الفهرس 
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Abstract
The human foot is a highly complex structure. It has two major functions: to support the body in standing and progression; to lever it forwards in walking, running and jumping.
The human foot, alone among primates, is normally arched in its skeletal basis. Its medial margin arches up between the heel and the ball of the big toe, forming a visible and obvious medial longitudinal arch. The bones that form the medial longitudinal arch are calcaneus, talus, navicular, the three cuneiform bones and their three metatarsal bones. The pillars of the arch are the tuberosity of the calcaneus posteriorly and the heads of the medial three metatarsal bones anteriorly. Bony factors do not play a significant role in maintaining the stability of this arch. Ligaments are important, but are unable to maintain the arch entirely on their own. The most important structure is the plantar aponeurosis. Deltoid, plantar and talocalcaneal interosseous ligaments, together with the capsule of the talonavicular and naviculocuneiform joints, play important role in maintaining the medial longitudinal arch. The posterior tibial muscle, flexor digitorum longus, flexor hallucis longus and intrinsic muscles of the foot also help in supporting the arch. loss of the medial longitudinal arch of foot results in Pes planus or flatfoot deformity. The term is used to describe a mixture of anatomical variations and pathological conditions. In children the most common disorders seen include flexible flatfoot, tarsal coalition, accessory navicular bone and congenital vertical talus. The most common cause of acquired flatfoot in adults is PTTD.
The management of flat foot must depend on accurate diagnosis and on accurate measurement and recording. The first consideration, in the presentation, is the age of the patient. A second consideration is whether the foot is flexible or secondary ones which can develop as a consequence of other pathologies. Tiptoe test and Jack’s test used clinically to differentiate flexible flatfoot from fixed (rigid) flatfoot.
Flexible flatfoot in most cases is a physiological variant rather than a pathological condition. It occurs in all infants and is common in children and adolescent. Many etiological factors contribute to flexible flatfoot, including familial tendency, generalized ligamentous laxity, obesity as well as shoe-wearing in early childhood. Diagnosis of flexible flat foot should be based on careful clinical examination which includes assessment of the height of the medial longitudinal arch, tightness of heel cord, integrity of muscles, subtalar joint motion and the degree of flexibility. Although x-ray is not necessary for diagnosis of flexible flatfoot, various angles have been described for the measurement of flatfoot. The presence of ”Meary angle” is most important feature in lateral weight-bearing plain x-ray. Treatment should be reserved for patients who have disability as a result of flatfoot. Shoe inserts have been proved to be ineffective in correction of the deformity but may relieve symptoms in some cases. Surgery is indicated when non-operative treatment fails to relieve symptoms. Surgical options include soft tissue reconstruction, osteotomy, arthrodesis and arthroereisis. The most widely accepted surgery is osteotomy in the form of calcaneal lengthening (Evan’s calcaneal osteotomy) or medial displacement osteotomy.
Congenital vertical talus, a severe type of pediatric rigid flatfoot, may occur as isolated defect but occur more commonly in association with other congenital anomalies. The diagnosis must be established as soon after birth as possible. Surgical treatment is often required, however casting before surgery may stretch the soft tissues and make skin closure easier. Some authors have recommended a two-stage procedure but a single stage procedure is the most commonly utilized method.
Tarsal coalition is a relatively common form of rigid flatfoot. Its occurrence in general population is about 1% and may be associated with other congenital anomalies. The patient usually present at the age of 9 to 13 years. The chief complaints are pain in the midtarsal region and flatfoot. The diagnosis is made on the basis of clinical examination, the coalition is seen in plain x-ray and CT scanning. Conservative treatment in the form of heel cups medial longitudinal arch supports and short leg cast for brief periods should be tried. If these measures are not effective, surgery should be considered. Resection of the coalition is usually the first surgical choice. Triple arthrodesis is reserved for older patients with advanced degenerative changes.
Accessory navicular bone is one of the supernumerary bones which may be normally present in the foot. Some cases will present with pain in adolescence. Symptomatic treatment by altering activities or modifying the shoes may be successful. In resistant cases simple excision can be carried out. Rerouting the tibialis posterior tendon is still controversial.
An acquired flat-foot deformity caused by dysfunction of the tendon of tibialis posterior is common but often missed. The etiology of dysfunction of the tendon of tibialis posterior ranges from inflammatory synovitis to degenerative rupture and, occasionally, to acute trauma. Careful clinical examination is essential. Radiographic studies are not required to diagnose dysfunction of the tendon of tibialis posterior but theyare important for staging the deformity and selecting treatment. Tenography has been used to assess the integrity of the tendon. MRI is the best method for assessing a ruptured tendon. Classification system was described for PTTD ranging from tenosynovitis as a Stage I, elongation or tearing In stage II with various degrees of joint affections, a more severe deformity and a fixed hindfoot as in Stage III and stage IV with valgus deformity of the talus with early degenerative changes of the ankle.
Some authors recommend a 3- to 6-month trial of conservative management for PTT dysfunction. These involves rest of the tendon, medication, physical therapy, and management of orthotics and braces.
Surgical management during stage 1 PTTD primarily consists of synovectomy. In stage 2 , synovectomy, tendon debridement, and/or primary repair may be indicated. When tendon dysfunction is present, a tendon transfer should be considered. Calcaneal osteotomies has also been recommended when deformity is present. Posterior muscle group lengthening should be considered when equinus is present. Arthroereisis and different types of arthrodesis procedures have been recommended as an option. Stage 3 PTTD usually requires an arthrodesis procedure. An isolated joint arthrodesis may be considered. Triple arthrodesis is the procedure of choice in longstanding, rigid deformities with extensive arthrosis. Additional degenerative changes are present in the ankle joint in stage 4. The salvage treatment at this stage is usually a pantalar arthrodesis (ankle, subtalar, calcaneocuboid, and talonavicular articulations).