Small Steps Create Huge Advances in the Pediatric Foot

February 15, 2002

NEW YORK (Medscape Wire) Feb 19 — Children's foot problems have always been a topic of interest among parents as well as orthopaedic professionals. At a briefing held last week during the American Academy of Orthopaedic Surgeons' 69th Annual Meeting, Vincent S. Mosca, MD, Director Department of Orthopaedics, Children's Hospital and Regional Medical Center, gave an evaluation of common pediatric foot deformities.

Conditions such as flatfoot and clubfoot were highlighted, showing new advances in research as well as surgical and nonsurgical management of each. According to Dr. Mosca, flatfoot is a very commonly occurring foot shape in babies. "Almost all babies and at least 20% of adults have flatfeet. The shapes of the bones and laxity of the ligaments, which are genetically programmed, determine this foot shape. It is not determined by the strength of the muscles, the function of the nerves, or external forces," stated Dr. Mosca.

Researchers in the late 1940s identified flatfeet in 23% of adults and classified them into 3 types: flexible (or hypermobile), flexible but accompanied by contracture of the Achilles tendon, and rigid. The flexible type accounts for most flatfeet in adults and an even higher percentage of flatfeet in children. This research concluded that flexible flatfoot is a normal and commonly occurring foot shape that does not frequently cause pain or disability.

More recent research has added important knowledge to the understanding of flatfeet in children. "Most babies are flatfooted. The average arch height is lower in the child than the adult," added Dr. Mosca. "Corrective shoes and orthotics do not alter the natural history of spontaneous development of the arch in children - there is no scientific evidence that shoes can create an arch in the child's foot. Surgery for flexible flatfoot in children is rarely, if ever, indicated," said Dr. Mosca.

A flexible flatfoot with a short Achilles tendon in an adolescent or an adult may cause pain. Surgery is indicated to correct the flatfoot and Achilles tendon contracture can occur in this small group of individuals if conservative measures are not successful in relieving the pain. "One or more bone cuts of the bones of the foot combined with lengthening of the Achilles tendon is a biologic approach to the problem that has been shown to be successful in relieving symptoms and correcting deformities. This approach preserves motion of the joints and their shock absorbing function," according to Dr. Mosca.

Clubfoot is a term used to describe a complex, congenital, contractural malalignment of the bones and joints of the foot and ankle. The incidence is 1 to 1.5 per 1,000 births - making it a common condition. "The diagnosis of clubfoot can be made quite reliably, in experienced centers, on the fetal ultrasound examination as early as 16 weeks of gestation," stated Dr. Mosca. "Many parents seek prenatal counseling by a pediatric orthopaedic surgeon."

The methods for managing clubfoot deformity have changed dramatically and frequently over time. One method for managing clubfoot that was introduced almost a half century ago by Dr. Ignacio Ponseti, from Iowa, involved gentle manipulative and casting treatment with minimal surgery. The method did not receive widespread acceptance. During the ensuing decades, various other techniques were introduced in search of the perfect complex and extensive operation to correct clubfoot. "What resulted was a large number of stiff, painful overcorrected and undercorrected clubfeet that very often underwent one or more additional extensive operations for the secondary deformities and pain that followed," added Dr. Mosca.

The original Ponseti method has gained recent popularity. Colleagues of Dr. Ponseti at the University of Iowa evaluated the success of this method on former patients at an average age of 34 years. These individuals scored very close to normal controls using scales of function, comfort, range of motion, foot pressure analysis, and radiographic appearance. The Ponseti method is now being studied and applied by pediatric orthopaedic surgeons as if it were a brand new. The method involves weekly manipulation of the clubfoot according to a specific order of deformity correction that starts as soon after birth as possible.

A long leg cast with specific molding is immediately applied after each manipulation. After 4 to 7 weekly manipulations and castings, all deformities of the clubfoot are corrected, except for persistent contracture of the Achilles tendon that is present in over 90% of feet. The Achilles tendon is released under local anesthesia in the clinic setting. The final long leg cast is worn for 3 weeks.

Straight bordered shoes that are separated on a bar are worn full time for 2 to 3 months and then at night time only for 2 years. "This is not a method of treatment to modify, but to learn and implement as originated by the founder," said Dr. Mosca. "In our hands, less than 50% of clubfeet will require a simple tendon transfer to treat an underlying congenital muscle imbalance when the child is over 3 years of age. Neither the Achilles tenotomy nor the tendon transfer contributes to stiffness or other disability.&quo

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