Flatfoot is a common condition in children, where the arch of the foot is lower than usual, and the entire sole of the foot touches the ground. This condition may or may not cause any discomfort. However, some children with flat feet may develop pain and swelling in the area of the accessory navicular bone, which is a small bone on the inner side of the foot that is attached to the posterior tibial tendon. This condition is called Accessory Navicular Syndrome (ANS), and it is often associated with flatfoot. When a child presents with ANS and flatfoot, the orthopedic surgeon may recommend surgical intervention to alleviate pain and prevent further deformity. However, surgery is not always necessary and may be avoided in some cases.
Flatfoot in children is a natural physiological condition, which usually resolves by the age of six. However, some children may continue to have flat feet, which may be symptomatic or asymptomatic. Flatfoot in children may be flexible or rigid. Flexible flatfoot is a condition where the arch disappears when the child stands on tiptoe or sits with feet dangling. Rigid flatfoot is a condition where the arch does not reappear on tiptoe or sitting. Rigid flatfoot is less common and more severe than flexible flatfoot. Flatfoot in children may be caused by several factors, such as hereditary, ligamentous laxity, muscle weakness, obesity, and neurological disorders. ANS is a condition where an extra bone, called the accessory navicular, develops on the inner side of the foot, causing pain and swelling in the area of the posterior tibial tendon. ANS is often associated with flatfoot, and it may exacerbate the symptoms of flatfoot.
The diagnosis of flatfoot and ANS is based on clinical examination and radiographic imaging. X-rays may show a flattened arch, a prominent talus bone, and an enlarged accessory navicular bone. MRI may reveal inflammation of the posterior tibial tendon and the accessory navicular bone. The treatment of flatfoot and ANS is based on the severity of symptoms and the degree of deformity. Conservative measures may include shoe inserts, physiotherapy, weight loss, and activity modification. Surgery may be recommended in cases of severe pain, deformity, and failed conservative treatment.
However, the decision to operate on a child with flatfoot and ANS should not be taken lightly. Surgery is associated with risks and complications, such as infection, bleeding, nerve damage, and poor wound healing. Surgery may also cause scarring, stiffness, and altered foot biomechanics. Moreover, surgery may not always alleviate pain and may even exacerbate it in some cases. Therefore, the orthopedic surgeon should weigh the benefits and risks of surgery carefully and inform the parents and the child about the expected outcomes and possible complications.
The management of flatfoot and ANS in children should be tailored to each individual case. Conservative measures should be tried first before considering surgery. Shoe inserts, such as arch supports, can improve foot alignment and reduce pressure on the accessory navicular bone. Physiotherapy, such as stretching and strengthening exercises, can improve muscle function and stability. Weight loss, if necessary, can reduce the load on the foot and decrease pain. Activity modification, such as avoiding high-impact sports, can prevent further damage to the foot. However, conservative measures may not be effective in all cases, especially in severe and rigid flatfoot with ANS.
Surgery should be considered when conservative measures have failed, or the child has severe pain, deformity, or functional impairment. The surgical options for flatfoot and ANS in children include osteotomy, soft tissue reconstruction, and accessory navicular excision. Osteotomy is a procedure that involves cutting and reshaping the bone to improve its alignment and reduce deformity. Soft tissue reconstruction is a procedure that involves repairing or replacing the damaged tendons or ligaments that support the foot arch. Accessory navicular excision is a procedure that involves removing the extra bone to relieve pain and prevent further inflammation.
The choice of surgery depends on the severity and location of the deformity, the age and activity level of the child, and the surgeon’s preference and experience. Each surgery has its risks and benefits, and the surgeon should explain them to the parents and the child before making a decision.
The management of flatfoot and ANS in children is a complex issue that requires careful evaluation and individualized treatment. Surgery should be reserved for cases of severe pain, deformity, or functional impairment that have not responded to conservative measures. The decision to operate should be based on a thorough examination, radiographic imaging, and informed consent. The surgeon should discuss the risks and benefits of surgery with the parents and the child and ensure that they have realistic expectations and understand the postoperative care and follow-up. With proper management, most children with flatfoot and ANS can lead active and pain-free lives.
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