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Competencies

Flat Feet

Flat feet: general information

Non-physiological modifications of the foot (splaying, consequences of injuries, lowering of arches, flat feet) are common reasons why patients go to an orthopedist. Long-term deformity of the foot damages the integral structure which results in modifications in the proximal joints.

Valgus deviation of the first toe, which is called "Hallux valgus” (hereinafter HV) in foreign publications, is the most common type of static deformation of the front part of the foot.

Since the beginning of the 20th century the number of surgical methods of treating valgus deviation of the first toe has been exponentially growing. Nowadays the number of the most common methods is more than 100 and according to the Russian authors – more than 200. Over the last decades there have appeared a number of works whose authors suggest certain advanced, in their opinion, methods of surgical treatment. They treat both the distal and proximal parts of the first metatarsal bone as well as the proximal phalanx of the first toe and include operations on soft tissues of the first metatarsophalangeal joint and also on foot bones up to arthrodesis and arthroplasty of the first metatarsal and medial metatarsal cuneiform joint.

Treatment

Modern orthopedics has a range of surgical methods which make it possible to successfully correct all types of deformities. In order to choose the right surgical method it is not enough to consider only the complaints and age of patients, condition of articular surfaces, type of deformation, general statics of the foot and expectations of patients. The clinical practice and education of the operating orthopedist are also very important. The purpose of treatment, irrespective of the specified method, must be maximally exact reconstruction of the foot anatomy and thus restoration of the usual function of the first toe and the entire lower extremity. After surgery the patient won’t have any pain or problem choosing flat-sole footwear or any discomfort at work or leisure.

Causes

Modern interpretation of causes of the most widespread foot deformity which results in sharp discomfort and cosmetic defect (bumps and protruding bones on feet) – outward lateral deviation of the great toe (Greek – the first toe; valgus – lateral deviation) – has developed a lot since the early 19th century. It was considered then that the main cause was hypertrophy of soft tissues and first metatarsal head. The methods like incision of plantar callosities and exostoses used in that times had just a temporary effect and the disease came back again.

Nowadays it is known that deformities appear due to outward lateral deviation of the first metatarsal bone and inward deviation of phalanges of the first toe. Moreover, collocation of foot bones and balance between soft tissues are damaged, and the articular congruence gets damaged as well.

Upon examination of patients who complain about ‘bones’, problems while wearing model footwear, pain and fatigability in legs, it is necessary to take into account all changes. A detailed clinical research is necessary: examination of foot flexibility, painful areas and callosities, lateral and longitudinal arches of the foot.

Next, it is necessary to make X-ray images of the forefoot in the direct and lateral projections under weight (even if it is unilateral deformity). In order to detect the character of load distribution on the forefoot plantography is used. In more serious cases magnetic resonance tomography and computer tomography are necessary.

Based on the results, the most important parameters of treatment tactics are determined: type of deformity, presence of hyper mobility, angle of deviation in the metatarsal bone and phalanx of the first toe, inclination of articular surfaces and presence of any changes caused by arthrosis and many others.

In the early stages and also for women who are apt to develop a deformity (due to heredity, wearing high-heeled footwear, flat feet) it is indicated to use individual orthotics which support foot arches, eliminate discomfort and prevent deformity.

In more serious cases surgical treatment is inevitable as it implies elimination of the cause of the condition i.e. correction of the capsuloligamentous imbalance, restoration of the articular congruence and proper collocation of foot bones. Most commonly this can be solved by means of osteotomy in combination with manipulations on soft tissues – tendons and articular capsule. The most common types of osteotomy are SCARF, Akin, Chevron, Mitchel. As a result bones get back into the proper position, pathologic deviation of articular surfaces and excess thrust of tendons are eliminated.

After most operations immobilization in plaster is not necessary. Conditions for walking without loading the forefoot are provided (by means of Barouk footwear). Recovery usually takes from 1 to 1,5 months.


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