Pediatric Foot and Ankle Deformities: An Introduction

Abstract

Unlike long bone deformities, where most often one or two bones are affected, foot and ankle deformities usually involve multiple bones and joints. Thus, a careful assessment of the site of the deformity (hindfoot, midfoot, forefoot), type of deformity (varus, valgus, supination, pronation, adduction, abduction), and the particular bones and joints that are involved is a prerequisite for preoperative planning.

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Unlike long bone deformities, where most often only one or two bones are affected, foot and ankle deformities usually involve multiple bones and joints (Table 1). Thus, a careful assessment of the site of the deformity (hindfoot, midfoot, forefoot), type of deformity (varus, valgus, supination, pronation, adduction, abduction), and the particular bones and joints that are involved is a prerequisite for preoperative planning.

Table 1 Details of the 6 Pediatric Foot and Ankle Deformity cases discussed in this Atlas

The goals in the management of foot deformities are to obtain a plantigrade, painless, and functional foot and ankle. In general, fusion of joints should be avoided if possible, as this will ultimately increase the stress on adjacent joints and may lead to pain and future degenerative changes in those joints. In this section, six cases are discussed: gradual correction through soft tissues only (cases 111, 112), acute correction of cavus deformity (case 113), gradual correction through midfoot osteotomies with a TSF mitter frame (case 114), foot stump lengthening (case 115), and correction of severe rotational deformities of the foot (case 116). Several other foot cases are discussed in detail in the section Pediatric Arthrogryposis: An Introduction and the Adult Deformity section (Volume 3 of this Atlas).

The status of the soft tissues , especially after multiple surgeries, crush injuries, or burns, is of special importance when deciding whether a gradual versus acute correction will be performed. In addition, the severity of the deformity is another factor to consider. Acute correction may be indicated in mild to moderate deformities (case 113), whereas acute correction of severe deformities may necessitate resection of significant amounts of bone and shortening the foot in order to obtain adequate correction. This has to be taken into consideration, especially if the deformity is unilateral. Prophylactic tarsal tunnel release is to be considered for large acute corrections. Gradual correction , on the other hand, has the advantage of allowing the simultaneous correction of numerous deformities that would have been otherwise very difficult and unsafe to correct without excessive soft tissue dissection and/or resection of bone. In many cases, especially before the age of 8 years, this may be possible through soft tissue distraction only (cases 111, 112). At an older age, osteotomies and gradual correction through these osteotomies is usually, but not always, necessary (case 114). A possible complication of midfoot osteotomies is premature consolidation of the distracted site at the level of the osteotomy (case 115).

In many pediatric foot and ankle cases, muscle imbalance is one of the precipitating causes of these deformities, and correction of the bony and soft tissue deformities is only one step in the surgical treatment. Correcting the muscle imbalance by appropriate muscle transfer, particularly in neuromuscular conditions such as in children with Charcot-Marie-Tooth disease, is key to maintaining the correction (cases 111, 113).

In skeletally immature patients, the possibility of recurrence of the deformity is to expected, hence the importance of adequate follow-up. This also needs to be clearly explained to the patient and the family.