Jay Lieberman DPM, FACFAS

This was a 7-year-old female who was brought to the office by her mother for evaluation of aberrant gait pattern. The mother related that her daughter had worn custom molded orthotics in the past, but however, had not noticed any significant relief of pain. She also reported that the patient's feet fatigued very easily. Prior to her initial evaluation, she did not engage in very many athletic activities. Even while shopping in the mall, they had to stop several times to rest the child's feet.

Pre- Op Flatfoot

PAST MEDICAL HISTORY

The child's past medical history was negative.

General: The patient was well nourished, well developed and in no acute distress.

HEENT: Examination was within normal limits. Normocephalic, atraumatic, extraocular movements were intact. The pupils were equal and reactive to light. Tympanic membranes were clear. The nose was clear.

Heart: Regular rate and rhythm, S1 and S2 no murmurs or gallops.

Lungs: Clear to auscultation bilaterally.

Abdomen: Soft, non tender, non distended, positive bowel signs.

Neurologic: Grossly intact.

Clinically there was a decreased medial longitudinal arch bilaterally. The left greater than the right. Gastrocnemius equinus with approximately 0 degrees of dorsiflexion with the knee extended and only slightly increased dorsiflexion with the knee flexed was evident. Subtalar, mid tarsal and first MPJ ranges of motion were fluid and unrestricted. The patient developed a longitudinal arch in the toe-raised position, but had difficulty maintaining this position. The heel was in a valgus position and the head of the talus was protruding medially. Gait analysis revealed a virtual collapse of the medial column on mid stance of gait; left greater than right. There was no genuvalgum or coxavarum. Transverse plane motion at the hip was normal. There was no limb length discrepancy.

IMAGING

X-rays revealed an increased talo calcaneal angle, decreased calcaneal inclination angle, increased talar declination angle, increased calcaneal cuboid abduction angle, mid foot fault and decreased longitudinal arch.

TREATMENT

Conservative

Initially, the patient was treated with a UCBL type orthotic. After some time, the patient related to us that she was getting discomfort along the medial talar head. We attempted to accommodate for this by flaring out the orthotic a bit more. Unfortunately, these measures did not adequately control the patient's symptomatology.

The patient went on to wear orthotics for approximately one year. She reported improvement with less fatigue but continued pain. There did not appear to be any significant difference in her pain score when her standard orthotics were changed to a Shaffer medial flare or when her UCBL was modified.

At one point, the patient attempted to participate in a recreational soccer league. Her mother indicated that she was a good player. However, the pain and fatigue that she experienced limited the activity.

Surgical

We discussed expectations and possible complications associated with repair of painful pediatric flatfoot deformity. The patient underwent the following procedures:

1. Gastrocnemius recession
2. Evans calcaneal osteotomy with Allographic bone graft
3. Subtalar joint arthroereisis
4. Posterior tibial tendon placation and repair
5. Placation of the spring ligament

Postoperatively the patient was maintained in a posterior splint. An infusion pump with catheter was placed proximal to the incision site. A small dose of Marcaine kept her pain well controlled. The patient was placed in a non-weight bearing below knee cast for approximately seven weeks.

X-rays demonstrated a good incorporation of the graft. The patient was then transitioned to a low profile cast boot. At three months, she began a course of physical therapy.

The plate which maintained fixation of the Allograft is an Integra product called Uni-CP™ . The sizes are extraordinarily good to accommodate for the osteotomy and the bone graft (up to 30mm). Some staples are not wide enough for this procedure and as a result, the graft can displace, fracture through the osteotomy, or heal very slowly. Prior to placement, two drill holes are made proximal and distal to the osteotomy site. The screws act much like the prongs of a bone staple, however, they do not need to be malleted into position which can damage the osteotomy or graft. Once properly positioned, the spreading instrument is used to open the oval center of the clip and compress the osteotomy. The compression is quite impressive, much like the AO technique using a lag effect.

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