Babies With Duck Feet Babies With Down Syndrome

J Kid Orthop. 2018 Jun i; 12(iii): 218–226.

Human foot and ankle deformities in children with Down syndrome

L. R. Perotti

ⁱSection of Orthopedics, Nemours/Alfred I. duPont Infirmary for Children, Wilmington, Delaware, The states

O. Abousamra

¹Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA

Thousand. del Pilar Duque Orozco

^oneDepartment of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, Usa

K. J. Rogers

¹Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.s.

J. P. Sees

^oneDepartment of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware, U.s.a.

F. Miller

¹Department of Orthopedics, Nemours/Alfred I. duPont Infirmary for Children, Wilmington, Delaware, USA

Received 2017 Nov 28; Accepted 2018 May ten.

Abstract

Purpose

Pes and ankle deformities are common orthopaedic disorders in children with Down syndrome. Even so, radiographic measurements of the foot and ankle have not been previously reported. The aim of this study is to describe the human foot and ankle deformity in children with Downwards syndrome.

Methods

Children who had foot and ankle radiographs in the standing weight-bearing position were selected. Three groups of patients were identified. The human relationship of radiographic measurements with age, trunk mass index and hurting is discussed. In all, 41 children (79 anxiety) had foot radiographs and 60 children (117 ankles) had talocrural joint radiographs, with 15 children overlapping between Groups I and Ii.

Results

In Grouping I, hallux valgus deformity was seen before 10 years of age and hallux valgus bending increased after. Metatarsus adductus angle showed a pregnant increase (p = 0.006) with obesity and was higher in patients who had pes pain (p = 0.05). In Group Ii, none of the talocrural joint measurements showed a significant difference with age or body mass index percentiles. Tibiotalar bending (TTA) and medial distal tibial bending (MDTA) were college in patients who had ankle pain. In Group Iii, correlation analysis was performed between the different measurements with the strongest correlations establish between TTA and MDTA.

Conclusion

In children with Down syndrome, radiographic evaluation of the foot and ankle reveals college prevalence of deformities than clinical examination. Yet, human foot and talocrural joint radiographs are needed but for symptomatic children with pain and gait changes.

Level of Evidence

Level 4 - Prognostic Study

Keywords: ankle, foot, deformity, Down syndrome, treatment

Introduction

Musculoskeletal disorders occur in 20% to 27% of patients with Down syndrome,^1,2 and foot deformities comprise 30% of all reported orthopaedic problems.³ Hallux valgus and pes planus (flatfoot) are frequently reported.^1,3,four These findings are described secondary to increased trunk mass index (BMI),^v muscular hypotonia,⁶ ligamentous laxity⁷ and ankle instability.⁸ While progressive ankle valgus is common in a diversity of conditions,^nine–12 there have been no reports almost ankle deformities in children with Down syndrome.

Although pes and ankle disorders are frequent complaints for children with Down syndrome visiting orthopaedic clinics, and although these disorders accept an affect on these children's gait,^eight,13 the priority is usually to accost other major and more severe disorders such equally upper cervical spine instability, scoliosis, hip instability and knee malalignment.¹⁴ However, it is reported that most human foot deformities in Downward syndrome, if not managed or treated in childhood, can get major problems in adulthood.^fifteen

Radiographic measurements of the foot and ankle have not been previously reported for children with Down's syndrome. The aim of this written report is to draw the foot and talocrural joint deformities in children with Down's syndrome. The relationship of these deformities with age, body mass index (BMI) and pain is discussed. Radiographic measurements of the foot and ankle, as well as the correlation between the dissimilar measurements, are reported.

Patients and methods

Later on obtaining the approval of our Institutional Review Board, records of all children with Downward syndrome, who were seen at AI duPont Hospital for Children, Wilmington, Delaware between 2004 and 2015, were reviewed. Demographic and clinical data included age, gender, weight (kg), height (cm), BMI (kg/g^two), foot and ankle hurting, reason for consultation and prior surgeries on the foot and ankle. The clinical findings that necessitated a radiographic evaluation were recorded based on the patient'south chart review.

Children who had pes and ankle radiographs equally part of their orthopaedic evaluation were identified. Only radiographs that were taken in the continuing, weight-bearing position were reviewed. If a patient had multiple radiographs, the first radiograph was selected. Radiographic measurements on the anteroposterior view of the pes included hallux interphalangeal angle,¹⁶ hallux valgus angle,¹⁷ distal metatarsal articular angle,¹⁸ first and second intermetatarsal bending,¹⁷ first and second intermetatarsal relative length^19,twenty and metatarsus adductus angle (MAA).²¹ Radiographic measurements on the lateral view of the foot included talo-first metatarsal angle,²² talo-horizontal angle,²³ talocalcaneal axial angle,²⁴ talocalcaneal pitch bending²⁵ and calcaneal pitch.^22,26 Radiographic measurements on the anteroposterior view of the talocrural joint included tibiotalar angle (TTA)^x and medial distal tibial angle (MDTA).²⁷ All radiographs were reviewed and measured past one paediatric orthopaedic surgeon (LRP).

Three groups of patients were identified: children who had pes radiographs (Group I), children who had talocrural joint radiographs (Group Two) and the third group (Grouping III) included children who had both pes and talocrural joint radiographs at the same visit (the overlap between Groups I and Two).

Grouping I

Radiographic measurements of this group were start compared betwixt children younger than ten years former, children between ten and 13.9 years one-time and children xiv years onetime or older. Then, the measurements were compared between children with a BMI in the 95th percentile or greater and children with a BMI less than the 95th percentile. The third comparing was performed between children who had pain and children who did non.

Group 2

Radiographic measurements in this grouping were get-go compared between children younger than ten years old and children ten years sometime or older. Then, and like to Group I, the measurements were compared between children with a BMI in the 95th percentile or greater and children with a BMI less than the 95th percentile. The third comparison was besides performed between children who had pain and children who did non.

The age limits in Grouping I and Ii were selected so that a like number of patients could be compared. The BMI percentiles were recorded using the Center for Disease Control growth reference charts.²⁸ The obesity limit (95th percentile) was suggested in a previous study²⁹ as a better cutting off than the overweight limit (85th percentile), and therefore, it was used in our study. The BMI and pain data were obtained at the same visit when the radiographic evaluation was performed.

Group III

In this grouping, correlation analysis was performed to detect any clan betwixt the different deformities. Statistically, independent t-exam was used to compare the radiographic measurements. Pearson correlation was used for the correlation assay performed in Group III. SPSS software (SPSS version 22, Chicago, Illinois) was used. Level of significance was set at 0.05.

Results

Records of 581 children with Downwardly syndrome were reviewed (Fig. i). Of these children, 101 children (58 boys and 43 girls) had foot and/or ankle radiographs and were included in the assay. Grouping I included 41 children (27 boys and 14 girls) with anteroposterior and lateral radiographs of 79 anxiety in the standing weight-bearing position. Grouping Two included 60 children (31 boys and 29 girls) with anteroposterior radiographs of 117 ankles in the standing weight-bearing position. Group Iii included 15 children (eleven boys and 4 girls) with bilateral human foot and talocrural joint radiographs.

Study population and the different groupings of children with Down's syndrome included in the study.

In Group I, indications for the foot radiographic evaluation were flat feet (pes planus valgus) in 36 feet (46%), foot pain in sixteen (20%), hallux valgus in 12 (15%), gait abnormalities in 12 (15%), cavus foot in two (3%) and difficulty in using shoes in one foot (ane%). Clinical observation reported flat feet in 46% and hallux valgus in fifteen% of patients. All the same, radiographic evaluations showed flat feet in 58% and hallux valgus in 45% of patients (Fig. two). Flatfoot prevalence was consistent across historic period groups (58% in children less than ten years of age, 59% in children betwixt ten and 13.9 years of age and 57% in children > xiv years of age). However, hallux valgus was more than common in older age groups (32% in children less than ten years of age, 52% in children between 10 and 13.9 years of historic period and 55% in children > 14 years of age). Changes in the measurements between the different ages are shown in Table i. The MAA was the simply measurement that showed a significant increase (p = 0.006) with obesity (Table ii, Fig. three). The MAA was besides higher in patients who had pes pain (p = 0.05) (Table 3).

A 10.three-year-quondam male with body mass index over 95th percentile presenting with no pain and high metatarsus adductus angle (HVA, hallux valgus angle; IMA, first and second intermetatarsal bending).

Table one

Comparisons of radiographic measurements between different ages

Radiographic measurements	< 10 yrs (28 feet)		10 to 13.nine yrs (29 feet)		≥ xiv yrs (22 feet)		p-values
	Hateful	sd	Hateful	sd	Mean	sd	< 10 yrs and 10 to 13.nine yrs	< x yrs and ≥ 14 yrs	10 to 13.ix yrs and ≥ fourteen yrs
Anteroposterior view radiographs
HIA (°)	xv.seven	5.6	17.ix	7.two	15.three	five.ii	0.207	0.186	0.150
HVA (°)	12.three	vi.nine	nineteen.iii	fourteen.2	24.9	17.iii	0.022	0.003	0.226
DMAA (°)	10.3	5.4	16.seven	9.six	20.4	10.7	0.003	0.0003	0.211
IMA (°)	xiv.1	4.6	xv.5	7.1	15.seven	4.9	0.388	0.238	0.885
RL (mm)	ii.iv	two.3	four.ii	2.4	5.2	2.5	0.005	0.0002	0.162
MAA (°)	15.9	iv.8	fifteen.7	6.eight	13.0	v.two	0.891	0.037	0.117
Lateral view radiographs
TMA (°)	viii.7	8.1	14.1	12.7	xiii.7	14.7	0.069	0.163	0.922
THA (°)	28.1	6.5	32.4	viii.6	32.0	xi.i	0.047	0.152	0.911
TCAA (°)	43.0	5.0	48.8	7.8	49.4	10.viii	0.002	0.017	0.830.
TCPA (°)	52.six	5.0	56.three	8.9	54.3	nine.3	0.066	0.439	0.455
CP (°)	fourteen.9	7.1	sixteen.iv	eight.3	17.4	7.iii	0.476	0.249	0.681
BMI percentile	73.three	26.3	72.5	24.half-dozen	eighty.8	18.0	0.998	0.187	0.681

Table 2

Comparisons of radiographic measurements angles betwixt dissimilar body mass index

Radiographic measurements	≥ 95th (25 feet)		< 95th (54 feet)		p-values
	Mean	sd	Mean	sd	≥ 95th and < 95th
Anteroposterior view radiographs
HIA (°)	15.ane	half dozen.7	17.0	v.nine	0.246
HVA (°)	16.2	xiv.half dozen	19.4	xiii.7	0.356
DMAA (°)	13.iii	10.7	sixteen.4	8.9	0.208
IMA (°)	15.0	7.1	15.i	5.0	0.924
RL (mm) (°)	3.6	3.ane	four.0	2.4	0.646
MAA (°)	17.3	4.five	thirteen.9	5.7	0.006
Lateral view radiographs
TMA (°)	8.5	9.6	13.5	12.7	0.072
THA (°)	28.0	7.4	31.nine	ix.2	0.060
TCAA (°)	45.4	vi.ane	47.6	9.1	0.228
TCPA (°)	52.2	6.8	55.3	8.iii	0.109
CP (°)	17.four	8.7	15.7	seven.one	0.424

Bilateral anteroposterior human foot radiographs in the standing weight-bearing position of a 12.9-year-old female (trunk mass alphabetize = 30 kg/m²; over 95th percentile), with bilateral hallux valgus, presenting with pain in both feet (MAA, metatarsus adductus angle).

Table iii

Comparisons of radiographic measurements angles betwixt painful and not-painful

	Pain (26 feet)		No pain (43 feet)		p-values
Radiographic measurements	Mean	sd	Mean	sd	Pain and no pain
Anteroposterior view radiographs
HIA (°)	17.0	seven.8	16.1	5.3	0.580
HVA (°)	22.ii	xviii.seven	sixteen.5	10.seven	0.162
DMAA (°)	17.3	eleven.4	14.5	8.5	0.263
IMA (°)	xv.8	7.6	14.7	4.5	0.473
RL (mm)	4.one	3.ane	3.7	2.4	0.589
MAA (°)	16.eight	five.iv	fourteen.two	5.5	0.050
Lateral view radiographs
TMA (°)	10.7	11.4	12.7	12.5	0.491
THA (°)	29.viii	8.2	31.3	9.2	0.469
TCAA (°)	45.iv	7.6	47.vii	8.eight	0.248
TCPA (°)	54.ix	4.7	54.2	9.ane	0.652
CP (°)	15.7	6.0	16.iv	8.2	0.651
BMI percentile	76.3	21.five	73.v	24.half-dozen	0.599

In Group II, the indications for the ankle radiographic evaluation were lower limb malalignment evaluation in 73 (62%), pain in 20 (17%), in toeing in sixteen (fourteen%), valgus in vi (5%) and out toeing in two (2%) children. None of the ankle measurements showed a significant difference with different ages or dissimilar BMI percentiles (Tables 4 and ​ 5). Withal, both TTA and MDTA were higher in patients who had ankle pain (p < 0.01) (Table half dozen).

Tabular array 4

Comparisons of radiographic talocrural joint measurements between unlike ages

	< ten yrs (60 anxiety)		≥ ten yrs (57 feet)		p-values
	Mean	sd	Mean	sd	< 10 yrs and ≥ 10 yrs
TTA	5.0	4.v	iv.6	6.4	0.745
MDTA	94.3	iv.1	93.3	v.eight	0.260
BMI percentile	81.9	20.4	86.2	14.0	0.186

Table five

Comparisons of radiographic talocrural joint measurements between different body mass index

	≥ 95th (61 anxiety)		< 95th (56 feet)		p-values
	Mean	sd	Mean	sd	≥ 95th and < 95th
TTA	4.6	6.0	5.0	5.0	0.690
MDTA	93.6	5.5	94.0	4.5	0.688

Table half dozen

Comparisons of radiographic talocrural joint measurements between painful and non-painful ankles

	Pain (19 anxiety)		No pain (98 feet)		p-values
	Mean	sd	Hateful	sd	Pain and no hurting
TTA	eight.ane	4.2	4.ii	5.v	0.001
MDTA	97.3	4.0	93.1	4.9	0.0004
BMI percentile	88.2	14.3	83.2	eighteen.1	0.199

In Group 3, correlation assay was performed between the different measurements, with the strongest correlations constitute between Meary angle and talo-horizontal angle and between TTA and MDTA (Tables vii to ​ 9).

Tabular array seven

Shows Pearson correlation analysis between the measurements

Correlations		HIA	HVA	DMAA	IMA	RL	MAA	TTA	MDTA
HIA	r	one	−0.254	−0.144	−0.387*	0.078	−0.011	−0.451*	−0.369*
	p		0.183	0.456	0.038	0.689	0.955	0.014	0.049
HVA	r	−0.254	1	0.608**	0.635**	0.132	−0.158	−0.017	−0.188
	p	0.183		0.000	0.000	0.494	0.413	0.932	0.329
DMAA	r	−0.144	0.608**	1	0.345	0.061	−0.353	−0.213	−0.418*
	p	0.456	0.000		0.067	0.752	0.060	−0.266	0.024
IMA	r	−0.387*	0.635**	0.345	1	−0.122	−0.242	0.112	0.016
	p	0.038	0.000	0.067		0.527	0.205	0.565	0.935
RL	r	0.078	0.132	0.061	−0.122	i	0.525**	0.383*	0.248
	p	0.689	0.494	0.752	0.527		0.003	0.040	0.195
MAA	r	−0.011	−0.158	−0.353	−0.242	0.525**	1	0.446*	0.490**
	p	0.955	0.413	0.060	0.205	0.003		0.015	0.007
TTA	r	−0.451*	−0.017	−0.213	0.112	0.383*	0.446*	1	0.920**
	p	0.014	0.932	−0.266	0.565	0.040	0.015		0.000
MDTA	r	−0.369*	−0.188	−0.418*	0.016	0.248	0.490**	0.920**	1
	p	0.049	0.329	0.024	0.935	0.195	0.007	0.000

Tabular array 9

Shows Pearson correlation analysis between the measurements

Correlations		HIA	HVA	DMAA	IMA	RL	MAA
TMA	r	0.438*	0.248	0.617**	0.008	0.168	0.398*
	p	0.029	0.232	0.001	0.968	0.422	0.049
THA	r	0.206	0.209	0.583**	0.009	0.189	−0.332
	p	0.323	0.317	0.002	0.964	0.365	0.105
TCAA	r	−0.296	0.073	0.355	−0.256	0.289	0.169
	p	0.151	0.730	0.081	0.217	0.161	0.418
TCPA	r	−0.290	−0.090	0.281	−0.252	0.099	0.133
	p	0.159	0.670	0.174	0.225	0.639	0.528
CP	r	−0.472*	−0.132	−0.228	−0.247	0.087	0.475*
	p	0.017	0.529	0.272	0.235	0.678	0.017

Table 8

Shows Pearson correlation analysis betwixt the measurements

Correlations		TMA	THA	TCAA	TCPA	CP	TTA	MDTA
TMA	r	i	0.876**	0.156	0.078	−0.693**	−0.438*	−0.561**
	p		0.000	0.456	0.711	0.000	0.028	0.004
THA	r	0.876**	1	0.437*	0.390	−0.551**	−0.393	−0.563**
	p	0.000		0.029	0.054	0.004	0.052	0.003
TCAA	r	0.156	0.437*	one	0.876**	0.510*	0.073	−0.136
	p	0.456	0.029		0.000	0.009	0.730	0.517
TCPA	r	0.078	0.390	0.876**	1	0.440*	−0.060	−0.186
	p	0.711	0.054	0.000		0.028	0.777	0.374
CP	r	−0.693**	−0.551**	0.510*	0.440*	1	0.443*	0.413*
	p	0.000	0.004	0.009	0.028		0.026	0.040
TTA	r	−0.438*	−0.393	0.073	−0.060	0.443*	ane	0.920**
	p	0.028	0.052	0.730	0.777	0.026		0.000
MDTA	r	−0.561**	−0.563**	−0.136	−0.186	0.413*	0.920**	1
	p	0.004	0.003	0.517	0.374	0.040	0.000

In Group I, only ane child with a painful flatfoot and interphalangeus hallux valgus had surgical correction (lateral calcaneal lengthening and Alike osteotomy). In Grouping Two, 2 children with painful ankle valgus had bilateral distal medial tibial epiphysiodesis with screws. In these three cases, pain was not relieved with conservative direction. Otherwise, all patients who had pain were managed conservatively.

Discussion

In Downward syndrome, the prevalence of pes planovalgus (flatfoot) is reportedly two% to six%, and this deformity correlates with ligamentous laxity.^2,3 Severe flatfoot is uncommon and is constitute more than oft in institutionalized patients.^ii,3 Flat feet and lesser toe deformities have non been associated with specific activity limitation in children and adolescents with Down syndrome; however, hallux valgus has been associated with disability during school and play activities.³⁰ In a podiatric study with l children, Concolino et al¹⁴ reported pes planovalgus in 60% and hallux valgus in 60% of children with Downwards syndrome (26% isolated hallux valgus and 34% associated with metatarsus primus varus) and nigh of these deformities were secondary to hypotonia and ligamentous laxity.^fourteen A true prevalence of foot deformities in children with Down syndrome could not exist reported in this study since but children who had radiographic evaluation were assessed.

Although no previous studies in Downwardly syndrome have reported the changes of foot measurements with age, in the general population (children without Down syndrome), comeback of flexible flatfoot with historic period has been reported,³¹ and age is considered the most important factor related to improvement of the curvation pinnacle.³² This improvement with age was not shown by our results in children with Down syndrome (Fig. 4). Nonetheless, hallux valgus, seen afterward ten years of age in our grouping, followed a like occurrence to that shown in the general population.³³ This finding suggests that the prevalence of hallux valgus reported for immature children with Down syndrome (four to eight years) in a previous study¹⁴ might increase with older historic period.

Lateral foot radiograph in the continuing weight-bearing position of a 10.eight-yr-one-time male person with flatfoot and no pain. Body mass index = eight.4 kg/1000² (near to 50th percentile). The radiograph shows the correlation between two measurements in the lateral radiograph (TMA, talo kickoff-metatarsal bending; THA, talo-horizontal angle).

Reduced plantar arch height is reported in overweight and obese children without Downwardly syndrome.¹⁹ Structural changes in the pes anatomy are suggested with possible exacerbation equally excess weight-bearing continues throughout childhood and into adulthood.¹⁹ Foot deformities in Down syndrome have been reported with increased BMI.³ In our grouping of patients, radiographic evaluation did not evidence a divergence in the arch peak measurements, nor in the hallux valgus measurements, with different BMIs (Figs 2 and ​ 4).

No difference in foot radiographic measurements was plant betwixt children with or without pain in our written report; all the same, the hurting reported past our patients and their families was mainly associated with abnormal walking, and localization of pain was difficult to appraise.

Multiple studies take discussed ankle deformities in children;^{10,27,34–36} nonetheless, to our knowledge, ankle measurements and deformities in children with Down's syndrome have not been previously reported. While no association was constitute in our study between ankle valgus and historic period or increased BMI, the association betwixt talocrural joint pain and valgus (Fig. 5) supports previous studies showing that, although talocrural joint valgus might remain asymptomatic for many years, information technology can result in walking instability, mechanical pain and difficulty wearing shoes.^10,34

Anteroposterior ankle radiographs in standing weight-bearing position of a nine-year-old male with ankle valgus and pain. The radiographs show the difference betwixt two unlike measurements: (a) medial distal tibial bending (MDTA); (b) tibiotalar bending (TTA), in the same ankle.

The difference in the direction of human foot and talocrural joint deformities between children with and without Down syndrome was non addressed in our study. Although follow-upwards data were not available to evaluate the results of bourgeois treatment, most children with painful feet or ankles had other major musculoskeletal disorders (cervical instability, scoliosis, hip disorders or patellar instability) that might be more of a priority for the families. However, since our information did not testify improvement with age, farther investigation is necessary to establish the proper management options. The function of surgery is not clear, and the conservative arroyo is still the mainstay of treatment until further research is bachelor.

The limitations of our study included its retrospective nature and the small number of patients. In addition, our group consisted only of children who had radiographic evaluation. The functional contour was not evaluated in our group due to the absence of an objective functional cess tool. However, the condition is rare, and pes and ankle radiographic measurements in Down syndrome have not been previously reported. We programme to investigate the relationship between foot and ankle deformities and other lower limb malalignment deformities to observe any effect of the foot and talocrural joint deformities on the alignment of the extremity.

In children with Down syndrome, radiographic evaluation of the human foot and talocrural joint reveals college prevalence of deformities than clinical test. However, foot and talocrural joint radiographs are needed only for symptomatic children with hurting and gait changes. Although our study showed that no change of flatfoot is expected with growth, and that increased BMI is not associated with specific deformities, the effect of ankle alignment on knee and lower extremity alignment is all the same not clear and needs to be investigated farther. The radiographic findings reported in this study can serve as a useful baseline for hereafter clinical investigations of foot deformities in Down syndrome. Moreover, the late furnishings on the patient's level of activeness as an adult also need to exist addressed, peculiarly with elevated BMI, taking into consideration the recent improvements in life expectancy and the active participation in sports for many individuals with Down's syndrome.

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FUNDING STATEMENT

No benefits in any class have been received or will be received from a commercial party related directly or indirectly to the bailiwick of this article.

OA LICENCE TEXT

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ETHICAL Statement

Ethical approval: All procedures performed in studies involving human participants were in accord with the upstanding standards of the institutional and/or national enquiry committee and with the 1964 Helsinki declaration and its subsequently amendments or comparable ethical standards.

IRB approval was obtained prior to the study.

Informed Consent: Informed consent was non required for this work.

ICMJE CONFLICT OF INTEREST Argument

None alleged.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005220/

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