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Review Article

Flatfoot Deformity in Children and


Adolescents: Surgical Indications
and Management
Abstract
Maryse Bouchard, MD, MSc
Vincent S. Mosca, MD

Most children with flatfeet are asymptomatic and will never require
treatment. In general, flatfoot deformity is flexible and will not cause pain
or disability; it is a normal variant of foot shape. Thus, it is essential to
reassure and educate patients and parents. A flatfoot with a contracture
of the Achilles tendon may be painful. In these cases, a stretching
program may help relieve pain. Scant convincing evidence exists to
support the use of inserts or shoe modifications for effective relief of
symptoms, and there is no evidence that those devices change the
shape of the foot. The surgeon must be vigilant to identify the rare rigid
flatfoot. Indications for flatfoot surgery are strict: failure of prolonged
nonsurgical attempts to relieve pain that interferes with normal activities
and occurs under the medial midfoot and/or in the sinus tarsi. In nearly all
cases, an associated contracture of the heel cord is present.
Osteotomies with supplemental soft-tissue procedures are the best
proven approach for management of rigid flatfoot.

A
From the Department of Orthopedics
and Sports Medicine, Seattle
Childrens Hospital, University of
Washington School of Medicine,
Seattle, WA.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Bouchard
and Dr. Mosca.
J Am Acad Orthop Surg 2014;22:
623-632
http://dx.doi.org/10.5435/
JAAOS-22-10-623
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.

October 2014, Vol 22, No 10

lthough flatfoot deformity is


a common reason for a child to
present for evaluation by a healthcare
provider, understanding of the deformity and consensus regarding its
management is poor, particularly
among healthcare providers in different medical specialties. This is due to
several factors, including the poor
methodology of published reports, the
lack of controlled research studies,
and conflicting evidence in the literature. Studying the natural history
of the flatfoot is difficult because most
affected patients are asymptomatic
and do not seek medical attention.
Moreover, because no established
clinical or radiographic criteria exist
to define the flatfoot, the true prevalence of the deformity is unknown.
Traditionally, flatfoot was described
as a low or absent medial longitudinal arch, with the hindfoot in
excessive valgus alignment.1

The present consensus is that flexible


flatfoot is present from birth and exhibits good joint mobility and normal
muscle function.1 Despite the lack of
high-quality research, it is clear that
most flatfoot deformities in children
are flexible, painless, and functional
and do not require treatment. Children with a painless flatfoot who visit
an orthopaedist are generally brought
in because their parents are concerned
that the foot deformity will cause pain
and/or disability in adulthood. The
role of the orthopaedist is to reassure
patients and parents of children with
flexible flatfeet that no treatment is
necessary and to identify and treat the
rare flatfoot deformities that may
become disabling.
In their 1947 study of foot pathology
in 3,600 Canadian soldiers, Harris and
Beath2 reported that flatfeet were seen
in approximately 23% of the recruits.
Sixty-four percent of flatfeet were

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Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management

flexible and were rarely the cause of


pain or disability. The authors concluded that a flexible flatfoot was
within the spectrum of normal. Flexible flatfoot with a short Achilles
tendon and rigid flatfoot accounted
for the remaining flatfeet, and these
deformities sometimes led to pain and
disability.

Epidemiology
The literature suggests that the prevalence of flatfoot deformity varies with
age, sex, body weight, and ethnicity. In
general, the incidence of flatfoot in
adults is at least 20%.2 Most infants,
however, are born without a medial
longitudinal arch.1 According to
Staheli et al,3 in most children, the
arch develops naturally by the middle
of childhood (approximately age 5
years). In a study of 835 school children in Austria, Pfeiffer et al4 reported
that 54% of children aged 3 years had
a flatfoot deformity, whereas only
24% of children aged 6 years had
flatfeet. The overall prevalence of
flexible flatfoot deformity was 44%,
and ,1% of children had rigid flatfoot. The authors also found that boys
were twice as likely as girls to have
a flatfoot deformity, and children who
were obese were three times as likely
as those with a healthy weight. The
authors results are within the range of
prevalence reported in earlier studies
in which flatfoot was seen in as many
as 70% of children aged 3 to 4 years
and as few as 9.1% of children aged 7
years.4,5 In a recent Cochrane review,
Evans and Rome6 estimated that
flatfoot deformity affects approximately 45% of preschool children and
15% of older children (average age,
10 years). The authors also noted
a higher prevalence of flatfoot in
obese children and those with generalized joint hypermobility. Dowling
et al7 and Bordin et al8 also reported
a higher incidence of flatfoot in obese
children.

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Ethnicity may also play a role.


Mann9 noted a higher incidence of
flatfoot deformity in blacks than in
Caucasians. Studies of specific populations (eg, Chinese), have also suggested that consistently shod feet are
more likely to develop flatfoot deformities.10 These findings do not
support the tendency to prescribe shoe
inserts and braces for correction of the
flatfoot shape.
In all of the previously mentioned
papers, most of the patients with flatfoot deformities were asymptomatic.

Pathogenesis and Natural


History
In the literature, there are two main
theories that explain the development of flexible flatfoot deformity.
Duchenne, 11 Jones, 12 and others
believed that maintenance of the longitudinal arch was based on muscle
strength. However, Basmajian and
Stecko13 believed that the height of the
arch was determined by the boneligament complex. They provided
evidence that muscles function to
maintain balance, propel the body
forward, and navigate uneven terrain
but do not determine the shape of
the foot.
Based on their study of Canadian
soldiers, Harris and Beath2 subdivided
flatfeet into three types. Flexible flatfoot, which represented two thirds of
the total flatfeet, was characterized by
full range of motion of the ankle and
subtalar joints and rarely causes
symptoms or disability. Flexible flatfoot with a short Achilles tendon accounted for 27% of the flatfeet and
was characterized by restricted ankle
dorsiflexion. Patients with this deformity often report pain. Finally, rigid
flatfoot was characterized by decreased
subtalar joint motion and was present
in 9% of all flatfeet in the study.2 This
deformity is most commonly associated with tarsal coalitions (TCs) and is
occasionally symptomatic.

Evaluation
History
A careful history must be taken to
determine the reason for the consultation. Often, the concern about flatfoot is purely cosmetic or anxiety
exists regarding possible problems in
the future. If a patient presents with
symptomatic flatfoot, the orthopaedist must elicit the childs birth history,
medical history, family history, onset
and location of pain, pain triggers and
relievers, difficulty with shoe wear,
skin problems, functional disability,
and the results of any attempted
treatment.
Rigid or pathologic flatfoot may be
associated with paralytic or neuromuscular conditions such as cerebral palsy
and myelomeningocele,14 congenital
deformities such as a TC or accessory
navicular, and intrauterine positional
consequences such as calcaneovalgus.
Flatfoot is also part of the spectrum of
deformity associated with skewfoot
deformity.1 Flexible flatfoot and generalized ligamentous laxity can be
familial; therefore, obtaining a thorough family history is essential.1
Locating the pain and its precipitating
causes can be helpful in determining the
type of the flatfoot deformity.1 When
painful, flexible flatfeet are typically
sore under the plantarmedial aspect of
the midfoot and, occasionally, at the
sinus tarsi. This is especially true in
patients with a concomitant contracture of the Achilles tendon. In patients
with rigid flatfeet, pain can occur in
multiple areas, including the medial
hindfoot, the sinus tarsi and, occasionally, the plantarmedial aspect of
the midfoot. In patients with flexible
flatfoot, pain is typically related to
activity, although this is also true of
rigid flatfoot. Night pain as well as
swelling, warmth, and redness are
unusual in flexible and rigid flatfoot. Indications for surgery include
intractable pain and disability that
do not respond to nonsurgical

Journal of the American Academy of Orthopaedic Surgeons

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Maryse Bouchard, MD, MSc, and Vincent S. Mosca, MD

Figure 1

Clinical photographs of the feet demonstrating flexible flatfoot deformity (A), a valgus hindfoot (B), and restoration of hindfoot
varus when the patient stands on the toes (C). (Reproduced with permission from Mosca VS: Flexible flatfoot and skewfoot,
in McCarthy JJ, Drennan JC, eds: Drennans The Childs Foot and Ankle, ed 2. Philadelphia, PA, Lippincott Williams &
Wilkins, 2009, pp 136-159.)

treatment; thus, obtaining a detailed


history is an important part of flatfoot
assessment.1,14

Clinical Examination
A physical examination of the child is
performed, with particular attention
paid to the lower extremities. The orthopaedist should focus on torsional
and angular variations in the lower
extremities gait patterns, ligamentous
laxity, and signs of related medical
conditions (eg, Marfan syndrome,
Down syndrome, other connective tissue disorders).1 Although there is no
association between flexible flatfoot
and developmental dysplasia or dislocation of the hip, a focused examination of the hip should be performed
as a routine part of the physical
examination in an infant who is being
evaluated for flatfoot or any other
musculoskeletal deformity.
It is important to assess the overall
shape of the foot. A flexible flatfoot will
have a low or absent longitudinal arch
and hindfoot valgus and may have
mild abduction of the midfoot. Infants
will have a flat arch in all positions. By
walking age, children with flexible
flatfoot will appear to have an arch
when sitting with the foot dangling and
October 2014, Vol 22, No 10

a flat arch when weight bearing. In


patients with a physiologic flexible
flatfoot, the medial longitudinal arch
will elevate, and the hindfoot valgus
will change to varus when standing on
the toes (Figure 1). In patients with
a rigid flatfoot, the arch will be flat,
and the hindfoot will remain in valgus
whether the foot is dangling or weight
bearing and during toe standing.1
Determining whether a heel cord
contracture is present is essential
because this deformity can help the
orthopaedist differentiate between
asymptomatic flexible flatfoot and
the frequently symptomatic flexible
flatfoot with a short Achilles tendon.1
To clinically identify a tight heel cord
that limits ankle dorsiflexion, the Silfverskiold test is performed (Figure 2).
The position of the hindfoot is
important. The subtalar joint must
be inverted to neutral and held locked
in that position to isolate and assess
the motion of the talus in the ankle
joint. The knee is flexed, and the ankle
is dorsiflexed while neutral alignment
of the subtalar joint is maintained.
Dorsiflexion is measured as the angle
between the plantarlateral border of
the foot and the anterior tibial shaft.
Dorsiflexion of ,10 indicates contracture of the soleus muscle, which

Figure 2

Clinical photograph demonstrating the


Silfverskiold test. The subtalar joint
must be held in neutral position with the
knee extended to accurately assess
ankle dorsiflexion between the
plantarlateral border of the foot and the
anterior tibial shaft. (Reproduced with
permission from Mosca VS: Flexible
flatfoot and skewfoot, in McCarthy JJ,
Drennan JC, eds: Drennans The
Childs Foot and Ankle, ed 2.
Philadelphia, PA, Lippincott Williams &
Wilkins, 2009, pp 136-159.)

indicates a contracture of the entire


Achilles tendon. The orthopaedist then
extends the knee while maintaining

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Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management

Figure 3

A, AP radiograph of the foot demonstrating the talus-first metatarsal (T-1stMT) angle. B, Lateral radiograph of the foot
demonstrating the calcaneal pitch (CP) angle and T-1stMT angle. (Reproduced with permission from Mosca VS: Flexible
flatfoot and skewfoot, in McCarthy JJ, Drennan JC, eds: Drennans The Childs Foot and Ankle, ed 2. Philadelphia, PA,
Lippincott Williams & Wilkins, 2009, pp 136-159.)

neutral alignment of the subtalar joint


and trying to maintain dorsiflexion of
the ankle joint. Dorsiflexion is again
measured as the angle between the
plantarlateral border of the foot and
the anterior tibial shaft. If dorsiflexion
.10 is possible with the knee flexed,
but ,10 of dorsiflexion is possible
with the knee extended, a contracture
of the gastrocnemius muscle alone is
present.
The shoes and any inserts or braces
should also be examined. Asymmetric medial wear of the sole of the shoe
is common in the patient with flexible
flatfoot. Medial wear at the heel of
the shoe is most common. When the
Achilles tendon is tight, wear is typically seen at the medial midfoot.1

Imaging
Radiography is not indicated when
evaluating patients with asymptomatic
physiologic flexible flatfoot,1,14 but it
may be required for assessment of
a painful and/or rigid flatfoot. In these
cases, radiographic evaluation should

626

include weight-bearing AP and lateral


views of the foot and an AP view of
the ankle. An oblique view of the
foot and a Harris axial view of the
hindfoot can be ordered if there is
concern for a TC. This view can
provide an inexpensive and quick
(although not definitive) assessment
of the subtalar joint. If the physical
examination and Harris view raise
concern for a possible talocalcaneal
TC, then CT can be performed for
a more definitive evaluation.1 Several
studies have attempted to determine
which radiographic measurements are
most useful to diagnose flatfoot and to
assess the adequacy of surgical reconstruction. The most commonly used
and validated angles are the calcaneal
pitch, the talus-first metatarsal angle on
AP and lateral views, and talonavicular
coverage14,15 (Figure 3).
In the literature, normal values for
these angles vary and no clear consensus
exists regarding what constitutes
abnormal values. Meary 16 believed
that a foot with a normal longitudinal arch should have an angle of 0

from the axis of the talus and the axis


of the first metatarsal on both the AP
and lateral views.1 However, Davids
et al15 showed that these angles vary
(mean of 10 in the AP plane and 13
in the lateral) even in normal feet.
Davids et al15 also reported that the
normal calcaneal pitch angle was an
average of 17 and talonavicular coverage was 20.
Advanced imaging is rarely indicated
for assessment and/or management of
flatfoot deformity, with the exception
of TC. CT can better delineate the
extent and exact location of the coalition, the health of the remainder of the
subtalar joint, and the degree of hindfoot deformity17-20 (Figure 4).

Management
Nonsurgical
Children with flexible or rigid flatfoot
who experience pain or have difficulty
with shoe wear require treatment. A
small number of uncontrolled studies
have suggested that shoe modifications,

Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Maryse Bouchard, MD, MSc, and Vincent S. Mosca, MD

Figure 4

A, Lateral radiograph of the foot demonstrating a talocalcaneal coalition. Note the C-sign of Latour (dashed line), which
outlines the bony connection of the subchondral bone from the talar dome and the subchondral bone of the inferior aspect of
the sustentaculum tali. B, Coronal CT of the foot demonstrating a talocalcaneal coalition (arrow). The size and location of the
coalition are better assessed on CT. (Panel A reproduced with permission from Mosca VS: The foot, in Weinstein SL, Flynn
JM: Lovell and Winters Pediatric Orthopaedics, 7th ed. Philadelphia, PA, Lippincott Williams & Wilkins, 2014, pp 29-133.
Panel B reproduced with permission from Mosca VS, Bevan WP: Talcalcaneal tarsal coalitions and the calcaneal
lengthening osteotomy: The role of deformity correction. J Bone Joint Surg Am 2012;94[17]:1584-1594.).

arch supports, and orthoses can create


a longitudinal arch in a flatfoot.21,22
Others have refuted the effectiveness of
these devices in creating a longitudinal
arch.23,24 In a prospective, randomized
study, Wegner et al24 demonstrated no
treatment effect or permanent elevation of the arch associated with the use
of shoe modifications and orthoses in
otherwise normal children compared
with an untreated matched cohort
at a minimum follow-up of 3 years.
Intrinsic muscle strengthening exercises
also have no effect on the height or
development of the longitudinal arch.25
Uncontrolled and controlled studies have reported on alleviation of
pain with the use of certain types of
arch support.22-24 In the patient with
a supple flatfoot deformity, inversion
of the hindfoot may unload pressure
points and decrease exaggerated muscle activity, thereby reducing pain.14 A
recent Cochrane review by Evans and
October 2014, Vol 22, No 10

Rome6 reported that the pediatric


flatfoot was often unnecessarily
treated. With the lack of evidence to
support the use of orthoses, the authors recommended the use of inexpensive, over-the-counter devices on
the rare occasions that they are indicated for ongoing symptoms. The
use of custom orthotics and shoes
should be reserved for patients with
arthritis or those who are unresponsive to other nonsurgical treatments,
including over-the-counter orthotics.26 However, in a patient with
a rigid flatfoot deformity or flexible
flatfoot with a short Achilles tendon,
using these devices is likely to worsen
symptoms.1,26 As the orthosis or shoe
attempts to invert the rigidly everted
subtalar joint or dorsiflex the rigidly
plantarflexed ankle joint, increased
pressure is concentrated under the
medial midfoot, which exacerbates
the pain.1

If the flexible flatfoot deformity is


accompanied by a tight Achilles tendon, the child may benefit from
a stretching program.1 The child and
parents can learn the program and
perform it daily at home. It is important to instruct them in techniques to
ensure that the forefoot is supinated
and the hindfoot is inverted to neutral
during the heel cord stretch. This can
prevent injury to the midfoot and false
dorsiflexion through the subtalar joint,
respectively.1,14

Surgical
Evans and Rome6 concluded that surgery was rarely indicated for pediatric
flatfoot. In the patient with flexible
flatfoot, surgery is indicated after failure of prolonged nonsurgical attempts
to relieve pain that occurs under the
medial midfoot and/or in the sinus
tarsi and that interferes with normal

627

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Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management

Figure 5

Axial CT of the foot demonstrating


osteolysis secondary to a metal
arthroereisis implant. (Reproduced with
permission from Mosca VS: Flexible
flatfoot and skewfoot, in McCarthy JJ,
Drennan JC, eds: Drennans The
Childs Foot and Ankle, ed 2.
Philadelphia, PA, Lippincott Williams &
Wilkins, 2009, pp 136-159.)

activities.1,6,14 In nearly all cases, an


associated contracture of the heel cord
is present.1 Surgery should rarely be
performed in early childhood.3
Soft-tissue procedures such as tendon transfers, plications, and isolated
Achilles tendon lengthening are rarely
successful.1,14 Arthrodesis, either talonavicular or subtalar (triple), will
realign the foot but will significantly
reduce mobility, eliminate the shock
absorbing function of the foot, and
increase the risk of developing arthritis
in adjacent joints.27
Arthroereisis is a technique that attempts to correct the flatfoot by restricting excessive subtalar eversion
with a synthetic, metal, or bone
implant inserted into the sinus tarsi.
Outcomes of the procedure have been
poorly studied. Advocates suggest that
it is minimally invasive and preserves
subtalar joint motion, whereas opponents are guarded about the long-term
effects of placing a foreign body that
restricts motion into the subtalar joint.6
The reported rate of complications,

628

including undercorrection and overcorrection, implant resorption, inflammatory reactions, and persistent pain,
has been as high as 30%1 (Figure 5).
At this time, insufficient evidence
exists to define the indications for
arthroereisis or support its use.1,6
Osteotomies, which can realign the
foot without sacrificing mobility or
risking the development of early
arthritis, have become the mainstay of
surgical management of flexible flatfoot
deformity.28 Several types of osteotomies have been described, although
two techniques have become popular:
calcaneal lengthening
osteotomy
(CLO) and calcaneo-cuboid-cuneiform
(triple C) osteotomy.
CLO was originally described by
Evans.29 This surgical procedure corrects all of the components of valgus/
eversion deformity of the hindfoot at
the site of the deformity. A long-term
follow up study performed at Evans
institution confirmed the efficacy of
this approach.30 However, because the
description of the technique was terse,
poor outcomes were often achieved
by others who attempted to perform
the procedure. The technique was
interpreted, modified, and further
developed by Mosca,14 who described
the strict indications for the procedure, the specific location of the
osteotomy, and the shape of the
bone graft (Figure 6). In addition,
the author described the management of the medial and lateral soft
tissues, the need to temporarily stabilize the calcaneocuboid joint, and the
need to assess and concurrently manage rigid forefoot supination deformity and contracture of the Achilles
tendon or gastrocnemius muscle.
Recognition and concurrent management of coincident forefoot deformity
and heel cord contracture are critical
components of the procedure. The
Silfverskiold test is performed after
correction of the hindfoot deformity
to determine whether the Achilles
tendon or the gastrocnemius muscle
alone should be lengthened. Consis-

tently good results, with satisfaction


rates as high as 93.5%, have subsequently been reported.1,14 Similar
results have been achieved with the use
of autograft or allograft.28,31
Rathjen and Mubarak32 developed
the triple C osteotomy. It consists of
sliding and medial closing wedge
osteotomies of the posterior calcaneus,
a plantar-based closing wedge osteotomy of the medial cuneiform, and an
opening wedge osteotomy of the
cuboid. This technique creates deformities of the hindfoot/midfoot to
compensate for the valgus/eversion
deformity of the hindfoot rather than
correcting the deformity. A recent
prospective study by Moraleda et al28
compared this osteotomy with CLO
(as described by Mosca14) after nonsurgical interventions failed in symptomatic pediatric patients with flexible
flatfeet. The authors reported that both
techniques achieved good clinical and
radiographic outcomes. CLO produced significantly better correction of
the subluxated navicular on the head of
the talus (talonavicular coverage on an
AP radiograph) and improvement of
the talus-first metatarsal angle on the
AP view, but the procedure was associated with a marginally higher rate of
complications. Most of these complications were related to subluxation of
the calcaneocuboid joint and can be
avoided with proper stabilization of the
joint, as described in the literature.
The Dwyer lateral opening wedge
osteotomy of the posterior calcaneus,33 which attempts to correct the
hindfoot valgus alone, has also been
used to manage flexible flatfoot. The
use of double osteotomies, such as
a combined calcaneal lengthening and
a posterior medial calcaneal slide osteotomy, has been described, as well.14

Other Flatfoot Conditions


Calcaneovalgus Deformity
This deformity, which is present at
birth, consists of hyperdorsiflexion at

Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Maryse Bouchard, MD, MSc, and Vincent S. Mosca, MD

Figure 6

Figure 7

Clinical photograph demonstrating


calcaneovalgus foot deformity.

Illustrations of the dorsal (A) and lateral (B) views of the foot demonstrating the
calcaneal lengthening osteotomy. After an osteotomy is performed in the anterior end
of the calcaneus (gray area), an appropriately sized wedge-shaped tricortical iliac
crest bone graft is inserted to create inversion of the subtalar joint and correct the
deformity. (Reproduced with permission from Mosca FS: Calcaneal lengthening for
valgus deformity of the hindfoot. J Bone Joint Surg Am 1995;77[4]:500-512.)

the ankle and mild valgus alignment


at the ankle and subtalar joints
(Figure 7). The longitudinal arch is
present, with normal alignment at
the talonavicular joint. This deformity may be present in 30% to 50%
of neonates and is likely due to
intrauterine positioning.34 Calcaneovalgus foot deformity resolves
spontaneously and has not been
found to lead to a flatfoot deformity
or any disability. It must be differentiated from congenital vertical
talus (CVT), which is a rigid, rockerbottom foot deformity that always
requires treatment.1

Congenital Vertical Talus


CVT presents at birth as a rigid flatfoot. It is characterized by dorsiflexion through the midfoot, which
may create a rocker-bottom deformity, and hindfoot equinovalgus
(Figure 8, A). The toe extensors may
also be contracted. The deformities
cannot be passively corrected and
October 2014, Vol 22, No 10

require management in the form of


casting, surgery, or both.35 The etiology of CVT is still unknown. Ogata
et al36 reported that the deformity can
have a familial tendency. It is frequently found in children with myelomeningocele and arthrogryposis.1
Radiographic assessment of the
foot shows vertical alignment of the
talus with the axis of the tibia on
a lateral view. The navicular, midfoot, and forefoot are dorsally dislocated on the talar head and neck, as
seen in Figure 8, B. The midfoot and
forefoot remain dorsiflexed, even in
forced plantar flexion.35
Management of CVT has evolved
in recent years from purely surgical
treatment to one in which serial
casting and minimally invasive surgery is frequently successful, particularly in idiopathic cases.37 For feet
that do not respond to nonsurgical
management, the dorsal approach
for surgical reconstruction is the
treatment of choice.38

Tarsal Coalition
TC is the abnormal fusion of two or
more bones in the midfoot or hindfoot
and has a reported prevalence of 2%,
although it may be as high as
13%.18,39 Talocalcaneal and calcaneonavicular coalition are the most
common types.17,20 Up to 75% of feet
with coalitions are asymptomatic.18 If
pain develops, it is usually not until
age 8 years, when ossification or
maturation of a fibrous coalition to
a cartilaginous coalition takes place.
Pain may be experienced at the site of
the coalition, at adjacent joints, or
under the medial midfoot. It is worse
with activity and forced foot inversion.1,18 As mentioned previously,
TCs are typically diagnosed with
radiography and CT (Figure 4). MRI
may be useful in the case of a fibrous
coalition, but treatment decisions are
based on CT findings.17-20,40
Initially, patients with symptomatic
feet and TCs are treated nonsurgically.34 When nonsurgical management fails to relieve the pain,
surgery may be considered.18,19,34,40,41
TC resection involves removal of the
bar and interposition of either fat,
tendon, muscle, or bone wax at the
coalition site.18-20,40,41 Good short-

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Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management

Figure 8

Figure 9

A, Clinical photograph of the foot in an infant with congenital vertical talus


deformity. B, Lateral radiograph of the foot in forced dorsiflexion showing
persistent plantar flexion of the talus and dorsal dislocation of the navicular on
the talar head, which is indicated by the dorsal alignment of the axis of the first
metatarsal with the axis of the talus.

and long-term outcomes have been


reported following resection of a calcaneonavicular coalition.19,34,40,41
Reported outcomes following resection of talocalcaneal coalitions have
not been as good. The results seem to
correlate with the size of the coalition,
the health of the posterior facet of the
subtalar joint, and the degree of hindfoot valgus deformity.18,19,34 Historically, subtalar or triple arthrodesis has
been recommended for large coalitions (.50% of the joint), inadequate
pain relief after resection, recurrence
of the coalition, and significant hindfoot valgus malalignment, and when
significant degenerative changes are
present.17,19,34
In a recent retrospective review of 32
resected TCs in 24 patients, Khoshbin
et al41 reported good long-term clinical and functional outcomes when
the coalition involved .50% of the
joint and hindfoot valgus exceeded
16. Of note, one patient required
a concurrent Achilles tendon lengthening and two had concomitant
Dwyer osteotomies. Gantsoudes
et al40 published a retrospective
review on 49 feet (32 patients) treated
with excision and fat graft interposition for symptomatic talocalcaneal
coalitions. They reported that 11 feet
(22%) required subsequent surgery: 8
(16%) needed flatfoot reconstruction,

630

2 (4%) had re-excision for recurrence


or incomplete excision, and 1 (2%)
required wound dbridement.
Recently, Mosca and Bevan18 reported on an algorithmic approach to
the surgical management of talocalcaneal coalitions that includes resection
and fat grafting alone, deformity correction with CLO alone, or resection
and fat grafting with concurrent
deformity correction and CLO. Management of TC requires a thoughtful
plan based on the size and type of
coalition, health of the posterior facet,
and presence of concurrent deformity.

Skewfoot
The exact etiology and natural history
of idiopathic skewfoot are unknown.
Skewfoot can be present at birth,
develop during growth, or exist as
a postoperative iatrogenic deformity.
It is characterized by a Z-shape, with
significant hindfoot valgus and metatarsus adductus1,14 (Figure 9).
In our experience, symptoms caused
by skewfoot deformity in early childhood typically manifest as calluses and
difficulty with shoe wear related to the
metatarsus adductus segmental deformity. In adolescence, symptoms are
similar to those of a painful flatfoot
with a tight Achilles tendon. Patients
present with pain at the plantarmedial

AP radiograph of the foot


demonstrating skewfoot deformity. This
deformity is characterized by
translation of the parallel axes of the
talus (solid line) and first metatarsal
(dashed line) and results in forefoot
adductus and hindfoot valgus.
(Reproduced with permission from
Mosca FS: Calcaneal lengthening for
valgus deformity of the hindfoot. J Bone
Joint Surg Am 1995;77[4]:500-512.)

midfoot and possibly impingementtype pain in the sinus tarsi region.


Coincident tightness of the Achilles
tendon is typically identified.
Although modified shoe wear,
orthotics, and insoles are successful
in relieving symptoms in some cases,
surgical management may be
required in recalcitrant cases.14 A
CLO with medial cuneiform opening
wedge osteotomy and Achilles tendon
lengthening can correct segmental
deformities in most cases, while
maintaining subtalar joint motion.
Good results have been reported with
this approach for severe skewfoot
deformity.14

Summary
Most flexible flatfoot deformities are
asymptomatic, will not lead to future
pain or disability, and do not require
treatment. Patient and parent reassurance and education by the

Journal of the American Academy of Orthopaedic Surgeons

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Maryse Bouchard, MD, MSc, and Vincent S. Mosca, MD

orthopaedist are essential. For the


rare painful flatfoot, there is little
convincing evidence that nonsurgical treatment is consistently
effective. If shoe modifications, inserts, or orthoses are prescribed, cost
should be kept in mind.
Indications for surgery are strict,
thereby making surgery for flatfoot
uncommon. Indications include
intractable pain and disability despite
prolonged attempts at nonsurgical
management. In nearly all cases, an
associated contracture of the
Achilles tendon is present. Osteotomies are generally the best
approach, with concurrent procedures performed as needed. The
surgeon must also be vigilant to
identify the rare rigid flatfoot because
a different treatment approach is
required.

References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6
and 24 are level I studies. Reference 21
is a level II study. References 28, 31,
and 41 are level III studies. References
18, 22, 37, and 40 are level IV studies.
References printed in bold type are
those published within the past 5 years.
1. Mosca VS: Flexible flatfoot in children and
adolescents. J Child Orthop 2010;4(2):
107-121.
2. Harris RI, Beath T: Army Foot Survey: An
Investigation of Foot Ailments in Canadian
Soldiers. Ottawa, Ontario, National
Research Council of Canada, 1947, vol 1,
pp 1-268.

shoes. J Pediatr Orthop B 2003;12(2):


141-146.
6. Evans AM, Rome K: A Cochrane review of
the evidence for non-surgical interventions
for flexible pediatric flat feet. Eur J Phys
Rehabil Med 2011;47(1):69-89.
7. Dowling AM, Steele JR, Baur LA: Does
obesity influence foot structure and plantar
pressure patterns in prepubescent children?
Int J Obes Relat Metab Disord 2001;25(6):
845-852.
8. Bordin D, De Giorgi G, Mazzocco G,
Rigon F: Flat and cavus foot, indexes of
obesity and overweight in a population of
primary-school children. Minerva Pediatr
2001;53(1):7-13.
9. Mann RA: Biomechanics of the foot and
ankle, in Mann RA, ed: Surgery of the Foot.
St. Louis, CV Mosby, 1986, pp 1-30.
10. Sim-Fook L, Hodgson AR: A comparison
of foot forms among the non-shoe and
shoe-wearing Chinese population. J Bone
Joint Surg Am 1958;40(5):1058-1062.
11. Duchenne GB: Physiology of motion.
Philadelphia, PA, WB Saunders, 1959,
p 337.
12. Jones BS: Flat foot: A preliminary report of
an operation for severe cases. J Bone Joint
Surg Br 1975;57(3):279-282.

22. Bordelon RL: Correction of hypermobile


flatfoot in children by molded insert. Foot
Ankle 1980;1(3):143-150.
23. Rose GK: Correction of the pronated foot.
J Bone Joint Surg Br 1962;44:642-647.
24. Wenger DR, Mauldin D, Speck G,
Morgan D, Lieber RL: Corrective shoes and
inserts as treatment for flexible flatfoot in
infants and children. J Bone Joint Surg Am
1989;71(6):800-810.
25. Mann R, Inman VT: Phasic activity of
intrinsic muscles of the foot. J Bone Joint
Surg Am 1964;46:469-481.
26.

14. Mosca VS: Calcaneal lengthening for


valgus deformity of the hindfoot: Results in
children who had severe, symptomatic
flatfoot and skewfoot. J Bone Joint Surg
Am 1995;77(4):500-512.
15. Davids JR, Gibson TW, Pugh LI:
Quantitative segmental analysis of weightbearing radiographs of the foot and ankle
for children: Normal alignment. J Pediatr
Orthop 2005;25(6):769-776.
16. Meary R: On the measurement of the angle
between the talus and the first metatarsal:
Symposium. Le Pied Creux Essential. Rev
Chir Orthop 1967;53:389-467.
17. Scranton PE Jr: Treatment of symptomatic
talocalcaneal coalition. J Bone Joint Surg
Am 1987;69(4):533-539.
18. Mosca VS, Bevan WP: Talocalcaneal tarsal
coalitions and the calcaneal lengthening
osteotomy: The role of deformity
correction. J Bone Joint Surg Am 2012;94
(17):1584-1594.

4. Pfeiffer M, Kotz R, Ledl T, Hauser G,


Sluga M: Prevalence of flat foot in
preschool-aged children. Pediatrics 2006;
118(2):634-639.

19. Wilde PH, Torode IP, Dickens DR,


Cole WG: Resection for symptomatic
talocalcaneal coalition. J Bone Joint Surg Br
1994;76(5):797-801.

5. Echarri JJ, Forriol F: The development in


footprint morphology in 1851 Congolese
children from urban and rural areas, and
the relationship between this and wearing

20. Luhmann SJ, Schoenecker PL: Symptomatic


talocalcaneal coalition resection:
Indications and results. J Pediatr Orthop
1998;18(6):748-754.

Jane MacKenzie A, Rome K, Evans AM:


The efficacy of nonsurgical interventions
for pediatric flexible flat foot: A critical
review. J Pediatr Orthop 2012;32(8):
830-834.

27. Saltzman CL, Fehrle MJ, Cooper RR,


Spencer EC, Ponseti IV: Triple arthrodesis:
Twenty-five and forty-four-year average
follow-up of the same patients. J Bone Joint
Surg Am 1999;81(10):1391-1402.
28.

13. Basmajian JV, Stecko G: The role of


muscles in arch support of the foot: An
electromyographic study. J Bone Joint Surg
Am 1963;45:1184-1190.

3. Staheli LT, Chew DE, Corbett M: The


longitudinal arch: A survey of eight
hundred and eighty-two feet in normal
children and adults. J Bone Joint Surg Am
1987;69(3):426-428.

October 2014, Vol 22, No 10

21. Bleck EE, Berzins UJ: Conservative


management of pes valgus with plantar
flexed talus, flexible. Clin Orthop Relat Res
1977;122:85-94.

Moraleda L, Salcedo M, Bastrom TP,


Wenger DR, Albiana J, Mubarak SJ:
Comparison of the calcaneo-cuboidcuneiform osteotomies and the calcaneal
lengthening osteotomy in the surgical
treatment of symptomatic flexible flatfoot.
J Pediatr Orthop 2012;32(8):821-829.

29. Evans D: Calcaneo-valgus deformity.


J Bone Joint Surg Br 1975;57(3):270-278.
30. Phillips GE: A review of elongation of os
calcis for flat feet. J Bone Joint Surg Br
1983;65(1):15-18.
31.

Vining NC, Warme WJ, Mosca VS:


Comparison of structural bone autografts
and allografts in pediatric foot surgery.
J Pediatr Orthop 2012;32(7):719-723.

32. Rathjen KE, Mubarak SJ: Calcanealcuboid-cuneiform osteotomy for the


correction of valgus foot deformities in
children. J Pediatr Orthop 1998;18(6):
775-782.
33. Dwyer FC: Osteotomy of the calcaneum for
pes cavus. J Bone Joint Surg Br 1959;41(1):
80-86.
34. Sullivan RJ: Adolescent foot and ankle
conditions, in Pinzur MS, ed: Orthopaedic
Knowledge Update: Foot and Ankle 4.
Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2008, p 47-55.
35. Clark MW, DAmbrosia RD,
Ferguson AB: Congenital vertical talus:
Treatment by open reduction and
navicular excision. J Bone Joint Surg Am
1977;59(6):816-824.
36. Ogata K, Schoenecker PL, Sheridan J:
Congenital vertical talus and its familial

631

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Flatfoot Deformity in Children and Adolescents: Surgical Indications and Management


occurrence: An analysis of 36 patients.
Clin Orthop Relat Res 1979;139:
128-132.
37. Dobbs MB, Purcell DB, Nunley R,
Morcuende JA: Early results of a new
method of treatment for idiopathic
congenital vertical talus. J Bone Joint Surg
Am 2006;88(6):1192-1200.

632

38. Mazzocca AD, Thomson JD, Deluca PA,


Romness MJ: Comparison of the posterior
approach versus the dorsal approach in the
treatment of congenital vertical talus.
J Pediatr Orthop 2001;21(2):212-217.
39. Harris RI, Beath T: Etiology of peroneal
spastic flat foot. J Bone Joint Surg Br 1948;30
(4):624-634.

40.

Gantsoudes GD, Roocroft JH,


Mubarak SJ: Treatment of talocalcaneal
coalitions. J Pediatr Orthop 2012;32(3):
301-307.

41.

Khoshbin A, Law PW, Caspi L, Wright JG:


Long-term functional outcomes of resected
tarsal coalitions. Foot Ankle Int 2013;34
(10):1370-1375.

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