fragment of calcaneus is displaced medially until it lies below sustentaculum talk or 1/3 to 1/2 width of calcaneus, fixate with 1-2 screws
Arthrodesis proceduresMedial column joints, TN joint, CC distraction arthrodesis, double and triple arthrodesis
Cotton medial arthrodesisOpening wedge of 1st cuneiform with tenosuspension that produces plantar flexion of medial column, allogenic bone graft used, adjunct to complete medial column fusion
Soft tissue post-op care4-6 wks post op NWB
Bone post-op care10-12 wks NWB
Implant post-op care3-4 wks post-op shoe