List of Abbreviations
PFVD – plano-valgus foot deformity,
CP – cerebral palsy,
MRI – magnetic resonance imaging,
CT – computed tomography.
MMA – multimodal analgesia
NSAIDs – nonsteroidal anti-inflammatory drugs (from group M01A Nonsteroidal anti-inflammatory and antirheumatic products)
Surgical antibiotic prophylaxis
Terms and Definitions
Antibacterial drug, antibiotic – a medicinal product from the group of antibacterials for systemic use (J01).
Arthroereisis is a surgical technique for flatfoot correction that involves the implantation of a device/fixator that restricts excessive motion in the subtalar joint (foot eversion).
Beta-lactam antibiotics are a group of antibacterial agents sharing a common structural element, the beta-lactam ring. They inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins, leading to lysis and death of the microbial cell. According to the Anatomical Therapeutic Chemical classification, beta-lactam antibiotics include the following main groups: "Beta-lactam antibacterials, penicillins" (J01C) and "Other beta-lactam antibacterials" (J01D), of which the most clinically significant are first-generation (J01DB), second-generation (J01DC), third-generation (J01DD), and fourth-generation (J01DE) cephalosporins, "other cephalosporins and penems" (J01DI), "carbapenems" (J01DH), and "monobactams" (J01DF).
Inversion is a stereotyped foot movement comprising plantarflexion, varus, supination, and adduction,
Nonsteroidal anti-inflammatory drugs – nonsteroidal anti-inflammatory drugs belonging to the group "Anti-inflammatory and antirheumatic products, non-steroids" (M01A).
Eversion is a stereotyped foot movement comprising dorsiflexion, valgus, pronation, and abduction,
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Flatfoot in children is a foot shape feature characterized by flattening of the longitudinal arch. In some cases, flatfoot reflects the stages of child foot development, while in others, it is a manifestation of a pathological condition [1, 2].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Physiological flatfoot is a stage of the child's foot development and tends to decrease as the child grows. The prevalence of flatfoot reaches 97% in 1-year-old children, 54% in 3-year-olds, and 4% in 10-year-olds, indicating spontaneous correction [3, 4]. The cause of physiological flatfoot is increased connective tissue laxity and specific distribution of subcutaneous adipose tissue on the foot. Flatfoot is more common in boys than in girls (9.3% and 2.4%, respectively) [5]. There is a correlation between body mass index and the prevalence of flatfoot; for instance, overweight children have a flatfoot prevalence of 62% [1]. Genetic factors play an important role, as children with a positive family history show a lower rate of spontaneous flatfoot correction with growth [4]. Etiological factors leading to pathological forms of flatfoot include neuromuscular disorders (cerebral palsy, myopathies, and muscular dystrophies), genetic and chromosomal disorders (osteogenesis imperfecta, Marfan syndrome, Down syndrome, etc.), tarsal bone developmental anomalies (tarsal coalitions, hemimelias, etc.), gastrocnemius-soleus contracture, and trauma sequelae [6–8]. Muscle imbalance is an important etiological element in the development of various forms of flatfoot in children [8, 9]. Alterations in the lower limb torsional profile in children also affect flatfoot prevalence, including the presence of complaints and functional limitations [8, 10].
Pathological flatfoot disrupts relationships within the tarsal joints, leading to increased talocalcaneal divergence, dorsolateral displacement of the navicular bone, and talar plantarflexion. Clinically, this manifests as increased hindfoot valgus, and forefoot supination and abduction. All these changes lead to impaired propulsive function and biomechanical alterations throughout the lower extremity [11–14].
1.3 Epidemiology of the Disease or Condition
Because the prevalence of flatfoot in childhood depends on multiple factors (child's age, assessment method, flatfoot type), it ranges from 0.6 to 97% in the population [2–6]. Due to the lack of clear clinical criteria for defining flatfoot as a nosological entity, determining the true prevalence of this condition is difficult [5, 7]. Certain flatfoot types have a more precise prevalence. Flatfoot with gastrocnemius-soleus retraction (hypermobile flatfoot with a shortened Achilles tendon) occurs in an average of 6% of the population [8, 9]. Rigid flatfoot associated with tarsal bone developmental anomalies has the following prevalence: tarsal coalitions range from 0.004 to 13% in the population (averaging about 1–2%), and an accessory anterolateral facet of the subtalar joint ranges from 10 to 35% in the population [10–14]. The rarest form of pathological flatfoot in children is congenital vertical talus, with an average prevalence of 1 in 10,000 newborns [15–17].
1.4 Features of Coding the Disease or Condition
According to ICD-10, flatfoot in children is coded based on the presence and type of foot deformity, as well as the etiology of the deformity (Table 1).
Table 1. Nosological forms of flatfoot in children
ICD-10 Code | Nosological form of the disease |
|---|---|
M21.0 | Valgus deformity, not elsewhere classified |
M21.4 | Acquired flat foot [pes planus] |
Q66.5 | Congenital flat foot [pes planus] |
Q66.6 | Other congenital valgus foot deformities |
Q66.8 | Other congenital foot deformities |
Q74.8 | Other specified congenital malformations of limb(s) |
1.5 Classification of the disease or condition
Lynn T. Staheli classified childhood flatfoot into physiological and pathological. Physiological flatfoot is one of the stages of child foot development. Pathological flatfoot can lead to pain and functional impairment [18–20]. Childhood flatfoot is also categorized based on the severity of deformity observed during clinical examination, plantography, and radiography. The literature lacks convincing data to consider deformity severity as a predictor of symptom development and a factor determining further management [6, 7]. There are few publications reporting a correlation between certain radiomorphometric values (lateral talar-first metatarsal angle [Meary's angle], lateral navicular displacement angle) and the presence of symptoms [21, 22]. When standard weight-bearing foot radiographs are performed, flatfoot is categorized by the localization of the deformity: plano-valgus deformity at the subtalar joint level, midtarsal joints, and mixed forms [23]. The American College of Foot and Ankle Surgeons has developed a project aimed at creating a biomechanically and prognostically sound flatfoot classification based on deformity type, foot mobility, and the presence of symptoms (Figure 1) [7, 24].
Figure 1. Classification of flatfoot developed by the American College of Foot and Ankle Surgeons.
As can be seen in Figure 1, the key criterion in this classification is deformity mobility. In this classification, flatfoot combined with Achilles tendon shortening is categorized as a valgus-adducted foot deformity, although a number of authors consider this flatfoot type as a separate nosology [25]. Conversely, many authors classify flatfoot with Achilles tendon shortening within the mobile flatfoot group [7, 20, 26]. Furthermore, the literature lacks a clear definition of deformity mobility in flatfoot. Mobile forms of flatfoot include those types of deformities that manifest only under load, i.e., in the standing position. Another important criterion for deformity mobility is the restriction of motion in the tarsal joints [2, 4, 20, 27].
1.6 Clinical presentation of the disease or condition
The clinical presentation consists of general and specific manifestations. In children with physiological flatfoot, the general clinical manifestation is an alteration in foot shape—flattening of the longitudinal arch and increased hindfoot valgus. Additionally, parents of children with physiological flatfoot may report gait abnormalities, such as an unsteady gait and internal rotation of the lower limbs during walking. Most often, these complaints are due to similar physiological features and tend to resolve spontaneously [2,6,18,20,24,28,29]. Parents of children with flatfoot may also complain of rapid shoe wear, which they view as an indication to use stiffer footwear. A study by Bhaskara Rao U. and Joseph B. demonstrated that the prevalence of flatfoot is higher in children wearing rigid shoes compared to those wearing soft shoes or going barefoot [30]. Among general complaints, children with physiological flatfoot also frequently experience leg pain, which is typically symmetrical and poorly localized. This type of pain is not always related to foot shape and may result from hypermobility syndrome, growing pains, and excessive physical exertion. The causes of this pain syndrome are poorly understood, but the pain often resolves on its own as the child grows [18,31,32]. Specific complaints in children with pathological flatfoot include localized pain, gait disturbance (antalgic gait), restricted foot mobility, and frequent foot injuries. Furthermore, pathological flatfoot may present with progressive foot deformation and worsening pain over time [28,33,34].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
The diagnosis of flatfoot is recommended to be established primarily clinically, based on a combination of clinical symptoms: flattening of the longitudinal arch of the foot and hindfoot valgus. Diagnosis also involves the analysis of instrumental examination data: plantography (obtaining a graphical "print" of the plantar surface of the foot) and two-view radiography of the foot. Determining foot flattening does not affect treatment tactics and prognosis due to the wide variability of arch height in children of different ages. Clear and universal criteria for flatfoot are lacking [2,4,18,20,28,35].
GPP BLOE 2Grade of Recommendation – B (Level of Evidence – 2).
2.1 Complaints and Anamnesis
It is recommended that all patients with flatfoot, when taking their medical history, take into account data on the progression of deformity, pain syndrome, and functional limitations as the child grows, in order to identify pathological forms of flatfoot [13,18].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended when taking the medical history of all patients with flatfoot to account for recurrent foot injuries in order to perform differential diagnosis with tarsal coalitions [28,33].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is recommended when collecting complaints from all patients with flatfoot to take into account the following information: localized pain in the foot area, antalgic gait, and complaints of restricted foot motion, in order to rule out a pathological process that may be etiologically and pathophysiologically associated with flatfoot [12,28].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: pain in the foot area is an important clinical criterion that allows suspecting pathological flatfoot. It should be noted that in the presence of localized pain syndrome, restricted foot mobility, and progressive functional impairment, other conditions leading to similar complaints (traumatic, rheumatological changes, neoplastic process, osteochondropathies, etc.) should be ruled out.
2.2 Physical Examination
It is recommended that all patients with suspected flatfoot undergo an initial consultation (examination, assessment) by a trauma and orthopedic surgeon (service nomenclature B01.050.001) in order to verify the diagnosis and determine further management tactics, including a physical examination of the patient with evaluation of the following criteria [1, 4, 6, 18, 28, 35, 42, 44]:
- degree of foot deformity (severity of longitudinal arch flattening, hindfoot valgus), including the use of the Foot Posture Index (FPI-6) [131,138].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
- deformity mobility using basic mobility tests (toe-raise test, assessment of passive foot inversion and eversion, determination of the range of ankle dorsiflexion with subtalar joint stabilization and the Silfverskiöld test) [36].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
- restriction of ankle dorsiflexion to less than 100 with subtalar joint stabilization in a neutral position during knee flexion and extension indicates a tight triceps surae; restriction observed only during knee flexion indicates a tight gastrocnemius muscle [37].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
- evaluation of local status (detection of edema, hyperemia, tenderness upon palpation) [132].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: an important criterion for the clinical diagnosis of flatfoot in children is the assessment of deformity mobility. If restricted mobility of the tarsal joints is detected (toe-raise test, assessment of passive foot inversion and eversion), diagnostic evaluation must be continued to identify developmental anomalies of the tarsal joints (tarsal coalitions), verify neuromuscular pathology (cerebral palsy, myodystrophies, polyneuropathies, etc.), and detect traumatic changes.
The criterion for Achilles tendon shortening in flatfoot is a range of ankle dorsiflexion of less than 100 with the subtalar joint in a neutral position and full knee extension. Furthermore, when Achilles tendon shortening is detected, neuromuscular pathology leading to secondary triceps surae retraction must be ruled out.
It is recommended to arrange consultations with relevant pediatric specialists in the presence of comorbid pathology and secondary foot deformity in order to rule out other diseases [7,23].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comment: flatfoot in childhood may be associated with hereditary, neuromuscular, and other disorders (Ehlers-Danlos syndrome, Marfan syndrome, Down syndrome, cerebral palsy, myodystrophies, etc.). If a comorbid condition is suspected, diagnostic workup must be continued to identify other diseases requiring management adjustments.
2.3 Laboratory Diagnostics
It is recommended that all patients undergoing preparation for and performance of surgical treatment undergo laboratory tests, including general (clinical) blood and urine tests, general somatic biochemical blood test, determination of the international normalized ratio (INR), coagulogram (exploratory hemostasis screening), determination of ABO blood groups, determination of Rhesus factor (Rh factor), determination of antibodies to Treponema pallidum in the blood, determination of hepatitis B virus surface antigen (HBsAg) in the blood, determination of antibodies to hepatitis C virus in the blood, and testing for IgM and IgG antibodies to human immunodeficiency virus HIV-1/2 along with p24 antigen (HIV 1/2 + Agp24) in the blood [133-135].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
2.4 Instrumental Diagnostics
It is recommended to perform two-view foot radiography in a standing position for all patients to assess tarsal joint relationships and the degree of foot deformity [21,23,26,38–40].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
When congenital vertical talus (congenital equinovalgus foot deformity) (1:100,000 newborns) is suspected, it is recommended to perform functional lateral foot radiographs (single-view foot radiography) with maximum plantarflexion and dorsiflexion. Persistence of the equinus position of the calcaneus on lateral foot radiographs with maximum dorsiflexion; absence of restoration of the relationship between the talar axis and the first metatarsal axis on lateral foot radiographs with maximum plantarflexion indicates the presence of congenital vertical talus [15,16].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended that upon identifying indirect radiographic signs of tarsal coalitions in children ("antler" sign, "C" sign, "anteater nose" sign, altered contours of the sustentaculum tali, non-visualization of a tarsal joint space), further investigation is indicated, including computed tomography (CT) of the lower extremity and magnetic resonance imaging (MRI) of the lower extremity [41–44].
GPP BLOE 3Grade of Recommendation – B (Level of Evidence – 3).
It is recommended to perform computed tomography of the bones of the foot and ankle joint in order to rule out tarsal coalitions in complex clinical cases in children (30-35% of examined patients) [13, 27, 41–43, 45–47].
GPP BLOE 3Grade of Recommendation – B (Level of Evidence – 3).
It is recommended to perform magnetic resonance imaging of the foot to assess the condition of soft tissue structures, including the joint hyaline cartilage, determine areas of bone trabecular edema as a probable cause of pain syndrome due to overload or impingement, and detect synovitis and tendinitis in approximately 40-50% of cases in children [41, 42, 48].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is not recommended to use plantography (obtaining a graphical "print" of the plantar surface of the foot) as the primary diagnostic method for flatfoot in children due to the lack of pronounced correlations between plantographic parameters and clinical data [49].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
2.5 Other Procedures
No.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
It is recommended to use soft and comfortable shoes in children with flatfoot to achieve walking comfort [50].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is not recommended to provide conservative treatment in children with mobile asymptomatic flatfoot to avoid unjustified therapeutic interventions [51].
Level of Evidence C (Reliability of Evidence – 1)Level of Consensus ALevel of Consensus – A (Level of Reliability of Evidence – 1).
Comment: The effectiveness of orthotic treatment in children with flatfoot aimed at correcting foot deformity (orthopedic shoes, insoles) is questionable, and literature data are contradictory. The wearing regimen for orthopedic insoles is determined individually depending on the severity of the pain syndrome and the effectiveness of the ongoing conservative treatment [31, 51–55].
It is not recommended to use orthopedic insoles to correct the foot shape in children with flatfoot due to the weak effect of orthotics on foot shape in flatfoot, while the continuous use of orthopedic insoles by a child reduces their quality of life [51, 52, 56–60].
Level of Evidence C (Reliability of Evidence – 2)Level of Consensus ALevel of Consensus – A (Level of Reliability of Evidence – 2).
It is recommended to use special exercises for passive stretching of the triceps surae, training of the short foot muscles (therapeutic exercise for musculoskeletal diseases in children), and training of body balance in space in children with flatfoot (balance therapy) [61–67].
Level of Evidence C (Reliability of Evidence – 3)Level of Consensus CLevel of Consensus – C (Level of Reliability of Evidence – 3).
Comment: Universal conservative treatment programs for children with flatfoot do not exist; therefore, the effectiveness of conservative treatment is low. The main target that can be influenced through conservative treatment is pain and discomfort. To reduce the pain syndrome, various conservative treatment approaches can be used, such as orthotics, exercise therapy, etc. The impact of conservative treatment on the potential correction of foot shape in flatfoot is limited, and several studies have shown its ineffectiveness.
3.2 Surgical Treatment
It is not recommended to perform surgical treatment in children with mobile asymptomatic flatfoot [68–70].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: despite the lack of clear criteria for flatfoot, as well as the absence of standardized indications for the surgical treatment of children with flatfoot, many researchers acknowledge that mobile asymptomatic flatfoot is not an indication for surgical treatment, even in cases where the severity of the deformity falls outside the age-specific reference ranges.
It is recommended to consider conservative treatment as the first-line choice in the management of children with mobile symptomatic flatfoot [37, 68, 69, 71].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended to rule out other pathologies that may cause pain syndrome in addition to foot shape abnormalities in children with mobile flatfoot who present with complaints of pain in the feet and lower extremities [10, 11, 14, 20, 24, 31, 32, 41, 43, 46, 48].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comment: often in children with painful forms of mobile flatfoot, the pain syndrome is associated not with the foot shape abnormality, but with other conditions leading to pain (growing pains, osteochondropathy, specific and non-specific inflammatory diseases, tumors, and other conditions).
It is recommended to consider surgical treatment in patients with rigid symptomatic flatfoot, as well as flatfoot combined with triceps surae contracture [13, 14, 36, 45, 46, 68, 70, 72, 73].
GPP BLOE 3Grade of Recommendation – B (Level of Evidence – 3).
Comment: the main category of patients requiring surgical treatment consists of patients with symptomatic rigid flatfoot, which is most often associated with tarsal bone developmental anomalies (tarsal coalitions, subtalar joint anomalies, and others). Asymptomatic rigid flatfoot requires careful monitoring to determine the need for surgical treatment based on follow-up results. Flatfoot combined with triceps surae contracture is also an indication for surgical treatment, since the natural history of this type of deformity carries a high probability of developing pain syndrome at an older age.
It is recommended to plan the surgical treatment strategy for children with pathological flatfoot depending on the degree of mobility of the tarsal joints [2, 4, 12, 15, 16, 28, 46, 68, 72–74].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: the mobility of the tarsal joints is a key element when choosing the surgical treatment method. With satisfactory mobility of the subtalar and transverse tarsal (Chopart) joints, deformity correction can be achieved by subtalar arthroereisis or lengthening osteotomy of the calcaneus; with low tarsal joint mobility, the corrective potential of these interventions is minimal. In such cases, correction of the foot deformity is achieved through periarticular osteotomies. In the presence of pronounced degenerative changes in the tarsal joints and associated pain, arthrodesis procedures may be performed in children over 12 years of age.
It is recommended to use serial casting according to the Dobbs method (application of a plaster cast) as preoperative preparation in patients with congenital equinovalgus foot deformities with a vertically positioned talus [15, 16].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended to perform surgical treatment in children with congenital equinovalgus foot deformities with a vertically positioned talus prior to the age of two years by open reduction of the talus [15, 16].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: the extent of release during open talar reduction is determined by the rigidity of the deformity and the possibility of correcting the dorsal subluxation of the navicular bone. The release may be limited to the talonavicular joint, but may also include release of the subtalar and calcaneocuboid joints, lengthening of the tibialis anterior muscle, long toe extensors, and plication of the tibialis posterior tendon. To correct the equinus deformity, an Achilles tenotomy is usually sufficient; for pronounced and rigid deformity, a posterior release may be performed. Fixation of the tarsal joints (talonavicular and, if necessary, – subtalar) is performed using Kirschner wires, which are removed 6-8 weeks after surgery (depending on the degree of impairment of tarsal joint congruence).
It is not recommended to use isolated procedures aimed at strengthening the medial soft tissue structures of the foot (plications/transpositions/augmentations of the tibialis posterior muscle, calcaneonavicular ligament, deltoid ligament [bone reconstruction; corrective osteotomy for foot deformities; lengthening, shortening, transfer of muscle and tendon; muscle and tendon repair; tendon plastic surgery]) in children [70].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: isolated interventions on the medial soft tissue structures in flatfoot have low effectiveness. These interventions are used as adjunctive procedures to standard surgeries—subtalar arthroereisis, periarticular osteotomies, arthrodesis. Currently, the advisability of using techniques to strengthen the medial soft tissue structures remains debatable, as standard surgeries for foot deformity correction (arthroereisis, osteotomies) are usually sufficient for complete correction.
It is recommended to use various options for triceps surae lengthening in children's foot reconstruction for flatfoot, depending on the type of retraction based on Silfverskiöld test results (isolated gastrocnemius retraction, entire triceps surae retraction) and the degree of retraction. Lengthening options may include Achilles tendonoplasty and various gastrocnemius recession techniques (lengthening, shortening, muscle and tendon transfer; tendonoplasty) [2,4,25,28,36,37,46,70,72,75,76].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comment: triceps surae retraction is frequently observed in pathological flatfoot; therefore, triceps surae lengthening is often used in the surgical treatment of children with flatfoot.
It is recommended to consider coalition resection as a first-line procedure when choosing a treatment strategy for children with tarsal coalitions. Correction of foot deformities in children with tarsal coalitions depends on the degree of mobility of the tarsal joints following coalition resection [12,45,46,73,77].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comment: in children with flatfoot and tarsal coalitions in the absence of severe degenerative changes in the tarsal joints, surgical treatment consists of coalition resection and interposition arthroplasty (bone wax, subcutaneous adipose tissue). If satisfactory mobility of the subtalar joint is achieved, correction of the foot deformity is possible by performing subtalar arthroereisis. If subtalar mobility is unsatisfactory after coalition resection, but Chopart joint mobility is preserved, foot deformity correction is possible by performing extra-articular osteotomies—calcaneal lengthening osteotomy, calcaneal tuberosity osteotomy, and flexion osteotomy of the medial cuneiform bone. In cases of severe degenerative changes in the tarsal joints (subtalar, Chopart joints) detected by MRI, CT scans, or intraoperatively, as well as in the presence of pain syndrome associated with movements in the altered tarsal joints, arthrodesing procedures may be performed.
It is recommended to consider calcaneal lengthening osteotomy and subtalar arthroereisis as the main interventions in the surgical correction of flatfoot in children (bone reconstruction; bone osteotomy; bone reconstruction, corrective osteotomy for foot deformities; foot and ankle arthrodesis; arthroscopic ankle arthrodesis) [78–82].
GPP BLOE 3Grade of Recommendation – B (Level of Evidence – 3).
Comment: currently, the most frequently used techniques for flatfoot correction in children are calcaneal lengthening osteotomy and subtalar arthroereisis. According to a number of studies, the deformity correction potential of both techniques is comparable. Calcaneal lengthening osteotomy requires a longer immobilization and recovery period compared to subtalar arthroereisis. There is scarce literature on the long-term outcomes of subtalar arthroereisis in children. Among all variants of subtalar arthroereisis, techniques using a blocking screw to restrict excessive subtalar eversion (the "calcaneo-stop" technique) have the largest clinical evidence base and the lowest complication rate.
It is recommended to use calcaneal lengthening osteotomy in cases of reduced subtalar mobility with preserved Chopart joint mobility and the predominance of the abduction component of the deformity over the valgus component during surgical treatment of children with pathological flatfoot [78,79,83,84].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is recommended to use additional interventions aimed at correcting residual deformities when performing calcaneal lengthening osteotomy—calcaneal tuberosity osteotomy, flexion osteotomy of the medial cuneiform bone during the surgical treatment of children with pathological flatfoot [70,84–89].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is recommended to use tricortical allo- or autografts when performing calcaneal lengthening osteotomy in the surgical treatment of children with pathological flatfoot [136].
Level of Recommendations CLevel of Evidence 5Level of Recommendations – C (Level of Evidence – 5).
It is recommended to use subtalar arthroereisis in cases of satisfactory subtalar mobility and the predominance of the valgus component of the deformity over the abduction component during the surgical treatment of children with pathological flatfoot [90–92].
Level of Recommendations BLevel of Evidence 5Level of Clinical Recommendation – B (Level of Evidence – 5).
Comment: the primary condition for the correct performance of subtalar arthroereisis is satisfactory subtalar mobility. The range of motion in the subtalar joint can serve as a criterion for choosing between subtalar arthroereisis and calcaneal lengthening osteotomy. Furthermore, a patient age older than 15–16 years and a weight of more than 80 kg make calcaneal lengthening osteotomy more justifiable compared to subtalar arthroereisis. The optimal age for subtalar arthroereisis is 10–12 years. The choice between calcaneal lengthening osteotomy and subtalar arthroereisis should be based on these criteria and other factors influencing the correction potential of each method.
It is recommended when choosing the method of subtalar arthroereisis to give preference to techniques that minimize trauma to the sinus tarsi (blocking or stop-screw techniques – "calcaneo-stop" in antegrade approach (screw inserted into the calcaneus) and retrograde approach (screw inserted into the talus) during the surgical treatment of children with pathological flatfoot [90–98].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comment: there are publications reporting a relatively high incidence of pain syndrome in the sinus tarsi region (up to 30%) when using subtalar implants. When using blocking screws, the incidence of pain syndromes in the sinus tarsi area does not exceed 6–8%, which is due to the specific placement of the screw (vestibule of the sinus tarsi) and the absence of damage to nerve endings in the sinus tarsi area during screw insertion.
It is recommended to perform the removal of blocking screws (orthopedic non-absorbable non-sterile bone screw***, orthopedic non-absorbable sterile bone screw***) 2–3 years after insertion to minimize the risk of hardware breakage in children following subtalar arthroereisis using blocking/stop screws [90,97–99].
Level of Recommendations BLevel of Evidence 4Level of Clinical Recommendation – B (Level of Evidence – 4).
Comment: there are isolated publications describing blocking screw breakage in children after intensive physical activity. Therefore, patients are advised to meter physical activity following surgery depending on the presence and severity of pain syndrome. In cases of severe pain after blocking screw placement, early removal may be performed, which can lead to a loss of foot deformity correction.
It is recommended to minimize the use of arthrodesing procedures in children with flatfoot, as this leads to significant restriction of tarsal joint mobility, the development of degenerative changes in adjacent joints, and the recurrence of pain syndrome in the long-term period [70,72,100–102].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
Comment: arthrodesing interventions in children with flatfoot are used in cases where preserving joint mobility is not feasible – severe degenerative changes in the joints accompanied by significant pain syndrome, tarsal coalitions with substantial involvement of articular surfaces (talocalcaneal coalitions affecting the medial and more than 50% of the posterior facet of the subtalar joint), post-traumatic changes, inflammatory destructive processes, and others. Whenever possible, it is recommended to preserve the maximum number of tarsal joints—giving preference to local arthrodesis over triple arthrodesis.
It is recommended to use plaster immobilization (application of an immobilization bandage during bone surgeries) following subtalar arthroereisis combined with triceps surae lengthening, osteotomies, and arthrodesis in the surgical treatment of children with pathological flatfoot [137].
Level of Recommendations CLevel of Evidence 5Level of Recommendations – C (Level of Evidence – 5).
Comment: for subtalar arthroereisis, the duration of plaster immobilization depends on the method of triceps surae lengthening (when performing achilloplasty, the duration of plaster immobilization is 4 weeks). When performing periarticular osteotomies and arthrodeses, the duration of immobilization is determined by the rate of bone healing on radiographs and averages 2.5–3 months. With Kirschner wire fixation, hardware removal is performed on an outpatient basis during cast change 6 weeks after surgery. When using internal fixation (screws, plates), the duration of plaster immobilization can be reduced depending on the stability of the fixation.
3.1.2 Postoperative analgesia
To ensure adequate pain relief in patients after surgical treatment of flatfoot, it is recommended to use multimodal analgesia for children, taking into account age restrictions, which may include NSAIDs (from group M01A Non-steroidal anti-inflammatory and antirheumatic products), paracetamol**, gabapentinoids (ATC group code N02BF), and immediate-release opioids (ATC group code N02A) taking into account age restrictions in the instructions for medical use; if its administration is not possible, monomodal analgesia [122, 123, 124, 125].
GRL ALEL 2Grade of Recommendation – A (Level of Evidence – 2).
Comments: Among pharmacological strategies, the current consensus is the use of multimodal analgesia (MMA), which involves the use of multiple analgesics (opioids combined with non-opioid analgesics) from group N02AJ Analgesics with different mechanisms of action and non-pharmacological interventions aimed at targeting peripheral and/or central parts of the nervous system [126]. This combination allows for more effective pain relief by enhancing the effects of various drugs, which in most cases leads to a reduction in the frequency of prescription and/or doses of opioid analgesics. Thus, MMA improves the risk profile of each drug while providing synergistic pain control using different drug classes. Postoperative MMA may include psychotherapy, physical therapy, NSAIDs, paracetamol**, gabapentinoids (ATC group code N02BF), regional anesthesia (single injection or peripheral nerve catheter placement), local injections, and opioids [123, 127].
It must be kept in mind that the duration of parenteral administration of most NSAIDs from the ATC group M01A "Anti-inflammatory and antirheumatic products, non-steroids" (ketorolac**, ketoprofen**, diclofenac**) is limited to two days in accordance with the instructions for medical use, which requires timely switching of the patient to oral administration, changing the drug, or approving further use with the medical commission. The specific choice of local anesthesia method and medicinal products is made by the attending physician individually, in accordance with the patient's characteristics, local protocols, and the equipment of the medical organization.
When prescribing analgesic therapy for children, a single dose should be chosen taking into account the child's weight and age. Preference should be given to analgesics with oral or rectal administration routes, avoiding intramuscular injections.
Recommended analgesics from group N02 Analgesics are listed in Appendix A3.1.
3.3 Other Treatment
No.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Medical rehabilitation after surgical treatment of children with flatfoot is carried out at various stages following the surgical intervention. The postoperative period consists of the early postoperative period (1–4 weeks), the immobilization period (if applicable) with a cast or orthosis, and the late postoperative period (up to 3–6 months). Rehabilitation treatment is determined individually depending on the patient's age and the extent of the surgical treatment performed. The goal of rehabilitation treatment is to reduce pain, edema, and trophic disorders in the area of surgery, as well as to restore locomotor function. During the recovery period, physical activity should be restricted depending on the presence and severity of pain syndrome.
It is recommended to restrict physical activity after the cessation of immobilization, with partial weight-bearing on the operated limb depending on the presence and severity of pain after surgical treatment of children with pathological flatfoot [78,98,103,104].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
It is recommended to provide rehabilitation treatment in the postoperative period when functional impairments associated with the performed surgery develop, including physical therapy exercises (therapeutic gymnastics for musculoskeletal disorders in children), and physical therapy methods aimed at reducing edema and pain in the surgical area to gradually restore locomotor function after surgical treatment of children with pathological flatfoot [78,98,103,104].
GPP CLOE 4Grade of Recommendation – C (Level of Evidence – 4).
5. Prevention and Dispensary Observation
5.1 Prevention of flatfoot
There are no specific prevention measures for flatfoot in children. Dispensary observation is aimed at the timely detection of pathological forms of flatfoot and the implementation of appropriate treatment.
It is recommended to conduct an initial appointment (examination, consultation) with a traumatologist-orthopedist during the 1st year of life (at 1 month, 1 year) to detect congenital equinovalgus foot deformities. Subsequent examinations are performed at 3 years, 6–7 years, 10–12 years, and 15–18 years of age. Examinations are performed at any age if the patient or their parents have complaints [15,17,60,71,105–107].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended to monitor patients after surgical treatment once limb weight-bearing capacity is restored, and then once a year to evaluate long-term outcomes [78,91,99,101,104,108].
GRC CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
It is recommended to use a validated Oxford Ankle and Foot Questionnaire for Children during dispensary observation of children with flatfoot [106,109].
GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2).
5.2 Surgical antibiotic prophylaxis
In the surgical treatment of patients with rigid symptomatic flatfoot, as well as flatfoot combined with triceps surae retraction, it is recommended to perform surgical antimicrobial prophylaxis (SAP) of surgical site infections with a single preoperative systemic antibacterial drug (J01) to reduce the risk of infectious complications [115, 116].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments. In accordance with international clinical guidelines for the prevention of surgical site infections [115, 117], the objective of SAP is to establish bactericidal concentrations of a systemic antibacterial drug (J01) in tissues exposed to microbial contamination during surgery to prevent surgical site infections. The need for SAP is determined by the surgical wound class of the upcoming operation: SAP is not required for "clean" surgical wounds not involving the placement of orthopedic implants and metal hardware. SAP should be performed for clean-contaminated and contaminated surgical wounds, as well as for "clean" surgical wounds where orthopedic implants and metal hardware are placed. For infected ("dirty") wounds, SAP is not indicated; instead, antibiotic therapy is administered.
For patients scheduled for surgical treatment of flatfoot, it is recommended to use first-generation (J01DB) and second-generation (J01DC) cephalosporins (cefazolin**, cefuroxime**) as the primary drugs for SAP, and glycopeptide antibacterial drugs (vancomycin**), lincosamides (#clindamycin**) as alternatives in case of hypersensitivity to beta-lactam antibacterial drugs or penicillins (J01C) [115]. The use of these medications should take into account age restrictions in the instructions for medical use.
GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5).
Comments. For patients with an unburdened allergic history and no significant risk factors for methicillin-resistant Staphylococcus carriage, first-generation (J01DB) and second-generation (J01DC) cephalosporins (cefazolin**, cefuroxime**) are used for SAP, administered intravenously 30 to 60 minutes before skin incision.
It is recommended that in case of intolerance to beta-lactam antibacterial drugs or penicillins (J01C), vancomycin** should be prescribed, administered over a minimum of 60 minutes with the intravenous infusion starting 2 hours before the incision, or #clindamycin**. In the presence of significant risk factors for methicillin-resistant Staphylococcus (MRS) carriage, the SAP regimen should include systemic antibacterial drugs (ATC: J01) with anti-MRS activity (vancomycin**). In most cases, a single preoperative dose of a systemic antibacterial drug is sufficient for effective prophylaxis [115,118,119].
GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5).
It is recommended that for prolonged procedures (more than 3 hours) or massive blood loss, an additional intraoperative dose of a systemic antibacterial drug (ATC: J01) should be administered (the approximate timing of intraoperative administration is 2 half-lives after the preoperative dose). Administration of systemic antibacterial drugs (ATC: J01) after wound closure in the operating room is impractical even in the presence of indwelling drains [115,118,119].
GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5).
It is recommended that single doses of the main antibacterial drugs for SAP in surgical interventions in children should be calculated based on actual weight: cefazolin** 30 mg/kg, cefuroxime** 50 mg/kg, #clindamycin** 10 mg/kg, vancomycin** 15 mg/kg [115,118,119].
GCR CLEL 5Grade of Recommendation — C (Level of Evidence — 5).
In the surgical treatment of patients with flatfoot, it is recommended to administer antibiotic prophylaxis for surgical site infection for a duration of no more than 24 hours to achieve an effective concentration of the antibacterial drug in tissues and blood serum at the time of the skin incision [121].
GCR CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: In accordance with the regulatory documentation in force in the Russian Federation (SanPiN 3.3686-21) and clinical guidelines [121], antibiotics for the prophylaxis of surgical site infection should be administered intravenously 30 to 60 minutes before the skin incision, or within 2 hours before the incision in the case of vancomycin**. The maximum duration of prophylactic administration of a systemic antibacterial drug (ATC: J01) must not exceed 24 hours after the end of surgery. In most cases, a single dose of a systemic antibacterial drug (ATC: J01) is sufficient for effective prophylaxis. Additional doses should be administered during prolonged surgeries when the time elapsed from the preoperative administration of the systemic antibacterial drug exceeds the half-life of the administered systemic antibacterial drug (ATC: J01), creating a risk of the concentration of the systemic antibacterial drug (ATC: J01) dropping below the bactericidal level and an increased risk of surgical site infection.
6. Organization of Medical Care
Indications for hospital admission to a medical organization:
1) Elective surgical treatment of children with pathological flatfoot;
Indications for patient discharge from a medical organization
1) Performed surgical treatment or refusal of surgical treatment for objective reasons;
2) Absence of: persistent pain syndrome; persistent hyperthermia; significant laboratory abnormalities; complications requiring inpatient treatment;
7. Additional Information
Standardized approaches to choosing a treatment method for children with flatfoot do not exist. The choice of tactics depends on a multitude of factors, which are outlined in these clinical guidelines. Accounting for these factors (flexibility of the deformity, assessment of triceps surae retraction, correlation of the patient's complaints with the clinical picture) is the key to success. At the same time, the clinical experience of the orthopedic surgeon may dictate other approaches to the treatment of these patients. These clinical guidelines present world experience in understanding flatfoot as a condition and defining the physician's actions when planning examination and treatment tactics.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Yes/No |
|---|---|---|
1. | History taking and anamnesis | Yes/No |
2. | Assessment of foot shape based on clinical criteria | Yes/No |
3. | Assessment of deformity flexibility, including evaluation of the range of dorsiflexion of the foot | Yes/No |
4. | Performing plain radiography of the feet in two projections in a weight-bearing (standing) position | Yes/No |
5. | Performing CT of the lower extremity (feet) upon detection of radiological signs of tarsal coalitions | Yes/No |
6. | Determination of indications for conservative and surgical treatment based on the assessment of deformity flexibility and analysis of complaints | Yes/No |
7. | Performing resection of the tarsal coalition in the presence of pain syndrome and the absence of pronounced degenerative changes in the tarsal joints | Yes/No |
8. | Performing a lengthening osteotomy of the calcaneus or subtalar arthroereisis, depending on the flexibility of the subtalar and Chopart joints, as well as the severity of the valgus and abduction components of the deformity | Yes/No |
9. | Planning of triceps surae lengthening depending on the result of the Silfverskiöld test and the degree of triceps surae retraction | Yes/No |
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Briko N. I., Bozhkova S. A., Brusina E. B. et al.; National Association of Nosocomial Infection Control Specialists (NASCI). Prevention of surgical site infections. Guidelines. Moscow, 2022. 74 p. [Electronic resource]. URL: https: //www.nasci.ru/?id=102733&download=1 (accessed: 27.04.2024).
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Shabaldin N.A., Shabaldin A.V., Titov F.V., Kokina V.A. Comparative analysis of foot position in children using the Foot Posture Index (FPI-6) with symptomatic and asymptomatic forms of flatfoot. Fundamental and Clinical Medicine. 2020;5(4):76-83. https://doi.org/10.23946/2500-0764-2020-5-4-76-83
Appendix A1. Working Group Composition
1. Vavilov Maksim Aleksandrovich, MD, physician at the State Healthcare Institution of the Yaroslavl Region "Regional Clinical Hospital", Associate Professor of the Department of Pediatric Surgery at the Federal State Budgetary Educational Institution of Higher Education "Yaroslavl State Medical University" of the Ministry of Health of the Russian Federation
2. Kenis Vladimir Markovich, MD, Prof., Deputy Director for Innovative Development and Regional Affairs at the Federal State Budgetary Institution "H.I. Turner National Medical Research Center for Children's Orthopedics and Trauma" of the Ministry of Health of the Russian Federation
3. Kokorev Aleksey Ivanovich, PhD, orthopedic trauma surgeon, Head of the Department for Organization of Traumatological and Orthopedic Services at the Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Ministry of Health of the Russian Federation
5. Otdelyonov Vitaly Aleksandrovich, PhD, clinical pharmacologist, Head of the Department of Drug and Medical Device Safety Management at the Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Ministry of Health of the Russian Federation
4. Ochurenko Aleksandr Alekseevich, MD, Prof., Head of the Department for Implementation of NMRC Functions at the Federal State Budgetary Institution "N.N. Priorov National Medical Research Center of Traumatology and Orthopedics" of the Ministry of Health of the Russian Federation
5. Sapogovskiy Andrey Viktorovich, PhD, Leading Research Fellow at the Clinic of Foot Pathology, Neuroorthopedics, and Systemic Diseases of the Federal State Budgetary Institution "H.I. Turner National Medical Research Center for Children's Orthopedics and Trauma" of the Ministry of Health of the Russian Federation
Conflict of interest: none declared
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Orthopedic surgeons,
Pediatricians,
Pediatric surgeons,
Physical therapy physicians.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for grading levels of evidence certainty (LEC) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Kenis, V. M. Tarsal coalitions in children (clinical presentation, diagnostics, treatment): Study guide / V. M. Kenis, A. G. Baindurashvili, A. V. Sapogovskiy; Ministry of Health of the Russian Federation, Federal State Budgetary Institution "H.I. Turner Scientific and Research Institute for Children's Orthopedics" of the Ministry of Health of the Russian Federation, Federal State Budgetary Educational Institution of Higher Education "I.I. Mechnikov North-Western State Medical University" of the Ministry of Health of the Russian Federation. – Saint Petersburg : I.I. Mechnikov North-Western State Medical University, 2016. – 60 p. – EDN QYUUHC.
Flatfoot in children (diagnostics and treatment): Study guide / V. M. Kenis, A. G. Baindurashvili, A. V. Sapogovskiy, A. Yu. Dimitrieva; Ministry of Health of the Russian Federation, H.I. Turner National Medical Research Center for Children's Orthopedics and Trauma, I.I. Mechnikov North-Western State Medical University. – Saint Petersburg : H.I. Turner National Medical Research Center for Children's Orthopedics and Trauma, 2021. – 56 p. – ISBN 978-5-907276-25-3. – EDN EQMZOS.
Appendix A3.1 Dosage regimen of medicinal products for children for analgesia (ATX specified depending on the group)
Medicinal products | Single dose | Dosing regimen | Maximum daily dose | Maximum duration of use |
|---|---|---|---|---|
Non-opioid analgesic from the anilides group (ATC: N02BE) | ||||
Paracetamol** | Rectal suppositories: | |||
3-6 months (6-8 kg): 50 mg | rectally at intervals of at least 4-6 hours | 100 mg/day | Not specified in the instructions | |
7-12 months (8-11 kg): 100 mg | 200 mg/day | |||
1-4 years (12-16 kg): 100 mg | 400 mg/day | |||
5-9 years (17-30 kg): 250 mg | 1000 mg/day | |||
10-14 years: 500 mg | 2000 mg/day | |||
over 15 years: 500 mg | 4000 mg/day | |||
IV infusion: | ||||
10 kg and under: 7.5 mg/kg (0.75 ml/kg) | no more than 4 times/day, interval between infusions at least 4 hours | no more than 30 mg/kg/day | Not specified in the instructions | |
from 10 kg up to 33 kg inclusive: 15 mg/kg (1.5 ml/kg) | less than 60 mg/kg inclusive, but not more than 2 g | |||
from 33 to 50 kg inclusive: 15 mg/kg (1.5 ml/kg) | less than 60 mg/kg inclusive, but not more than 3 g | |||
over 50 kg: 1 g (100 ml) | no more than 4 g/day | |||
Tablets | ||||
3-5 years: 200 mg | Every 4-6 hours | no more than 4 times a day | ||
6-8 years: 250 mg | no more than 4 times a day | |||
9-11 years: 500 mg | no more than 4 times a day | |||
Over 12 years: 500-1000 mg | no more than 4 g/day | |||
Nonsteroidal anti-inflammatory and antirheumatic drugs (ATC: M01A) | ||||
Diclofenac** | Powder for oral solution | |||
14-18 years: 50-100 mg | 0.5-2 mg/kg per day orally, daily dose divided into 2-3 single doses | 150 mg | Not specified in the instructions | |
Tablets: | ||||
6-14 years: 25 mg | 0.5-2 mg/kg per day orally, daily dose divided into 2-3 single doses | 150 mg | Not specified in the instructions | |
14-18 years: 25-50 mg | ||||
Ibuprofen** | Suspension (100 mg/5 ml): | |||
3-6 months (5-7.6 kg): 2.5 ml (50 mg) | orally up to 3 times/day at intervals of 6-8 hours | 7.5 ml (150 mg) | No more than 5 days | |
6-12 months (7.7-9 kg): 2.5 ml (50 mg) | orally 3-4 times/day at intervals of 6-8 hours | 10 ml (200 mg) | ||
1-3 years (10-16 kg): 5 ml | orally up to 3 times/day at intervals of 6-8 hours | 15 ml (300 mg) | ||
4–6 years (17–20 kg): 7.5 ml | 22.5 ml (450 mg) | |||
7–9 years (21–30 kg): 10 ml | 30 ml (600 mg) | |||
10–12 years (31–40 kg): 15 ml | 45 ml (900 mg) | |||
Suspension (200 mg / 5 ml): | ||||
1–3 years (10–16 kg): 2.5 ml (100 mg) | orally up to 3 times/day at intervals of 6-8 hours | 7.5 ml (300 mg) | No more than 5 days | |
4–6 years (17–20 kg): 3.75 ml (150 mg) | 11.25 ml (450 mg) | |||
7–9 years (21–30 kg): 5 ml (200 mg) | 15 ml (600 mg) | |||
10–12 years (31–40 kg): 7.5 ml (300 mg) | 22.5 ml (900 mg) | |||
over 12 years of age (over 40 kg): 7.5–10 ml (300–400 mg) | 30 ml (1200 mg) | |||
Tablets: | ||||
aged 6 to 12 years (body weight > 20 kg): 200 mg | orally up to 4 times/day with an interval of at least 6 hours | 800 mg | Not specified in the instructions | |
children over 12 years: 200 mg | orally 3–4 times/day with an interval of at least 6 hours | |||
rectal suppositories, [FOR CHILDREN] | ||||
3–9 months (6.0 kg–8.0 kg): 1 suppository (60 mg) | Up to 3 times per 24 hours, maximum 180 mg per day | 30 mg/kg with dosing intervals of 6–8 hours | Maximum 3 days | |
9 months–2 years (8.0 kg–12.0 kg): 1 suppository (60 mg) | Up to 4 times per 24 hours, maximum 240 mg per day | |||
Ketorolac** | Tablets: | |||
children over 16 years: 10 mg | orally up to 4 times/day | 40 mg | 5 days | |
Parenteral solution | ||||
over 16 years: 10–30 mg | IV, IM with an interval of at least 6 hours | 90 mg | 2 days | |
Opioids (ATC: N02A) | ||||
Morphine** | Oral solution, oral drops, tablets | |||
3 to 7 years: 5 mg | orally, every 6 hours | 20 mg | Not specified in the instructions | |
7 to 17 years with body weight up to 70 kg: 5 mg | orally, every 4 hours | 30 mg | ||
7 to 17 years with body weight of 70 kg or more: 10 mg | 60 mg | |||
17 years and older: 5–10 mg | Not specified in the instructions | |||
Solution for subcutaneous injection: | ||||
birth to 2 years: 100–200 mcg/kg body weight (0.1–0.2 mg/kg) | SC, if necessary every 4–6 hours. | 15 mg | Not specified in the instructions | |
over 2 years: 100–200 mcg/kg body weight (0.1–0.2 mg/kg) | SC if necessary every 4–6 hours | |||
Tramadol**1 | Solution for injection | |||
1 to 12 years*: 1–2 mg/kg | IV, IM, SC | 8 mg/kg/day or maximum 400 mg/day | ||
Aged 12 years and older: 50–100 mg | IV, IM, SC; if satisfactory analgesia is not achieved within 30–60 minutes after the initial dose, an additional 50 mg may be administered | 400 mg/day | Not specified in the instructions | |
Tablets: | ||||
children over 14 years of age: 50–100 mg | Orally; if satisfactory analgesia is not achieved within 30–60 minutes after the initial dose, an additional 50 mg may be administered | 400 mg/day | Not specified in the instructions | |
Trimeperidine** (ATC: N02AB04) | Solution for injection | |||
Children2 over 2 years of age: 3–10 mg | IV, IM, SC | Not specified in the instructions | Not specified in the instructions | |
Fentanyl** (ATX:NO2B03) | Solution for intravenous and intramuscular administration | |||
children from 1 year of age with spontaneous breathing: initial dose 3–5 mcg/kg, additional dose 1 mcg/kg. | IV | Not specified in the instructions | Not specified in the instructions | |
children from 1 year of age receiving mechanical ventilation: initial dose 15 mcg/kg, additional dose 1–3 mcg/kg. | IV | Not specified in the instructions | Not specified in the instructions | |
1 In children under 12 years of age, morphine** is preferred if opioid analgesics need to be prescribed, as the use of tramadol** is associated with a higher risk of adverse reactions [128,129].
2 Trimeperidine should not be used in children, as its metabolite accumulates in the body and provokes seizures upon repeated administration [130].
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. Oxford Ankle and Foot Questionnaire – Child and Adolescent Version (5–16 years).
The Oxford Ankle Foot Questionnaire for children
Source - http://www.innovation.ox.ac.uk/.
Email address: enquiries@innovation.ox.ac.uk:
Type (underline):
- rating scale
- index
- questionnaire
Prescription:
Content (template): child version;
sections:
- physical component of symptoms,
- social component of symptoms,
- emotional component of symptoms.
Below are questions about foot-related problems in children and adolescents.
Think about each question and put a checkmark or cross next to the most appropriate answer: indicate how often the described problem bothers you – constantly, never, or with another frequency?
Think about the past week… |
|---|
1. Did you have difficulty walking because of your feet? | ||||
|---|---|---|---|---|
never | rarely | sometimes | very often | all the time |
2. Did you have trouble running because of your feet? | ||||
never | rarely | sometimes | very often | all the time |
3. Did you have difficulty standing for a long time? | ||||
never | rarely | sometimes | very often | all the time |
4. Were you bothered by foot pain? | ||||
never | rarely | sometimes | very often | all the time |
5. Did you experience discomfort or pain in your legs after walking or running? | ||||
never | rarely | sometimes | very often | all the time |
6. Were you bothered by tiredness because of your feet? | ||||
never | rarely | sometimes | very often | all the time |
7. Did it happen that, due to foot problems, you couldn't play active games on par with your friends? | ||||
never | rarely | sometimes | very often | all the time |
8. Did it happen that, due to foot problems, you couldn't play outside? | ||||
never | rarely | sometimes | very often | all the time |
9. Did it happen that, due to foot problems, you couldn't go to physical education class? | ||||
never | rarely | sometimes | very often | all the time |
10. Did it happen that, due to foot problems, you couldn't go to other classes at school? | ||||
never | rarely | sometimes | very often | all the time |
11. Were you bothered by the appearance of your feet? | ||||
never | rarely | sometimes | very often | all the time |
12. Were you bothered by how your gait looked from the outside? | ||||
never | rarely | sometimes | very often | all the time |
13. Did you feel embarrassed because of your feet? | ||||
never | rarely | sometimes | very often | all the time |
14. Were you teased because of the appearance of your feet? | ||||
never | rarely | sometimes | very often | all the time |
15. Did it happen that you couldn't wear shoes you like because of your feet? | ||||
never | rarely | sometimes | very often | all the time |
Appendix G2. Oxford Ankle Foot Questionnaire for Children – Parent Version
Source - http://www.innovation.ox.ac.uk/.
Email address: enquiries@innovation.ox.ac.uk:
Type (underline):
- rating scale
- index
- questionnaire
Prescription:
Content (template): parent version;
sections:
- physical component of symptoms,
- social component of symptoms,
- emotional component of symptoms.
Below are questions about foot-related problems in children and adolescents.
Think about each question and put a checkmark or cross next to the answer that corresponds to your child's condition: indicate the frequency of each described problem.
Think about the previous week… |
|---|
1. Did your child experience difficulty walking related to the foot? | ||||
|---|---|---|---|---|
never | rarely | sometimes | very often | all the time |
2. Did your child have trouble running due to foot problems? | ||||
never | rarely | sometimes | very often | all the time |
3. Did your child have difficulty standing for a long period of time due to foot problems? | ||||
never | rarely | sometimes | very often | all the time |
4. Was your child bothered by foot pain? | ||||
never | rarely | sometimes | very often | all the time |
5. Was your child bothered by discomfort or pain in the legs after running or walking? | ||||
never | rarely | sometimes | very often | all the time |
6. Was your child bothered by fatigue due to their feet? | ||||
never | rarely | sometimes | very often | all the time |
7. Did it happen that, due to foot problems, your child couldn't play active games on par with friends? | ||||
never | rarely | sometimes | very often | all the time |
8. Did it happen that, due to foot problems, your child couldn't play outside? | ||||
never | rarely | sometimes | very often | all the time |
9. Did it happen that, due to foot problems, your child couldn't go to physical education class? | ||||
never | rarely | sometimes | very often | all the time |
10. Did it happen that, due to foot problems, your child couldn't go to other classes at school? | ||||
never | rarely | sometimes | very often | all the time |
11. Were you bothered by the appearance of your child's feet? | ||||
never | rarely | sometimes | very often | all the time |
12. Were you bothered by your child's gait? | ||||
never | rarely | sometimes | very often | all the time |
13. Was the child embarrassed by the appearance of their feet? | ||||
never | rarely | sometimes | very often | all the time |
14. Was your child teased because of how their feet look? | ||||
never | rarely | sometimes | very often | all the time |
15. Did it happen that your child couldn't wear shoes they like due to foot problems? | ||||
never | rarely | sometimes | very often | all the time |