abstract
Flat foot is a kind of deformed foot, which is characterized by the reduction or disappearance of the longitudinal arch of the foot. Flat feet caused by ligament relaxation are very common in teenagers and have a genetic tendency.
Treatment measures
Mild to moderate asymptomatic patients do not need treatment. In the past, it was advocated to walk barefoot on the beach and grass to exercise the muscles of the calf and foot, increase the stability of the tarsal joint and improve the longitudinal arch of the foot. It is also recommended to wear various orthopedic shoes, hoping to correct flat feet. However, practice has proved that these measures have no orthopedic effect on flat feet. It can only relieve local discomfort and pain. Therefore, for people with moderate and severe flat feet, people under 10 can adopt passive or active stretching of calf triceps to relieve the discomfort of calf and foot caused by this muscle spasm. Thomas orthopedic shoes with a thickness of 0.3 ~ 0.6 cm or a support pad with a thickness of 0.5 ~ 0.75 cm on the inside of the sole can relieve or eliminate pain and discomfort, but it has no orthopedic effect.
If surgical treatment can't relieve pain, it will affect moderate and severe flat feet when walking with load and wearing shoes. The patient's age is over 10 years old, which is the indication of surgical treatment. Surgical treatment includes soft tissue surgery such as tendon transfer and ligament contraction, as well as bone surgery such as tarsal joint fusion, three-joint fixation and tarsal osteotomy. However, simple soft tissue surgery and single tarsal joint fusion have been abandoned because of poor curative effect. At present, it tends to combine soft tissue and bone surgery, and the curative effect is obviously improved.
Usually, according to X-ray measurement, after determining the descending position of the longitudinal arch of the foot, the surgical method is selected. Giannesstras operation is the fusion of navicular joint, the contraction of calcaneal plantar ligament and the displacement of anterior and posterior tendons of tibia. It is suitable for flatfoot caused by the relaxation of scaphoid ligament and has good curative effect. The main points of the operation are as follows: ① Expose talus, navicular bone, cuneiform bone and anterior and posterior tendons of tibia through longitudinal incision of medial foot; ② Cut off the anterior tibial tendon, posterior tibial tendon and calcaneus plantar ligament, and pull a joint capsule and ligament flap from front to back inside talus, navicular bone and cuneiform bone, and pay attention to keep a thin bone flap on the deep side of the flap (Figure 30). ③ Removal of scaphoid and cuneiform articular cartilage, drilling bone holes from the metatarsal side of scaphoid and cuneiform joint to the dorsal side, merging them into an inverted V-shaped bone tunnel, and fixing the scaphoid joint in the corrected position with catgut thread or nylon thread (Figure 31); ④ After the joint capsule, ligament flap and metatarsal ligament of the metatarsal scaphoid are closely stitched, the broken ends of the anterior tibial tendon and the posterior tibial tendon are knitted and stitched together, and the anterior tibial tendon and the posterior tibial tendon are pulled back from the metatarsal side of the prefabricated bone hole of the scaphoid and stitched and fixed on the periosteum of the dorsum of the foot (Figure 32); ⑤ After operation, the plaster was fixed for 8 ~ 12 weeks. There may be overcorrection at the initial stage after operation, but it will gradually disappear after 3 ~ 4 weeks of load-bearing walking.
Fig. 30 Formation of articular capsule and ligament bone flap in talus, navicular and cuneiform bone.
1. Posterior tibial tendon 2. Ligamentum plantarum calcaneus 3. Tendon of anterior tibia.
Fig. 3 1 removing articular cartilage of navicular bone and cuneiform bone (a) drilling holes on the metatarsal side of navicular bone and cuneiform bone (b)
Fig. 32 a. After suturing the articular capsule and ligament bone flap, drill holes from the dorsal scaphoid to the plantar side. B. Fix the anterior and posterior tibial tendons through the scaphoid foramen 1. Tendons of tibia anterior and posterior 2. Tendon sheath of anterior tibia.
Flat feet with loose calcaneal joints often have obvious calcaneal valgus deformity. The patient is not yet mature, so grice arthrodesis can correct flatfoot without affecting the longitudinal development of the foot. In this operation, the tarsal sinus is exposed through an oblique incision in front of the lateral ankle. After the tarsal sinus cortex was removed, it was filled with autogenous cancellous bone strips and fixed with screws. After operation, plaster external fixation was performed until the bone graft healed. Three-joint fusion is also a recommended method for older children or adolescents.
pathogenesis
The etiology is not clear, but epidemiological studies have found that the disease has obvious genetic tendency. Pathological observation showed that the tarsal bone of the foot was not deformed, but the ligament connecting the calcaneus, talus and scaphoid joint capsule was looser than that of normal people, which caused the calcaneus to pronate below the talus when the foot was loaded, and its front end shifted to the dorsal and lateral sides, while the talus shifted to the plantar and medial sides, which led to the loosening of the metatarsal ligament of the calcaneus, unable to support the talus, reducing the longitudinal arch of the foot, and causing the calcaneus to valgus.
clinical picture
Children are mostly asymptomatic. Parents often pay attention to the abnormal wear of soles. Obese children and adolescents will suffer from plantar pain and leg discomfort when standing for a long time. Usually, the arch of the foot still exists when there is no load, but the load inspection can find that the longitudinal arch of the arch decreases or disappears. Clinically, it can be divided into three types, but all of them should observe the changes of longitudinal arch of foot during loading, and the lighter ones are: the longitudinal arch of foot decreases; Medium: the longitudinal arch of the foot disappears; Severe: the longitudinal arch of the foot disappears, the medial edge of the foot protrudes and shifts to the plantar side of the foot, that is, the anterior lower part of the medial malleolus. Patients sometimes suffer from shortening of Achilles tendon and hallux valgus.
X-ray examination should take the positive lateral X-ray film of the foot under load, mainly measuring the angle change of the arch of the foot on the lateral X-ray film of the foot. ① Draw a straight line along the center of the long axis of talus, navicular bone, first cuneiform bone and metatarsal bone, and then draw a straight line at the center of navicular bone, which is equal to its anterior and posterior articular surfaces and intersects with each line. Usually, two arch lines intersect at right angles (Figure 29). If the lesion or ligament relaxation occurs in talus joint, the axes of navicular bone, first cuneiform bone and metatarsal bone are discontinuous with each other, forming an angle on the plantar side of foot, and the axis of talus passes through 1/4 on the plantar side of navicular bone (Figure 29b). If there is ligament relaxation in the navicular joint, the central axis of talus is located on the metatarsal side of the first cuneiform bone and intersects the vertical line of the navicular bone center at right angles (Figure 29c). When the straight line passing through the center of the scaphoid extends back and forth, both of which are located on the metatarsal side of the talus and the first metatarsal, it indicates that there is ligament relaxation in the talus and the scaphoid joint (Figure 29a). ② Talus plantar flexion angle: Draw a horizontal line along the plantar side and intersect the talus axis. The normal value is 26.5 3.5. When talus has plantarflexion deformity, this angle increases. ③ Dorsal metatarsal angle from scaphoid: Draw a parallel line along the distal joint of scaphoid, and then draw a central axis of talus. The medial angle formed by the intersection of two lines is called the dorsal metatarsal angle from scaphoid. The normal value is 60 ~ 80. This angle greater than 60 indicates talus displacement.
Fig. 29 Talus-metatarsal angle measured by lateral radiograph of foot under load.
differential diagnosis
Flat feet can be divided into primary and secondary categories. In the diagnosis of primary flatfoot caused by ligament relaxation, besides flatfoot complicated with paravertebral deformity, shortening of the first metatarsal, congenital clubfoot, paralytic flatfoot caused by neuromuscular diseases such as poliomyelitis and spastic flatfoot caused by cerebral palsy, the diagnosis should be carefully differentiated. According to the age of onset, detailed medical history, physical examination and X-ray examination, a correct diagnosis can be made.
The health massage of flat feet can improve the blood circulation of calves and feet, eliminate muscle fatigue, and has certain effect on preventing and treating children and adolescents with flat feet. Every day 1 time, you can do it before going to bed at night. Wash your feet with water first, and then do a massage when the water is dry.
(1) Sit down. Rub the calf with your palm for 3-5 times, then push the calf from bottom to top for several times, then rub the outside of the calf with your fingers or palm roots and knead the muscles at the back of the calf for several times. Finally, gently grasp the triceps surae with your hands and shake it for 20-30 seconds.
② Rub the instep and sole of the foot with your palm for 3-5 times, then rub the instep and sole with your fingers or palm roots, and finally spread your toes one by one. Do one side first, then do the other.
May everyone feel comfortable every day!