Pediatric flatfoot is a pathologic deformity that should not be ignored.

1. Pediatric Flatfoot:
to treat or not to treat,
you be the judge.
Michael E. Graham, DPM, FACFAS

2. There is an on-going debate as
to what to do with a
mis-aligned child’s foot.

3. The general consensus has been:

4. The general consensus has been:
if it’s a flexible deformity – let it be

5. The general consensus has been:
if it’s a flexible deformity – let it be
or
if it’s a rigid deformity – off to surgery.

6. The overall opinion is to do:

7. NOTHING!

8. Traditional reconstructive
procedures are rather invasive and
have their fair share of potential
complications.

9. So the perception is that the
“cure is worse than the disease.”

10. Why initiate a treatment that
could lead to symptoms or pain?

11. Most people don’t realize that those
misaligned feet lead to a chain
reaction of destruction.

12. Here’s why -

13. Walking isthe 2ndmost common
conscious function of our body.

14. One of the human physiognomies is
our ability to stand, walk and run –
on our two feet.

15. Feet are the foundation to our
body.

16. Aligned feet = Aligned body.

17. Mis-aligned feet = Mis-aligned body!

18. So whether or not there are painful
foot symptoms, there could be
symptoms to other parts of the
body.

19. Let’s explore misaligned feet a
little more.

20. What is the difference between an
aligned versus mis-aligned foot?
That is a very important question.

21. The answer begins with the
hindfoot

22. the most complex and arguably
one of the most important joints
of the skeletal system.

23. This joint mechanism
involves 3 bones
Navicular
Talus
Calcaneus

24. The
Talus,
Calcaneus
and
Navicular
form:
the TaloTarsal joint

25. with 4 articular joint contact areas.

26. There are two specific functions
of the talotarsal joint.

27. First is the efficient handling of the
vertical forces from the body above,
converting those forces horizontally
into the foot.

28. Those forces should be distributed
in such a way that the majority of
forces should pass posteriolateral
through the back of the calcaneus.

29. The second function is the
“locking” and “unlocking”
of the bones of the mid-foot.

30. The two complex triplane motions
of supination and pronation occur
between the talus on the tarsal
bones.

31. There should be a total of
2/3rds supination
and
1/3rd pronation

32. Why is this ratio important?

33. Talotarsal supination locks the foot
bones, creating a stable framework.

34. Talotarsal pronation unlocks the
bones of the foot in order to adapt
to an uneven ground surface.

35. There are specific times during the
walking/gait cycle when the
talotarsal joint should be in one of
three positions.

36. Supination Neutral Pronation
Neutral position is when the
talotarsal joint is neither supinating
nor pronating.

37. Back to pediatric flatfoot

38. The most important contributing
factor that leads to a mis-aligned
foot is?
Anyone? Anyone?

39. The alignment of the
talotarsal joint!

40. The difference between these two
feet is an aligned versus malaligned
talotarsal joint.

41. How does misalignment of the
talotarsal joint occur?

42. It occurs as a result of a partial
dislocation of the talus on the
calcaneus and/or navicular.

43. Recurrent talotarsal dislocation
occurs in a flexible deformity.

44. Some call this peri-talar instability
or subluxation, either way it is a
complex partial joint dislocation.

45. So what?

46. This represents a major flaw within
the musculoskeletal system.

47. The forces that should be passing
through the back of the heel are
now passing through the inner-front
of the foot.

48. These excessive forces create a path
of destruction adversely affecting
the bones, ligaments and tendons
to the inner aspect of the foot while
standing, walking and running.

49. Furthermore, there
is yet another path
of destruction up
the
musculoskeletal
chain.

50. The foundation to the body is
now pathologically altered.

51. Every step leads to an
“earth-quake” effect to the
knees, hips, back and possibly even
the neck and shoulders.

52. Flexible recurrent talotarsal dislocation
is more destructive
than an inflexible rigid deformity.

53. That’s due to the potential
pathologic forces that are created
as the supinatory motion reloads
the joint forces that are repeatedly
stressing and straining the tissues.

54. A rigid inflexible talotarsal joint
stays in the locked position and
does not have the same “reloading”
of force.

55. The role of “locking” and
“unlocking” of the talotarsal joint
must also be taken into
consideration.

56. Partial talotarsal dislocation leads to
a pathologic duration of pronation – called
over-pronation/excessive
pronation/hyperpronation.

57. Instead of the bones of the foot in a
stable locked position, they are in
an unstable unlocked position.

58. This leads to increased stress and
strain on the bones, ligaments and
tendons which leads to the majority
of secondary deformities within the
foot and ankle.

59. We now see that a flexible mis-
aligned foot is a very dangerous
deformity that could be responsible
for many of the musculoskeletal
disorders throughout the body.

60. What’s the fix?

61. Depends if it’s a recurrent partial
talotarsal dislocation or rigid
deformity and also if there are other
pathologic osseous alignment
issues.

62. There are 2 Treatment Categories
External Internal

63. Problem with External Options
• Cannot stabilize the talus
on the tarsal mechanism.
• Gives a false sense of
correction.
• Not corrective, just
supportive.
• Compliance issues –
patient must wear them
for them to be effective.

64. Internal options: depends on the
degree and location of deformities.

65. A Recurrent Talotarsal Dislocation:
Neutral Position Relaxed Stance Position Internal EOTTS
Can possibly be internally stabilized via an
internal, extra-osseous, extra-articular talotarsal
joint stabilizing stent.

66. Extra-osseous Talotarsal Stabilization
(EOTTS)
• Stent is made of
titanium.
• Talus glides over a Type
II EOTTS device.
• Instantly the joint
forces are normalized.
• Talotarsal joint is now
internally stabilized.

67. Many times this procedure alone is
enough to stabilize the deformity.

68. Need to evaluate the whole foot
This image exhibits a talotarsal joint This image shows a talotarsal joint
dislocation with a normal calcaneal dislocation in addition to a lower than
inclination angle. normal calcaneal inclination angle.

69. Lower than normal Calcaneal
Inclination Angle
This patient could benefit
from the EOTTS device
but also requires either a
lengthening of the
Achilles tendon complex
and/or calcaneal
osteotomy.

70. Instability in the Medial Column
• If there is significant
instability to the mid-
foot then additional
surgery will be required
here.
• Many times, this
procedure is not
performed until the
child is older.

71. Rearfoot reconstructive surgery
is reserved until there is so much
destruction that there is no other
option.

72. Don’t blow off those misaligned
feet as normal!

73. Children do not out-grow this
pathologic deformity.

74. Where is the evidence that a
recurrent talotarsal joint dislocation
will heal on its own?
There isn’t any, they just get worse!

75. Not only does this deformity lead to
destruction within the foot and
ankle,

76. it leads to a path of destruction
up the body.

77. Benefits of Treatment
• Internal option – does not rely on patient
compliance
• Reversible
• Time tested
• Scientifically based
• Just makes sense

78. Risks of No Treatment
Not only will this lead to problems within the
foot and ankle, it leads to problems in the
knees, hips, pelvis, back and neck.

79. Risks of Treatment
Possible need to remove the stent (EOTTS)
Revision
Resize – under/over-correction
Failure to achieve the desired result
There are no complication free procedures

80. For more information on EOTTS
please visit:
www.AlignMyFeet.com