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Harold Schoenhaus: Our first speaker is probably well-known to some of you. Many of the faculty know, it happens to be myself. Not at a purpose or a reason, but I'm going to kick off the morning session. And the topic that I've selected is pediatric osseous flatfoot reconstruction. And then, following that talk, we're going to have a talk by Dr. David Solomon, sorry, Marshall, on arthroereisis.

So let's talk about pediatric osseous flatfoot reconstruction. First, one has to look at the fact that you're dealing with a pediatric population. These are youngsters. These are the gems of what we create that eventually become adolescents, teenagers and adults. And we look at this pediatric flatfoot and say, first of all, does it need any treatment at all? Should we be treating it? And certainly, should we be treating it surgically? And when one looks at the literature and the amount of articles that have been written on pediatric flatfoot, I'm not sure we've got the answer totally controlled or protected. One thing is for sure, there is really no other profession that looks at the flatfoot as critically as we do.

The parent who takes the child to the pediatrician and asks, "Are my youngster's feet too flat?" Is told, "Don't worry, the child is going to outgrow it." When they come in with pains in the legs that the kids may wake up at night complaining of, they're told it's growing pains, which implies, don't worry about it, they'll outgrow it.

[01:59]

It's not until the child matures a little bit more and they're awkward, and they are flat, and they are breaking down through shoes, and when you look at them, they looked like a duck walking. That now, the pediatrician may say, "Well, I think it's time we got them into an orthopedic shoe," with an insole or an insert in it, and maybe some type of heel that will help allow that foot to be controlled, protected and develop accordingly.

And then, when that doesn't work, then they send them to the orthopedic surgeon or the pediatric orthopedist, who then comes up with a fancy insert that goes into the shoe, and again, the encouragement that they will outgrow deformity. You almost have to scratch your head and look perplex and say, "What do you mean they are going to outgrow it?" What is there that's going to evolve functionally within the foot that's going to fight the forces of gravity, the forces of an equinus, the forces of an in-toe that are going to create changes within the architecture of the foot?

We know by the age of three, [Kleeger and Mankin] [03:15] talked about the fact that the articular facets and the shape of the foot are forming pretty much, and starting to establish their shape by the age of three. The maturation process isn't one. It's not a spring that's coming back into shape and when you hit 13, "Whoa, look at that, magic. It's back up to where it should be." Now, that's not to say certain types of flatfoot, which I refer to as fat foot, will change somewhat and will improve.

So learning objectives, you can see those, read them. I'm not sure we ever attain them.

[04:02]

Disclosures, I don't have any. So let's look at some indications which we've established for flatfoot reconstruction. One, uncontrollable hyperpronation, that I referred to as the uncontrollable hypermobile flatfoot. Normal to mild cuboid abduction, that would fall into a category, which Marshall is going to talk about.

Forefoot supinatus, the triplane soft tissue deformity which shows a marked inversion of the forefoot on the rearfoot, which occur secondary to severe rearfoot pronation. Sagittal plane subluxation of the subtalar joint, calcaneal eversion with abduction, obliteration of the sinus tarsi talar escape. Decreasing the calcaneal inclination angle, primary equinus, ligamentous laxity, moderate pronation secondary to CN bar or anterior middle facet coalitions.

Secondary effects of hyperpronation, juvenile HAV, that should read. Juvenile hallux abducto valgus is associated with severe hypermobile flatfoot, usually secondary to equinus or internal torques, or patients with significant ligamentous laxity and certainly hypermobility of the first ray.

What's the ideal age for reconstruction? When I look at the age group of three to six, I usually go toward arthroereisis procedures. And then, as the disease entity or this pathologic foot matures further and further, I often then have to consider extraosseous procedures. So what are the goals?

[05:58]

We're always trying to realign peritalar subluxation, block excessive pronation, allow for normal motion, allow for functional adaptation. That's why we want to address these problems earlier, functional adaptation. Adults don't undergo functional adaptation at joint levels. They undergo degenerative changes.

Early weight bearing postop reduction of supinatus, support the talus, and maintain space secondary to CN bar or anterior middle, if you're doing those type of reconstructions. We want to restore muscle balance, pronators versus supinators, and restore height of the arch. And I could not tell you what the normal height of an arch should be. It certainly varies.

But take a look at this youngster. Pronating, this is during gait, walking on a treadmill, actually. Look at the foot that's completely flat on the ground. No arch whatsoever, you could see the talar head bulging medially. And if you look at the first metatarsophalangeal joint, you'll notice that it is somewhat prominent where the metatarsal head is. That's hypermobility the first ray, which is visualized early on with severe hyperpronation.

The foot where the heel is off the ground, you see this typical abductory twist. The foot is abducting to avoid the need to come over in the sagittal plane because the great toe is jammed. Herein lies what I consider ideology of early development, leading to hallux limitus rigidus or hallux abducto valgus deformities. The tibial is posterior, the strongest supinator of the foot, is not going to bring that arch back up.

[08:03]

It works in conjunction with the peroneus brevis. They fire at the same time. They are stabilizers of the rearfoot, of the subtalar and midtarsal complex. In order for them to work synergistically and as stabilizers, the foot has got to be placed in a relatively normal position.

Clinical symptoms, growing pains, leg cramps, sedentary activity, the kid who wants to be a couch potato, or today, working with your computers all day as opposed to being outside. Arch pain, heel pain, postural symptoms, fatigue easily, doesn't wear shoes, can't tolerate neutral position orthosis, shin splints, plantar fasciitis as we move into adolescence.

Clinical signs, poor posture, breakdown of the shoe immediately, loss of the longitudinal arch, apropulsive gait, early heel lift, abduction of forefoot on rearfoot, abnormal calcaneal position, whether it's truly an everted position or abducted one. Helbing's sign, and then forefoot changes. As the youngster matures, HAV deformities, digital contractures.

Through the years, I've always felt that you can always treat conservatively and probably should before you make the move to go into surgical intervention. Many patients come to me that have already been in some type of orthotic, to try to control a foot, reposition it. Neutralize deforming forces, allow the foot to mature and develop as the youngster matures and develops.

[09:59]

You are not going to control a foot that has a primary equinus. Significant deforming force that requires some form of compensation, whether it's inflection of the knee or shorter stride, and abducted gait, or severe hyperpronation first at the subtalar complex, and then at the midtarsal with severe hyperpronation. No orthotic is going to fight that deforming force.

Internal torques, same type of problem. They may grow out of the internal gait because of internal tibial torsion, which improves with age. Internal femoral torsion may improve. So if you eliminate the deforming force, the foot isn't responsive, but should be controlled while that is taking place, if possible.

I think when [Martin Ruehl] [10:58] talked about frontal plane deformities and that if you control one plane, you will control the other two, because we – triplanar joints, subtalar joint, midtarsal, triplanar motion. So the axis deviates three body planes, posterior, inferior and lateral, to anterior, medial and dorsal. That's a pronatory, supinatory access. However, in the pediatric population, I have never felt comfortable or I've been effective in taking a rearfoot post on an orthotic and watching that foot being controlled.

Through the years, we've developed and designed different type of parameters that should be within an orthotic. What you're looking at is this device which I called DSIS, about 25 years ago. Dynamic Stabilizing Innersole System, which has an offset heel that when the heel hits the ground, it's going to be placed inverted and maintained in that position.

[12:07]

It's going to have long flanges that go down the side of the foot, medially and laterally, to the fifth and first metatarsal heads respectively, and has some component of an arch support in it. Now, we are guiding and controlling the foot. Otherwise, the foot slides right off the insert. So it brings us back to the goals and this is still part of goals that I look to see in an orthotic if you can achieve it.

Reposition subtalar subluxation. Block excessive motion. Allow for normal motion. Allow functional adaptability and enable the foot to be controlled. When you look at a transsection of the midtarsal complex, in the middle is the neutral appearing foot where the talus has some support under the sustentaculum tali. And when you go to pronate, talus plantar flexes and abducts, calcaneus everts, we are losing some of that support base.

When that foot has to compensate by pronating for an equinus deformity, this is the position that will be maintained, loss of support of the talar head. Now, the converse on the supinated side, you certainly don't want to overcorrect or overposition that foot as well. So flatfoot reconstruction is going to take place after the child has failed good functional orthotic control. You can't put an over-the-counter insert in a shoe and think it's going to do something. Robert's plates, Whitman plates, the UCBL is a good form of functional control, again, because of the deep heel seat and long flanges.

[14:04]

If the child can tolerate the insert, the orthotic can be diagnostic, as well as therapeutic. If they truly cannot wear the insert, it's an uncontrollable hypermobile flatfoot and surgical intervention is going to be necessary. So we can see the significant hyperpronation in the younger patient. We could see the tendency for the hallux to drift laterally, and hopefully, we can realign it. And if we can do it with the easiest surgical approach, that's the one that I would like to do. And I am a strong proponent of arthroereisis and eliminating the deforming force, such as equinus.

So I'm not going to bore you too much with all of these type of numbers but you can see the severity of hyperpronation. Here's the Helbing's sign we talked about. We always relate it to an everted calcaneus. I'm of the opinion more times than not the calcaneus is actually abducted compared to where the talus goes, which is internally, and the leg rolls with it, with the talus, which is important to realize with certain surgical procedures you're going to perform.

So we look at X-rays and certainly use this as a critical component of our diagnostic capabilities. And I'm not going to go into detail. You know all of these things about CIA, talar beaking or breaking, hypermobility of the first ray, metatarsus elevatus. The early signs are easily detected. When you see a foot that all the metatarsals appeared to be in one plane on a lateral view, that is passing the manic of forefoot supinatus.

[16:04]

That's associated with severe rearfoot hyperpronation syndromes. Some criteria are not rigid. When you look at a youngster who hyperpronate secondary to internal torques, you may have a relatively normal lateral looking X-ray, but a terrible dorsal plantar view, because of planal dominance and deformity. Here's cuboid abduction. And you see on the medial side of the foot talar escape. The talar head easily escapes out of the ball and socket talonavicular joint. Recognize the TN joint is a ball and socket.

So when deforming forces comes through that joint complex, the talus easily slides immediately, and then the rest of the foot seems to go in a lateral direction. The cuboid and calcaneus often have a good relationship but in more advanced states, you may see this abduction of the cuboid. So you're almost trying to get the forefoot back around the talar head.

And overtime, we watch the changes that take place at the great toe joint, with an increase in the intermetatarsal angle, and ultimate development of HAV problems, depending upon the severity and this is in the pediatric population. Adjunctive procedures tend to Achilles lengthening, gastrocnemius lengthening. I don't care where you do it, whether it's going to be endoscopic or whatever, for approach you're going to take, Kidner procedures. Whatever I need to do, I employ.

[18:00]

In the pediatric population, extra-articular approaches are the preferred procedure. I don't want to fuse joints. I don't want to do a triple arthrodesis on a youngster. Even at an adolescent age, you may have to do it, depending upon certain conditions that may exist. But the majority of things that we're talking about this morning are related to extra-articular procedures. Maintain the integrity of the joint complex. Allow normal motion to continue and to occur. Restore balance. Do not fuse joints if you can avoid it.

Paralytic flatfoot, you may have a different animal there to deal with. Certain tarsal coalitions, more involved. But these are relatively normal looking joints, good cartilage, good margins. Unfortunately, the joint complex is however, maybe deformed. So here's this tendon Achilles lengthenings. I don't care how you do it, your procedure of choice. Just recognize the importance of this deforming force.

Kidner procedures. Kidner is not a flatfoot reconstructive procedure. It's removing an offensive component of bone or an accessory ossicle, the tibiale externum. The medial body of the talus, often large out of the navicular, large. The gorilla-form navicular, altering possibly the insertion of the tibialis posterior. So if that is prominent or the ossicle is present and creating a problem, I will do it as an adjunctive procedure. If you think you're just going to do that and tighten up tibialis posterior or advance it distally, or try to tighten it, don't expect that to hold a foot in a controlled position.

[20:06]

But adjunctively, it can help. So ideally, I'd like to bring a foot back to a relatively normal position with an acceptable arch and allow for the normal motion to take place. And whether you can accomplish this with an arthroereisis or you're going to accomplish this with osseous procedures, it's going to be based upon your clinical examination, age of the patient, and diagnostic X-rays and what your goals are to recreate.

I always say to the enemy, "Good is perfect." I don't want to take a foot that's significantly flat and now make it a high arch foot. That's not my goal. Beware of adductus. In some of our corrective procedures, we may not evaluate or appreciate that there's an adduction component within the foot, metatarsus adductus or forefoot adductus. And if you don't evaluate that in advance and you correct for the flatfoot, and reposition everything, now you got a youngster that's toeing in because of the adduction of the forefoot.

Parents don't like seeing that happen. That, to me, is just poor planning preoperatively, poor evaluation. Take neutral position X-rays. I've been doing this for years. You take a weight bearing regular X-ray, put the foot back to the position that you think it's going to be placed in, regardless of what surgical procedure you're doing, and now look at the relationship of the forefoot to the rearfoot.

[21:58]

And you could see on this picture how much adduction is actually present. The rearfoot has been beautifully reestablished and I'm left with a kid who toes-in. So let's look at some functional flatfoot surgery which I consider extra-articular, Evans, TAL. The Evans procedure was designed a good number years ago and it's an osteotomy to pretty much lengthen the lateral column of the foot, which will abduct or take the abduction, and move the foot back around the sublux talus.

So it's in uncontrollable pronation, moderate to severe cuboid abduction, moderate to mild calcaneal eversion, supinatus, obliteration of the sinus tarsi, moderate to severe talar escape, decrease in the CIA and hypermobile first ray. Transverse plane dominant deformity with some sagittal plane component. All right. So we talked about the short lateral column, recognizing that the peroneus brevis may be somewhat tight because the column has been abducted for a considerable period of time. The ideal age for this procedure, six to 12.

Goals, elongate the lateral column. Reduce the supinatus, which happens as soon as you elongate the lateral column, you put a force on the peroneus longus, and the peroneus longus traversing the arch, de-rotates the forefoot supinatus. This, you can see happening right on the table. Reduce peritalar subluxation, and I will just move on.

[23:58]

So there it is, increased tension on the peroneus longus. Restore muscle balance of pronators and supinators. Increase retrograde force on the first ray and deal with what happens at the great toe joint. So severe eversion or what appears to be eversion, it's actually abduction. If you take an axial X-ray and look at the back, then determine whether a calcaneus is everted or is it transposed? And the rest of the forefoot where you see the whole forefoot abducting. Are you going to get rid of this quickly?

All right. So there is our divergence. There is the amount of abduction. [LaPorte] [24:49] wrote an article many years ago talking about cuboid abduction. So planal dominance, sagittal. We think about Cotton osteotomies, TALs, arthroereisis, transverse plane deformities, more toward Evans osteotomy.

Now, the osteotomy anatomically occurs approximately a centimeter or a centimeter and a half proximal to the calcaneal cuboid joint, which you can palpate pretty easily. And it's almost into the sinus tarsi, just by the distal end of it. So you can identify, and residents always like to mark everything on the thing, outline every anatomic structure. Then I walk in and say, "Okay. Now, where are you going to cut? Which line are you going to follow?" But in any event, it's an opening osteotomy of the calcaneus. Don't go more than two centimeters proximal to the CC joint by the way.

[25:57]

Once you have opened or elongated the calcaneus, how are you going to maintain it? Bone grafting is one, and I'll show you some other materials that have been used, titanium that we put wedges into the calcaneus, as well. As soon as you elongate that calcaneus, you will see and appreciate what happens on the forefoot with supinatus. Incisional planning is important. You don't have to make these large incisions. Be careful of the anatomic structures.

We identify the calcaneus. Do not strip away the EDB. If you're stripping the EDB off the calcaneus, you've gone too distal. So I'm into the sinus tarsi and I'm going to make a cut directly across, dorsal plantar, lateral to medial. And through the years I've used different things to open the calcaneus, here's a navicular clamp so that it enables me now to put a bone graft or whatever material you're going to use into this calcaneus to abduct the forefoot. And here you can see the goal and the postop versus the preop, how you have realigned and repositioned the foot.

Extra-articular procedure. Now, one of the problems that I've seen through the years, look on the bottom view. Supinatus has improved dramatically by forefoot, looking at the metatarsals in differentiating them one through five. We've realigned the midtarsal complex but look on the calcaneus distally. You could see the graft and some of the distal part of the calcaneus has come up. You do not want to interfere with the ligaments of the calcaneal cuboid articulation.

[28:00]

It's almost like having an arthroereisis procedure done. That's not the goal. So what I do now is I usually pin the distal part of the calcaneus with the graft into the body to maintain correct alignment, and I want to go through a little bit more of this. There, we are using that.

Here's another type of clamp that works beautifully to open the calcaneus up to determine different sizes of grafts that you want to use. Here's a procedure or actually putting a titanium plug into the canal or the osteotomy we've created. Now, you could put a plate over it. Obviously, everybody is putting plates on everything other than the kitchen table where they should be, where you can eat. Plates can be cumbersome. Plates cause prominence. Plates cause shoe irritation and we usually have to take them off.

Now, another procedure that I sometimes combine is the Koutsogiannis. So if I feel like I want to transpose the calcaneus more immediately, get it under the axial component of the leg, in addition to transverse plane dominant control, or change with the Evans, I just make my incision a little bit more curvilinear. I come back and do an osteotomy of the calcaneus to offset it. And then, I do use plates very effectively. So you got the distal part and possibly a proximal osteotomy, double osteotomy, extra-articular, extraosseous.

Here's what the X-ray looks like with this. The total realignment is taking place. The joint congruity has been maintained. Postoperatively, some of these feet are pudgy. They have some edema and swelling. So overtime, look at that top view, you'll look at the arch that's been created on the one side. Look at the flatfoot on the other with the HAV starting already and this is at the – about 12 years of age.

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