Subtalar extra-articular screw arthroereisis (SESA) for the treatment of flexible flatfoot in children

Functional and radiological outcome of subtalar arthroereisis for flexible pes planovalgus in children: A retrospective analysis

INTRODUCTION

Pediatric idiopathic pes planovalgus can correct itself with growth. Otherwise, in the event of functional impairment and after failed conservative treatment, surgery can be considered. Based on a multicenter retrospective study, we report the functional and radiographic results obtained after subtalar arthroereisis.

HYPOTHESIS

We hypothesized that this surgery improves functional and radiological parameters in childhood.

MATERIAL AND METHOD

Forty-eight medical records of children (78 feet) operated on between 2010 and 2019 were studied. Functional (FAOS score) and radiographic (Djian angle, calcaneal slope, lateral talocalcaneal divergence and calcaneus/M5 alignment, talonavicular coverage measurement, AP talocalcaneal divergence) results were studied. The analysis of these different criteria was carried out between the preoperative period and the last follow-up.

RESULTS

The functional outcome was satisfactory with an average FAOS questionnaire score of 95.5 out of 100 total points. All the radiographic parameters studied were significantly improved (p<0.001). The average age at the time of surgery was 11.3 years (range: 7 to 16) with a mean follow-up of 35 months (range: 18 months to 84). Spontaneous screw expulsion and subtalar pain were the main complications found.

DISCUSSION

The results obtained are consistent with those in the literature. The age at the time of the surgery is an essential factor to consider with the goal of optimal correction.

CONCLUSION

This technique is reliable and effective in the short term. It can be offered as first-line therapy in the management of symptomatic pes planovalgus in children. The follow-up is short, which necessitates longer term studies of this population. The ideal age for surgery remains to be determined.

LEVEL OF EVIDENCE

IV.

Outcomes of the "Calcaneo-stop" procedure for treating symptomatic flexible flatfoot in children: A systematic review and meta-analysis of 2394 feet

BACKGROUND

This study evaluates the efficacy of the calcaneo-stop (C-Stop) procedure's effectiveness in treating symptomatic flexible flatfoot (FFF) in children.

METHODS

A systematic review and meta-analysis were conducted using PubMed, Embase, and Cochrane databases to identify studies until 2023 on the outcomes of the C-Stop procedure in children with FFF. The risk of bias was assessed using MINORS criteria.

RESULTS

Of 85 studies screened, 20 involving 2394 feet from 1415 patients (mean age 11.2 ± 1.3 years) were included. Post-procedure, significant improvements were noted in pain reduction (93.5%), heel alignment (95.21%), and radiological measures, including reductions in Kite (7.32º), Meary (11.65º), Costa-Bartani angles (17.11º), talar declination (12.63º) and increase in Calcaneal Pitch Angle (5.92º). AOFAS scores increased by 22.32 points on average, with 94.83% reporting high satisfaction. Complication rate was low (7.8%).

CONCLUSIONS

The C-Stop procedure is effective for treating FFF in children, offering significant clinical, radiological, and functional improvements with high patient satisfaction and a low complication rate.

LEVEL OF EVIDENCE

Level IV, Systematic review of Level-IV studies.

Resection of Calcaneonavicular and Talocalcaneal Coalitions With Surgical Correction of the Hindfoot Valgus Deformity in One Step

Background

Calcaneonavicular (CNC) and talocalcaneal (TCC) coalitions are the most common cause of rigid flatfoot in children. After resection, correction of the most frequent valgus-hindfoot deformity usually requires a second-step surgery. We report results of a retrospective study of patients treated with a one-step correction.

Methods

Between 2008 and 2019, data were collected on 26 patients (19 male, 7 female) affected by CNC (n = 18) and TCC (n = 13), all with rigid symptomatic flatfeet. Average age at surgery was 12.5 ± 1.1 (SD) years (range, 9.8-15.2). All patients (26/26) underwent resection, 20 of 26 underwent at the same time subtalar extraarticular screw arthroereisis (SESA) for correction of residual hindfoot valgus deformity. Pre- and postoperative talocalcaneal angle according to Costa Bartani and Talar inclination angle in weightbearing were measured. Twenty-five of 26 patients had postoperative American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score.

Results

Pre- and postoperative talocalcaneal average angle for CNC was respectively 141.5 ± 7.7 degrees and 130.5 ± 5.2 degrees (P < .0001) and 143.7 ± 7.7 degrees and 129.7 ± 7.0 degrees (P < .0001) for TCC. Talar inclination average angle for CNC was 29.2 ± 5.3 degrees and 19.3 ± 1.6 degrees (P < .0001) and 31.2 ± 6.4 degrees and 21.4 ± 3.4 degrees (P < .0001) for TCC. Average follow-up (FU) was 4.7 ± 3.0 years (range, 6 months-11.9 years, median 4.9 years), with a mean age at FU of 17.2 ± 5.8 (SD) years (min 12.1, max 25.3, median 16.8 years). The mean AOFAS ankle-hindfoot score for CNC and for TCC was 96.6 (range 83-100) for resection and valgus correction as one-step procedure with no statistical difference (P = .5) between CNC and TCC. No patients had additional surgery for complications or recurrence.

Conclusion

Symptomatic rigid flatfeet affected by CNC and TCC treated with coalition resection and minimally invasive subtalar arthroereisis (SESA) for residual hindfoot valgus correction in one step in adolescent age achieved good to excellent results in all cases. Further surgery to correct malalignment was avoided.

Level of Evidence

Level IV, retrospective study.

Catania flatfoot score: A diagnostic-therapeutic evaluation tool in children

BACKGROUND

Flexible flatfoot (FFF) is a very common condition in children, but no evidence-based guidelines or assessment tools exist. Yet, surgical indication is left to the surgeon's experience and preferences.

AIM

To develop a functional clinical score for FFF [Catania flatfoot (CTF) score] and a measure of internal consistency; to evaluate inter-observer and intra-observer reliability of the CTF Score; to provide a strong tool for proper FFF surgical indication.

METHODS

CTF is a medically compiled score of four main domains for a total of twelve items: Patient features, Pain, Clinical Parameters, and Functionality. Each item refers to a specific rate. Five experienced observers answered 10 case reports according to the CTF. To assess inter- and intra-observer reliability of the CTF score, the intra-class correlation coefficients' (ICCs) statistics test was performed, as well as to gauge the correlation between the CTF score and the surgical or conservative treatment indication. Values of 75% were chosen as the score cut-off for surgical indication. Sensitivity, specificity, positive likelihood ratio (PLHR), negative likelihood ratio (NLHR), positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Overall interobserver reliability ICC was 0.87 [95% confidence interval (CI): 0.846-0.892; P < 0.001]. Overall intra-observer reliability ICC was 0.883 (95%CI: 0.854-0.909; P < 0.001). A direct correlation between the CTF score and surgical treatment indication [Pearson correlation coefficient = 0.94 (P < 0.001)] was found. According to the 75% cut-off, the sensitivity was 100% (95%CI: 83.43%-100%), specificity was 85.71% (95%CI: 75.29%-92.93%), PLHR was 7 (95%CI: 3.94-12.43), NLHR was 0 (95%CI: 0-0), PPV was 75% (95%CI: 62.83%-84.19%) and NPV was 100% (95%CI: 100%-100%).

CONCLUSION

CTF represents a useful tool for orthopedic surgeons in the FFF evaluation. The CTF score is a quality questionnaire to reproduce suitable clinical research, survey studies, and clinical practice. Moreover, the 75% cut-off is an important threshold for surgical indication and helps in the decision-making process.

Mid-term assessment of subtalar arthroereisis with Talar-Fit implant in pediatric patients with flexible flatfoot and comparing the difference between different sizes and exploring the position of the inserted implant

Background

Subtalar arthroereisis (STA) has gained growing acceptance as a viable approach solution for the management of pediatric flexible flatfoot. However, STA still remains controversial. The purpose of this study is to assess the effect of STA using the Talar-Fit implant for treating pediatric flexible flatfoot. Specifically, the aims of the study are as follows: first, to present the mid-term outcomes of STA using the Talar-Fit implant; second, to compare the radiographic and clinical outcomes associated with varying sizes of Talar-Fit implant; and third, to analyze the optimal position of the inserted implants.

Methods

A retrospective analysis was conducted on a cohort of 57 pediatric patients diagnosed with flexible flatfoot (77 feet) who underwent STA utilizing Talar-Fit between January 2014 and December 2021. The participants were categorized into five groups according to the size of the implant: Group 8, Group 9, Group 10, Group 11, and Group 12. The evaluation included the assessment of clinical function using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score, as well as the assessment of radiographic data such as the calcaneal pitch angle (CPA), lateral Meary angle (LMA), talar declination angle (TDA), and medial longitudinal arch angle (MLAA) were evaluated. Furthermore, the position of the inserted implants was also recorded, including angle, depth, and distance. The comparison of pre- and postoperation was conducted using the paired Student's t-test, whereas the analysis of differences among subgroups was performed using the Wilcoxon rank-sum test. A P-value < 0.05 is considered statistically significant.

Results

In total, 57 pediatric patients (77 feet) were successfully followed-up for an average period of 26.8 months. The overall AOFAS score significantly improved from 58.6 ± 10.9 to 85.2 ± 8.6 (P < 0.001). Furthermore, the LMA decreased from 20.3° ± 3.6° to 4.5° ± 1.3°, the CPA increased from 14.8° ± 1.6° to 23.6° ± 2.7°(P < 0.05), the TDA decreased from 40.2° ± 2.3° to 25.5° ± 3.2°(P < 0.05), and the MLAA decreased from 140.1° ± 2.8° to 121.4° ± 3.9°(P < 0.05). No statistically significant differences were observed among subgroups regarding the final outcomes. The improvements of CPA, TDA, and MLAA among different groups were significantly different; however, the adjusted P-values were all greater than 0.05. The implant were inserted at a mean angle of 89.5° ± 2.4°, a mean depth of 0.9 mm ± 2.1 mm, and a mean distance of 9.9 mm ± 0.9 mm. Eight patients experienced complications, including six cases of pain occurrence and two cases of implant dislocation.

Conclusion

STA with Talar-Fit has demonstrated satisfactory mid-term outcomes. A Talar-Fit with a larger size may demonstrate a superior effect when compared with that of a smaller size. The implants were inserted in a similar position, indicating that the medial edge of the implant may be possible to transcend the midline of the talus neck.

Subtalar arthroereisis post-operative management in children: A literature review

PURPOSE

Subtalar arthroereisis is a minimally-invasive technique for the treatment of flexible flatfoot. Some issues regarding the procedure are still debated, such as post-operative management. The aim of this study is to offer a review of the pertaining literature to identify current post-operative protocols and describe possible differences among them.

METHODS

We searched the PubMed database for all papers related to subtalar arthroereisis in children specifying the post-operative protocols. After reviewing all studies according to excluding criteria, 50 articles were selected for analysis.

RESULTS

Based on the literature review, different post-operative protocols emerged in the treatment of patients undergoing subtalar arthroereisis, in particular regarding length of hospital stay, type and duration of immobilization, weight-bearing management, adopted rehabilitation scheme, sport resumption and implant removal.

CONCLUSIONS

The most important finding was the existence of a wide variety in post-operative management after subtalar arthroereisis in children, thus confirming that no clear consensus still exists in this field.

Percutaneous minimal invasive Achilles tendon lengthening improves clinical and radiographic outcomes in severe flexible flatfeet with shortened triceps sureae complex in early childhood: A retrospective study

BACKGROUND

Severe flexible flatfeet with triceps surae complex shortening are prognostically unfavorable in early childhood and may compromise normal foot development.

METHODS

This retrospective, IRB-approved study included 20 children (38 feet) under 6 years with severe flexible flatfeet and triceps surae complex shortening. Treatment included minimally invasive percutaneous achilles tendon lengthening followed by a 4-week cast fixation and corrective orthotic therapy under talo-navicular reposition for at least 6-months. Preoperative weightbearing x-rays and at the last available follow-up included anteroposterior talus-first metatarsal angle and lateral talus pitch, Meary's and talocalcaneal angle and were compared to reference values. ROM, surgeon-rated clinical outcomes and complications/re-interventions were evaluated.

RESULTS

Age at surgery was 3.7 years (1.3-5.9 y) and follow-up time was 4.3 years (1.1-8.9 y). No complications occurred. Clinical outcome was good (68 %) to very good (26 %). Ratio of normal angles increased significantly for three angles. Dorsiflexion ROM improved from -5.0 ± 6.8° at baseline to 15.7 ± 7.6°.

CONCLUSIONS

With significant improvements in clinical and radiographic outcomes, minimal-invasive percutaneous Achilles tendon lengthening followed by orthotic therapy seems to be a valuable treatment option for selected preschool-aged patients with severe, flexible flatfeet with significantly shortened triceps surae.

LEVEL OF EVIDENCE

IV.

Subtalar arthroereisis combined with medial soft tissue reconstruction in treating pediatric flexible flatfoot with accessory navicular

PURPOSE

Accessory navicular is accompanied by the deformity of valgus flexible flatfoot. The surgical treatment includes reconstruction of insertion of posterior tibial tendon following resection of the accessory navicular. However, this treatment could not correct completely the deformity of valgus flexible flatfoot. This study aimed to evaluate the efficacy of subtalar arthroereisis combined with medial soft tissue reconstruction in treating 8-14-year-old flexible flatfoot patients with accessory navicular.

METHODS

Clinical data of 35 pediatric flatfoot patients (with 50 feet) with accessory navicular who underwent subtalar arthroereisis and medial soft tissue reconstruction between April 2013 and September 2018 were analyzed retrospectively. Anteroposterior, lateral, and hindfoot alignment radiological images were measured in the weight-bearing position, and visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and satisfaction degree were evaluated. Also, surgical complications were recorded.

RESULTS

The average follow-up time of the patients was 30 ± 9.3 months. None of the patients presented wound complications, and no implant loosening was detected. The AOFAS and VAS scores improved significantly (P < 0.001). Radiological parameters, such as the talar first metatarsal angle and talonavicular coverage angle on anteroposterior foot view, Meary's angle and calcaneal pitch angle on the lateral view, and calcaneus valgus angle on hindfoot alignment view improved significantly (P < 0.001). Postoperative complications were observed in three patients.

CONCLUSION

Subtalar arthroereisis combined with medial soft tissue reconstruction significantly alleviated pain and improved the functions in pediatric and adolescent flexible flatfoot patients with accessory navicular; also, the radiological manifestations and functions improved.

Satisfactory outcomes of post-operative subtalar extra-articular arthroereisis in juvenile flexible flat foot

OBJECTIVES

To analyze the surgical outcomes of subtalar extra-articular arthroereisis and the patient/parent satisfaction regarding the foot's shape, foot pain, ability to walk, ability to jump, and shoe wear.

METHODS

Our retrospective cross-sectional study was carried out through an online-based questionnaire to assess patient satisfaction postoperatively at 3 hospitals (King Khalid University Hospital, Sultan bin Abdulaziz Humanitarian City, and Dallah Hospital, Riyadh, Saudi Arabia) between the years 2014-2021.

RESULTS

A total of 65 patients participated in our study. Approximately 86.1% of them had the operation bilaterally. The most important aspects where patients noticed the most improvement were the foot's shape (90.8%), pain (81.5%), and ability to walk (76.9%).

CONCLUSION

Several studies have been carried out highlighting the surgical technique and complications of the procedure. However, a limited number of studies have been carried out to assess patient satisfaction with the procedure, especially in Saudi Arabia, as the procedure is considered relatively new in the region with insufficient data regarding it. Therefore, this study is considered one of the few articles regarding subtalar extra-articular arthroereisis in the region.

Foot Typology, Dynamic and Static Weight Distribution, and Radiographic Changes After Subtalar Arthroereisis in Juvenile Symptomatic Flexible Flat Feet

Flexible flatfoot is among the most common skeletal disorders in childhood. This study describes the dynamic and static correction effects of subtalar arthroereisis in adolescents with flexible symptomatic flatfeet in comparison to normal subjects as well as to results before and after removal of metal. Eighteen adolescents with 25 symptomatic flexible flatfeet were treated surgically with a subtalar arthroereisis at a mean of 12.5 (10-16) years. At follow-up (mean 3.9 years, range 0.4-8), patients filled out the American Orthopaedic Foot and Ankle Society questionnaire, received radiographs and were examined using dynamic and static pedobarography as well as static hindfoot axis examination. Results were compared to healthy controls (n = 13; 26 feet). Surgically treated feet (n = 25) had better questionnaire results after surgery than before, but lower scores than healthy feet. Radiological parameters improved significantly after surgery. Removal of metal did not influence post-surgical results (follow-up 2.8 years). Surgically treated feet had larger contact areas than normal feet with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of treated feet compared to controls. When comparing pedobarography data of treated versus untreated feet of the same patients (subgroup n = 11 feet), there were no differences. Subtalar arthroereisis was able to effectively treat symptomatic flexible flatfeet in this population. Results improved significantly evaluating a questionnaire, radiographs, dynamic and static weight distribution, but were still worse than results of healthy feet. There was no relapse after removal of metal.

Clinico-radiological factors predicting the failure risk of conservative management in moderate to severe pediatric idiopathic flexible flatfoot

This study aimed to investigate the clinico-radiological factors of related future surgical treatment in patients with pediatric flexible flatfoot (FFF) who first visited the orthopedic clinic before the age of 10 years. Sixty-five patients diagnosed with moderate/severe idiopathic FFF deformity between the ages of 2-10 years were included. We developed prognostic models for the risk of the surgery during the follow-up period. Twenty (30.8%) patients required surgical treatment, and all of them underwent calcaneal lengthening osteotomy. Among them, 7 (10.8%) patients required concomitant Achilles-lengthening surgery. Unilateral involvement, older age, smaller calcaneal pitch angle, and higher talo-first metatarsal malalignment were considered high-risk factors for pediatric FFF surgery. Prognostic models identified three prognostic risk groups based on those factors, and survival curves revealed significant differences among the groups. Our prognostic models help predict the failure risk of conservative management of pediatric idiopathic FFF. Level of Evidence: Level III, prognostic study.

HyProCure for Pediatric Flexible Flatfoot: What Affects the Outcome

BACKGROUND

The high success rate, minimal invasion, and safety of subtalar arthroereisis (SA) have made it a primary mode of surgical management for pediatric flexible flatfoot. The HyProCure procedure is a new surgery for SA, However, very few available studies reported the therapeutic effects of the HyProCure procedure, especially in pediatric flexible flatfoot. The main aim of the present study was to investigate the clinical and radiological outcomes of the HyProCure procedure for pediatric flexible flatfoot and analyze the risk factors for therapeutic outcomes and sinus tarsi pain.

METHODS

In this retrospective cohort study, 69 pediatric flexible flatfoot patients (107 feet) who underwent the HyProCure procedure were included between July 2015 and September 2020. All patients underwent the HyProCure procedure with or without gastrocnemius recession. The Maryland foot score (MFS), visual analog scale (VAS), radiographic data, and complications were assessed at a minimum 1-year follow-up and statistically analyzed.

RESULTS

The mean follow-up was 35.9 months (range, 13-73 months). At the last follow-up, VAS (0.64 ± 1.16) was significantly lower than the preoperative VAS (4.06 ± 1.43) (p < 0.001); MFS (90.39 ± 12.10) was significantly higher than the preoperative MFS (71.36 ± 10.25) (p < 0.001). The AP talar-second metatarsal angle (T2MT angle) significantly decreased from 17.0 ± 5.4° preoperatively to 11.4 ± 5.2° at the last follow-up (p < 0.001). The lateral talar-first metatarsal angle (Meary's angle) significantly decreased from 13.8 ± 6.4° preoperatively to 6.3 ± 5.0° at the last follow-up (p < 0.001). The calcaneal declination angle (Pitch angle) significantly increased from 13.5 ± 4.9° preoperatively to 14.8 ± 4.4° at the last follow-up (p < 0.001). Logistic regression analysis indicated that patients with a longer distance from the tail end of the implant exceeding the longitudinal talar bisection line had 275.8% greater odds of MFS < 90. Yet, no risk factors were found in connection with sinus tarsi pain.

CONCLUSIONS

The HyProCure procedure for pediatric flexible flatfoot achieved satisfactory curative effects with a low complication rate; implant depth was associated with unsatisfactory postoperative outcome.

Results of the Italian Pediatric Orthopedics Society juvenile flexible flatfoot survey: diagnosis and treatment options

The objectives of this study were to collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

Juvenile Hallux Valgus

Treatment of juvenile hallux valgus can be challenging. Initial treatment with conservative measures is appropriate until exhausted. Surgical treatment should be delayed until after skeletal maturity when possible. Before any intervention, a thorough understanding of the whole patient and any underlying systemic contributors to their hallux valgus, in addition to the radiographic foot parameters, is imperative. Careful and individualized surgical planning should be done to optimize results and decrease the risk for recurrence.

Subtalar Arthroereisis for Surgical Treatment of Flexible Flatfoot

Various surgical techniques are known for the treatment of flexible flatfoot in children after failure of nonsurgical attempts. Data collected in a review of the last 10-year period (2010-2020) show that among the 691 feet undergoing subtalar arthroereisis with endorthesis, average age at surgery was 11.40 years and in the 1856 feet that underwent subtalar arthroereisis with calcaneo-stop 11.69 years, while the complications rate was 9.00% and 6.38%, respectively. These data confirm that subtalar arthroereisis with calcaneo-stop may have an advantage over subtalar arthroereisis with endorthesis as the screw is not placed across the subtalar joint but instead into the calcaneus.

Diagnosis and treatment of flexible flatfoot: results of 2019 flexible flatfoot survey from the European Paediatric Orthopedic Society

The aim of the study was to evaluate flexible flatfoot (FFF) diagnostic and current therapeutic modalities, as well as treatment expectations, among members of the European Paediatric Orthopaedic Society (EPOS). A 59-questions survey on FFF diagnosis and treatment preferences was distributed to EPOS members. The survey consisted of six sections (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; and (6) management options. Descriptive statistics were performed. A total of 93 responses were analysed. In general, clinical parameters, age (91.4% of cases), laxity (81.7%), diffuse pain (84.9%), and pain at the ankle joint (81.7%) were rated as 'average' and 'crucial importance' by the vast majority of respondents. Meary's angle (47.3% of cases), talonavicular coverage (35.5%), and lateral talocalcaneal angle (35.5%) were assessed as main radiological tools in the FFF evaluation. Among respondents, 61.3% rated 'improved ability to walk longer without symptoms' as of 'crucial importance'. Eighty-two percent of the respondents felt less than 10% of patients with FFF are candidates for corrective surgery. Arthroereisis (29.3%) was the most common surgical procedure (16.4% for subtalar and 12.9% for extra-articular arthroereisis, respectively), followed by lateral column lengthening (17.9%) and medializing calcaneal osteotomy (12.3%). There is great variation among respondents in diagnostic and treatment preferences in the management of children with FFF. The results of the EPOS 2019 FFF survey clearly show that large-scale, multicentric, international studies are necessary to elucidate which diagnostic and treatment practices lead to the best outcomes.

[The talometatarsal-index ("TMT-Index") : A valuable X-ray parameter for differentiating between normal feet and planovalgus deformity in children and adolescents]

INTRODUCTION

The development of the shape of the shape from childhood to adulthood is a complex continuum. Deviations from this process occur frequently and, especially in asymptomatic patients, do not always include the need for therapeutic intervention. In the current S2-guideline on the juvenile flexible flatfoot, established x‑ray parameters for assessing the flatfoot deformity were judged to be sensitive, whereby no statement was made regarding the value of the parameters among themselves. The aim of the present work is to assess the talometatarsal Index (TMTInd) in comparison to established angle measurements.

METHODS

Twenty-two feet with and 22 feet without planovalgus deformity (age: 10-14 years) were investigated. Established radiological parameters (lateral view: talocalcaneal angle (TC-lat), calcaneal pitch angle (Calc-B), Costa-Bartani angle (Costa-B), talometatarsal‑I angle (TMTI-lat); dorsoplantar view: talometatarsal-I-basis angle (TMTIB), talonavicular coverage (TNG), calcaneal metatarsal- V angle (Calc-MTV), talocalcaneal angle (TC-dp), and talometatarsal‑I angle (TMTI-dp)) were measured on standardized X‑ray images and compared with the values of the TMTInd.

RESULTS

All parameters other than Calc-MTV, TC-dp, TC-lat and Calc‑B, showed a statistically significant difference between normal and planovalgus feet, although for almost all values measured (apart from TMTI-lat and TMTInd) there was a large overlap area (>10°) between the two groups. The comparison of TMTInd to all other parameters showed the highest discrimination factor (area-under-the-curve) for the TMTInd in the distinction between the groups.

CONCLUSION

Compared to conventional radiological parameters, the TMTInd shows the highest validity in the distinction between normal and planovalgus feet and can provide valuable information in clinical decision-making with regard to therapy specification.

Pedobarographic outcome after subtalar screw arthroereisis in flexible juvenile flatfoot

BACKGROUND

Flatfoot is a frequent skeletal deformity in childhood that can be minimally invasively treated by arthroereisis.

QUESTION

Does the motion of juvenile flexible flatfoot normalize after arthroereisis?

METHOD

Pedographic measurements were obtained from 39 patients preoperatively, six months postoperatively and compared to a healthy group. The footprints were divided into 8 areas. The selected parameters were: contact area and force-time-integral.

RESULTS

After surgery, a load shift from the medial to the lateral areas was detected under the midfoot and forefoot. The force-time-integral under the hallux normalized. However, under the lateral midfoot, the postoperative force-time-integral was significantly higher than in the control group.

SIGNIFICANCE

The study shows that arthroereisis is able to correct the medially displaced load distribution of juvenile flexible flatfoot. However, further investigations are required to find out if the higher punctual loading under the lateral midfoot may cause problems in the long term.

The outcomes of subtalar arthroereisis in pes planus: a systemic review and meta-analysis

INTRODUCTION

Subtalar arthroereisis has been increasingly accepted as a solution to manage symptomatic pes planus. However, despite the recent developments related to arthroereisis, no other published literature has aimed to review the outcomes in paediatric patients since 2010. This systematic review and meta-analysis, therefore, aims to evaluate the current outcomes of subtalar arthroereisis in the treatment of symptomatic pes planus among the paediatric population.

MATERIALS AND METHODS

The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reported on the clinical outcomes of subtalar arthroereisis in children aged 21 or younger were included.

RESULTS

A total of 17 publications were included, with 1536 feet. The average duration of follow-up of the studies included in the review is 43.52 months. The studies consistently reported improvement in the radiological outcomes, approximating that of a normal population. Subtalar arthroereisis has shown to restore the collapsed medial longitudinal arch, supported by the decrease in Meary's angle to 5.267° (95% CI: 4.695°-5.839°, normal: 0°-10.0°) post-operatively and an increased calcaneal pitch of 15.70° (95% CI: 15.41°-15.99°, normal 18.0°-20.0°). Deformities associated with pes planus such as heel valgus was also significantly reduced, evident by the post-operative lateral talocalcaneal angle of 27.19° (95% CI: 26.44°-27.93°, normal: 25.0°-45.0°) and a post-operative Kite's angle of 18.13° (95% CI: 17.73°-18.52°, normal: 15.0°-30.0°). Subjectively, subtalar arthroereisis has generally resulted in an improvement in the grading of outcomes postoperatively from the patient's point of view.

CONCLUSIONS

Subtalar arthroereisis could serve as a procedure to correct radiological abnormalities, as well as relieve pain in selected patients with symptomatic pes planus.

Subtalar Arthroereisis for Flexible Flatfoot in Children-Clinical, Radiographic and Pedobarographic Outcome Comparing Three Different Methods

Subtalar arthroereises (STA) is a minimally invasive and reversible surgery to correct symptomatic flexible flatfoot (FFF) in children. Various techniques were described either applying expandable sinus tarsi implants or lateral calcaneus stop screws. Studies comparing the outcome of STA with different devices are rare. This retrospective single-center cohort study analyzes the results of STA using three different implants. 113 STA were performed in 73 consecutive patients (28 females). Mean age at surgery was 10.8 years (range 5-16). Mean follow-up was 29.0 months (range 1-111). In 21 feet the non-absorbable Kalix^® endorthesis and in 56 feet the absorbable Giannini endorthesis were applied. Subtalar extraarticular screw arthroereises (SESA) was conducted in 36 feet. Clinical, radiographic and pedobarographic parameters were analyzed. No intraoperative complications were observed. All three procedures achieved comparable improvements of the clinical, radiographic and pedobarographic parameters. The mean foot function index (FFI) improved from 36.4 (range 12-63) to 22.8 (range 2-55). The mean preoperative calcaneal inclination angle and the lateral talocalcaneal angle improved from 9.5° (range 0-22) and 42.3° (range 21-62) to 12.8° (range 0-26) and 37.6° (range 15-56), respectively. Pedobarographically determined values of the arch index, the medial midfoot contact area and the medial forefoot peak pressure decreased. In contrast to SESA (1/36, 3%), a higher incidence of implant-related complications was observed using Kalix^® (6/21, 29%) and Giannini (10/56, 8%) sinus tarsi implants. Peroneal muscle contractures only occurred in the SESA group (4/36, 11%). Premature removal due to treatment-related complications was necessary in 6/21 Kalix^® implants (29%), 4/56 Giannini implants (7%) and 4/36 SESA implants (11%). Implant choice for treatment of painful FFF in children with STA seems to play a subordinate role. Clinical, radiographic and pedobarographic outcomes are comparable between the applied implants. Surgeons and patients should be aware of the different spectrum of implant-related complications. Treatment can be reliably monitored by radiation-free pedobarography providing dynamic information about the deformity.

Clinical and Radiological Outcomes of Subtalar Kalix II Arthroereisis for a Symptomatic Pediatric Flexible Flatfoot

Background. The purpose of this study is to evaluate functional and radiological outcomes of subtalar arthroereisis in the treatment of symptomatic pediatric flexible flatfeet. Methods. A total of 16 patients (26 feet) were treated with a Kalix II as subtalar motion blocker between 2009 and 2014. Calcaneal pitch (CP) and Meary's angle (MA) were measured on radiographs preoperatively, directly postoperatively, and at follow-up 47 ± 17 (range 19-79) months. Patient satisfaction surveys were used to assess functional outcome and patient satisfaction. Results. Surgery was performed mostly for pain, walking problems, or a combination of both at a mean age of 12.5 ± 1.5 (range 10-15) years. Symptoms were relieved in 62.5% of patients in the postoperative phase and increased to 68.75% at follow-up. A statistically significant increase in CP of 2.8° and decrease in MA of 14.0° was observed directly postoperatively, which persisted during the follow-up period irrespective of Kalix removal. Revision surgery was necessary in 6 cases (23%) because of arthroereisis migration. Conclusion. Subtalar Kalix II arthroereisis significantly reduced clinical symptoms and improved the CP and MA directly postoperatively, which persisted during follow-up, irrespective of Kalix removal. Therefore, subtalar arthroereisis is a considerable intervention to reduce symptoms in children with symptomatic flexible flatfeet.Levels of Evidence: Level IV: Case series.

Subtalar arthroereisis for the treatment of the symptomatic paediatric flexible pes planus: a systematic review

Subtalar arthroereisis has a controversial history and has previously been associated with high failure rates and excessive complications.A database search for outcomes of arthroereisis for the treatment of symptomatic paediatric flexible pes planus provided 24 articles which were included in this review, with a total of 2550 feet operated on.Post-operative patient-reported outcome measures recorded marked improvement. Patient satisfaction was reported as excellent in 79.9%, and poor in 5.3%. All radiological measurements demonstrated improvement towards the normal range following arthroereisis, as did hindfoot valgus, supination, dorsiflexion and Viladot grade.Complications were reported in 7.1% of cases, with a reoperation rate of 3.1%.Arthroereisis as a treatment for symptomatic paediatric flexible pes planus produces favourable outcomes and high patient satisfaction rates with a reasonable risk profile. There is still a great deal of negativity and literature highlighting the complications and failures of arthroereisis, especially for older implants.The biggest flaws in the collective literature are the lack of high-quality prospective studies, a paucity of long-term data and the heterogeneity of utilized outcome measures between studies. Cite this article: EFORT Open Rev 2021;6:118-129. DOI: 10.1302/2058-5241.6.200076.

Mid-term Results of Subtalar Arthroereisis with Talar-Fit Implant in Pediatric Flexible Flatfoot and Identifying the Effects of Adjunctive Procedures and Risk Factors for Sinus Tarsi Pain

Objectives

To (i) report the mid‐term outcomes of subtalar arthroereisis using Talar‐Fit implant for the treatment of flexible flatfoot patients; (ii) compare clinical and radiographic outcomes between arthroereisis with and without adjunctive operative procedures to investigate the effects of adjuncts on the outcomes; and (iii) analyze the risk factors associated with sinus tarsi pain, which is the most common postoperative complication of arthroereisis.

Methods

Thirty‐one flexible flatfoot children and adolescents (46 feet) treated with subtalar arthroereisis using Talar‐Fit implant from June 2014 to May 2019 were retrospectively analyzed. The feet were divided into four treatment groups: (i) arthroereisis alone, (ii) arthroereisis with gastrocnemius recession, (iii) arthroereisis with Kidner procedure, and (iv) arthroereisis with gastrocnemius recession and Kidner procedure. Clinical function was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The following angles were measured for radiographic evaluation: talar‐first metatarsal angle, calcaneal pitch angle, and talar declination angle on the lateral view; and talar‐first metatarsal angle, talocalcaneal angle, and anteroposterior talonavicular coverage angle on the anteroposterior (AP) view. The paired Student's t‐test was used to compare the pre‐ and postoperative angular measurements and AOFAS scores. The Wilcoxon rank‐sum test was undertaken to determine the outcome differences among four treatment groups. Multivariate logistic regression analysis was used to analyze risk factors for sinus tarsi pain. P value <0.05 is considered statistically significant.

Results

The mean follow‐up of the feet was 32.8 months (range, 10–71 months). The mean AOFAS score significantly improved from 55.5 ± 14.5 preoperatively to 86.3 ± 9.9 (P < 0.001). Comparison of radiographic outcomes showed that the lateral talar‐first metatarsal angle decreased by a mean of 19.1° ± 11.9° (P < 0.001), the calcaneal pitch angle increased by a mean of 5.4° ± 3.4° (P < 0.001), the talar declination angle decreased by a mean of 14.8° ± 9.9° (P < 0.001), the AP talar‐first metatarsal angle decreased by a mean of 15.6° ± 10.3° (P < 0.001), the AP talocalcaneal angle decreased by a mean of 7.2° ± 8.3° (P = 0.001), and the AP talonavicular coverage angle decreased by a mean of 20.4° ± 9.0° (P < 0.001). There were no statistically significant differences with regard to AOFAS score and all angle measurements on both the AP and lateral views among the four treatment groups. There was one dislocation case caused by a fall 6 weeks after surgery, which was treated nonoperatively. The incidence of sinus tarsi pain was 13% and logistic regression analysis indicated that patients with a longer distance from the tail end of the implant to the lateral calcaneal wall had 38.8% greater odds of developing sinus tarsi pain.

Conclusions

The mid‐term clinical and radiographic results were satisfactory in patients who underwent the subtalar arthroereisis procedure using Talar‐Fit implant, alone or in combination with other adjuncts, for the treatment of flexible flatfoot.

Is it possible to define reference values for radiographic parameters evaluating juvenile flatfoot deformity? A case-control study

Background

Numerous radiographic parameters are described to evaluate juvenile flexible flatfeet. Reference values for these measurements are based on few studies. The purpose of this study was to determine boundary values among the most widely used radiographic measurements to evaluate juvenile flatfeet.

Methods

Twenty-two patients with normal hind-, midfoot configuration (group A: control group; 22 ft, mean age: 12,1 years) and 19 patients with flatfoot deformity (group B: study group; 22 ft, mean age: 12,4 years) were retrospectively analyzed. Nine radiographic parameters were measured (Talocalcaneal-angles, Calcaneal-pitch-angle, Costa-Bartani-angle, Talo-metatarsal-I-angles, Talo-first-metatarsal-base-angle, Talo-navicular-coverage, Calcaneus-fifth-metatarsal-angle). ROC curve analysis was used to calculate optimal differentiating thresholds of each parameter.

Results

Four out of nine parameters (TC-dp, TC-lat, Calc-MTV, Calc-P) were not statistically different between the groups and their ability to distinct between normal foot and flatfoot was low (AUC values = 0,660 - 0,819). Calculation of reference values for these parameters was not performed due to threshold ranges between the groups of > 10°. Reference values could be defined only for three parameters: TMTInd >(−)31°, TMTIB >(−)7,5°, TMT-lat > (−)13,5°. The TMTInd was shown to be a very reliable and valid combination of two measurements (TMTIB and TMT-lat) in the differentiation of normal feet and flatfeet (AUC = 0,998).

Conclusion

The calculation of reference values for established radiographic parameters used to evaluate juvenile flatfeet is difficult for most parameters. The TMTInd as a combination of TMTIB and TMT-lat has been shown to be reliable and valuable to distinct normal feet from flatfeet.

Subtalar arthroereisis for treatment of children with flexible planovalgus foot deformity and analysis of CT data in long-term period

The aim of the study is to analyze the long-term results of the subtalar arthroereisis of the feet according to Grice in children with flexible symptomatic planovalgus foot deformity.

Methods

29 children (58 feet) were treated with symptomatic flexible planovalgus foot deformity.

Results

The average value of AOFAS increased from 63 (51-84) to 92 (53-96) points. According to CT size of the bone graft corresponded to 83% of the size of the subtalar sinus.

Conclusion

In compliance with all the technical features of this operation, it is effective for correction of flexible planovalgus foot deformity with pronounced verticalization of talus.

Level of evidence

IV.

Calcaneal lengthening osteotomy in spastic planovalgus feet

PURPOSE OF STUDY

Planovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters.

METHODS

17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance.

RESULTS

Improvement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis.

CONCLUSION

Calcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.

Endosinotarsal device exerts a better postoperative correction in Meary's angle than exosinotarsal screw from a meta-analysis in pediatric flatfoot

For pediatric flexible flatfoot, the subtalar extra-articular screw arthroereisis (SESA) and endosinotarsal device are the most popular techniques in current practice. Nevertheless, scarce literature is available comparing the outcomes between these two techniques. Thus, we aimed to provide a meta-analysis for the radiographic and clinical outcomes, respectively. A systemic search for correction of pediatric flexible flatfoot using subtalar arthroereisis was conducted mainly in Pubmed and Scopus, and the search was completed on 31 Dec., 2019. The standardized mean differences (SMD) of postoperative versus preoperative calcaneal pitch and Meary’s angle were defined as the primary outcomes, whereas the preoperative versus posteoperative AOFAS (American Orthopaedic Foot and Ankle Society) as the secondary outcome. The meta-analysis included 12 comparative studies comprising 2063 feet in total. The quantitative analysis showed a marked improvement in Meary’s angle of endosinotarsal cone implant group (SMD: 4.298; 95% CI 2.706–5.889) than exosinotarsal screw group (SMD: 1.264; 95% CI 0.650–1.877). But no significant difference was noted between both groups in calcaneal pitch and AOFAS. The exosinotarsal screw and endosinotarsal device are both effective arthroereisis implant for pediatric flexible flatfoot. While considering the correction of Meary’s angle, the endosinotarsal device is better than exosinotarsal screw.

Medium-term results of calcaneus lengthening in idiopathic symptomatic flat foot in children and adolescents

PURPOSE

Calcaneus lengthening can be used in symptomatic flat foot in children, but few details on its medium-term results and complementary procedures are available.

METHODS

A total of 20 flexible, symptomatic, idiopathic valgus flat feet (in 15 children; mean age 13.9 years (10 to 17)) were operated on. Complementary procedures were based on preoperative and intraoperative analyses. Radiographic measurements were obtained preoperatively and with at least four years follow-up.

RESULTS

At a mean of 8.3 years (4 to 15) postoperatively, 13 feet had good clinical and radiological results, with significant improvement in American Orthopaedic Foot & Ankle Society Ankle-Hindfoot scale scores and radiological measurements. Seven feet had residual pain. Six of them had no osteotomy of the first cuneiform.

CONCLUSION

Calcaneus lengthening with adequate complementary musculo-tendinous and/or bone procedures according to preoperative and intraoperative foot deformation leads to good medium-term results. Forefoot supination is the most frequent residual defect. If present intraoperatively, first cuneiform pronation-flexion osteotomy is indicated.

LEVEL OF EVIDENCE

IV.

Tarsometatarsal bone remodelling after subtalar arthroereisis

PURPOSE

Subtalar arthroereisis has been described for the treatment of flexible juvenile flatfoot. However, the mechanism responsible for deformity correction has not yet been investigated adequately. The aim of this study was to document the effect of subtalar arthroereisis on the tarsometatarsal bone morphology.

METHODS

We retrospectively reviewed the clinical and radiological data of 26 patients (45 feet) with juvenile flexible flatfoot deformity treated by subtalar arthroereisis at our department between 2000 and 2018. Radiological evaluation included angular measurements of tarsometatarsal bone morphology as well as hindfoot and midfoot alignment. Mean radiographic follow-up was 19.4 months (sd 8.8; 12 to 41).

RESULTS

A significant change of angular measurements of tarsometatarsal bone morphology was found after subtalar arthroereisis (p < 0.001). While there was an increase of the distal medial cuneiform angle (DMCA) and the medial cuneo-first metatarsal angle on the anteroposterior view, a decrease of the naviculo-medial cuneiform angle and the medial cuneo-first metatarsal angle was seen on the lateral view. Furthermore, we found significant improvements of all hindfoot and midfoot alignment parameters except the lateral tibio-calcaneal angle and the calcaneal pitch angle (p < 0.001).

CONCLUSION

Our data support the theory of tarsometatarsal bone remodelling, which may contribute to the effect of subtalar arthroereisis for the treatment of flexible juvenile flatfoot.

LEVEL OF EVIDENCE

IV.

Outcome after subtalar screw arthroereisis in children with flexible flatfoot depends on time of treatment: Midterm results of 95 cases

OBJECTIVES

The subtalar screw arthroereisis (SSA) is a treatment option for painful pediatric flexible flatfeet (PFF). Hence, the optimal time point for a SSA is discussed controversially. Therefore the present study evaluates the influence of the patient's age at surgery on the radiological outcome to provide further evidence in this matter.

METHODS

From 08/2007 to 12/2015 50 patients with 95 PFF were included. Inclusion criteria were: 1) Patients with PFF under or equal 15 years of age, 2) treatment with SSA and 3) presence of pre-op, post-op and follow up (FU) routine biplane radiographs. A subdivision was made into group A: 5-8 years, group B: 9-12 years and group C: 13-15 years. The radiographs were analyzed for: 1) calcaneal-pitch (CP), 2) lateral talocalcaneal angle (lat. TCA), 3) a.p. talocalcaneal angle (a.p. TCA, kite angle) and 4) navicular-cuboidal-index (NCI) and meary angle.

RESULTS

Our study showed the best deformity correction when surgery was conducted between 9 and 12 years of age (group B), with significant improvement in all measured parameters without secondary deterioration during FU. In group A, the SSA show inferior results with poorer long-term success with only an improvement in the a.p. TCA. Group C showed mixed results. While CP and NCI improved, the lat. TCA deteriorated in FU. In conclusion, the ideal age for surgical intervention by SSA is between 9 and 12 years. Surgery before the age of 8 years did not show long-term success and delayed treatment at the age of 13-15 was only partially successful with deterioration during FU period.

LEVEL OF EVIDENCE

IV.

Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition

Background

The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC.

Methods

We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis.

Results

Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9–17): 11.6 (9–17) for the nonoperative group, 12.2 (10–15) for the operative group. The mean follow-up averaged 6.6 (3–12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years.

There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables.

Conclusion

The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.

Pedobarographic changes during first month after subtalar extra-articular screw arthroereisis (SESA) operation of juvenile flexible flatfoot

BACKGROUND

Juvenile flexible flatfoot deformity is a common problem in childhood. In severe cases, the subtalar extra-articular screw arthroereisis (SESA) according to De Pellegrin is a viable and effective option. There are just a few retrospective studies showing long-term outcomes, but the interval right after the surgery has not been described so far, even though the short time of healing is one of the great benefits of this technique. In this study, we examined if the pedobarographic measurements are able to demonstrate functional changes in the month after surgery.

METHODS

Data were analyzed for seven patients (13 feet). Measurements were performed before surgery, as well as 3, 14 and 28 days after. For analysis, the foot was comparted in six areas-fore-, mid- and hindfoot, each split in their lateral and medial parts. Plantar forces and contact area were measured under static and dynamic conditions. Time-dependent changes of plantar acting forces and the contact area were compared.

RESULTS

During bipedal stance, the ground force increased significantly in lateral foot areas (p < 0.001) and decreased in medial areas (p < 0.001). While the force in the medial midfoot remained reduced, in the medial forefoot, the force increased 14 days after surgery (p < 0.05) CONCLUSION: The functional changes after SESA can be accurately assessed using pedobarography. The results indicate morphologic changes of the foot, in particular the development of a longitudinal arch. Post-surgical progression can be monitored and success of the surgery can be verified.

Is subtalar extra articular screw arthroereisis (SESA) reducing pain and restoring medial longitudinal arch in children with flexible flat foot?

Subtalar arthroereisis has been accounted for as a minimally invasive, successful and generally safe technique in the treatment of flatfoot in children. The primary aim of our study was to evaluate the subtalar extra-articular screw arthroereisis (SESA) in children with flexible flatfoot clinically and radiologically. This prospective case series study included 84 feet of 42 patients who underwent Subtalar Extra-articular Screw Arthroereisis (SESA) due to symptomatic flexible flatfoot. This study included 26 males (62 ℅) and 16 females (38℅). The mean age at surgery was (9.92 years); range from (7-15 years).The average follow up period was 29.1 months (ranged from 2 to 48 months). The values of the pre- and post-SESA weight bearing X-ray angles were 149 ± 6 and 127° ± 8° respectively for the Costa-Bartani angle, 43° ± 8° and 25° ± 6° respectively for the lateral T-1stMT angle and 26° ± 7° and 8° ± 3° respectively for calcaneal pitch angle 6° ± 4° and 15° ± 5°. The average AOFAS preoperative score was 68.7 ± 5.7 (Range, 58 to 78) whereas post operative AOFAS score was 97.4 ± 2.3 (range, 94 to 100). All data were analyzed statistically with graph instat. With final conclusion that SESA is an optimal technique for the correction of flexible flatfoot (FFF) as it is simple and can be performed rapidly and is effective procedure in reducing pain and restoring medial longitudinal arch in children with flexible flat foot. Level of clinical evidence (LOCE): Level 4.

Pediatric Flatfeet-A Disease Entity That Demands Greater Attention and Treatment

Background: Pediatric flatfoot is a common deformity. Unfortunately, the common opinion has been that most children with this faulty foot structure will simply out-grow it, despite no radiographic evidence to support this claim. Every step on a deformed foot leads to excessive tissue strain and further joint damage. Many forms of conservative and surgical treatments have been offered. This study was aimed at investigating the effectiveness of non-surgical and surgical treatment options. Main Text: faulty-foot structure is the leading cause of many secondary orthopedic deformities. A wide range of treatments for pediatric flatfeet have been recommended from the "do-nothing" approach, observation, to irreversible reconstructive surgery. Most forms of conservative care lack evidence of osseous realignment and stability. A conservative surgical option of extra-osseous talotarsal joint stabilization provides patients an effective form of treatment without the complications associated with other irreversible surgical procedures. Conclusion: Pediatric flatfeet should not be ignored or downplayed. The sooner effective treatment is prescribed, the less damage will occur to other parts of the body. When possible, a more conservative corrective procedure should be performed prior to irreversible, joint destructive options.

Prospective Early Clinical, Radiological, and Kinematic Pedobarographic Analysis Following Subtalar Arthroereises for Paediatric Pes Planovalgus

Introduction Arthroereises implants mechanically block eversion and limit subtalar motion. They are used in children with pes planovalgus in order to correct the valgus deformity. In this study, we aimed to objectively assess children with flatfoot before and after the insertion of the Kalix II implant, clinically, radiologically and by kinematic pedobarographic analysis. Materials and methods Six children (12 feet) were treated by the insertion of the Kalix II implant (Integra LifeSciences, Plainsboro, NJ). Patients completed the Manchester Oxford Foot Questionnaire (MOXFQ) preoperatively and at six months post operatively. Radiological outcome was assessed by lateral (L) and anterior posterior (AP) foot weight-bearing radiographs taken pre operatively and post operatively. Pedobarographic data was obtained pre operatively and at six months post operatively using a 1 meter RS Scan Footscan (RSscan International, Olen, Belgium) pedobarograph. In addition, patients underwent gait analysis pre and post operatively. Results Mean age was 11.05 +/-3.24 years (range 6.2 to 15.5 years). In all cases, screw removal was carried out at between 15 to 18 months post insertion. The mean pre op MOXFQ score was 55.3 +/-9.68 which reduced to 34.3 +/-15.66 post operatively with a p value < 0.00001 which was statistically significant. Mean Meary's angle preop was -15.21+/-5.51 degrees which corrected to -7.57+/-4.62 post op with a p value=0.00001. The mean calcaneal pitch before surgery was 11.96+/-3.8 which increased to 14.98+/-3.85 with a p value =0.00067. The first MTH: fifth MTH peak pressure ratio pre operatively was 4.53+/-2.78 which was found to reduce significantly post operatively to 1.35+/-0.97 (p=0.04), indicating a lateral shift of the foot pressures. Conclusion There were statistically significant improvements in the patient-reported MOXFQ, radiological improvements, and pedobarographic changes, indicating a lateral shift of the foot pressures. There were no complications.

Arthroereisis for Symptomatic Flexible Flatfoot Deformity in Young Children: Radiological Assessment and Short-Term Follow-Up

The purpose of this study is to recognize those young patients with symptomatic flexible flatfoot deformity who need treatment and to provide radiological evidence that arthroereisis is capable of relocating the talus properly over the calcaneus. We included 28 feet in 14 children who underwent subtalar arthroereisis in association with percutaneous triple-hemisection Achilles tendon lengthening. Selected for arthroereisis were children with symptomatic flexible flatfoot deformity who complained of foot and leg pain, had decreased endurance in sports activities and long walks, who did not respond to conservative treatment modalities for at least 6 months, and in whom at radiological assessment on stance position with the medial arch support orthosis the talonavicular joint lateral subluxation still remained, with Meary's angle in anteroposterior (A/P) and lateral view remaining increased. The mean age at surgery was 10.71 ± 1.58 (range 8 to 14) years. The minimum follow-up duration was 19 months, with mean follow-up duration of 35.14 ± 9.82 (range 19 to 60) months. For estimation of the efficacy of the surgical procedure, the American Orthopaedic Foot and Ankle Society (AFOAS) rating scale was used preoperatively and postoperatively in all patients. The mean preoperative AFOAS ankle-hind foot rating score was 65.14 ± 7.16 (range 58 to 75) points. The mean postoperative AFOAS score was 88.851 ± 5.61 (range 83 to 97) points and the 2-tailed p value <.0001. After arthroereisis surgical treatment, all AOFAS scores and all foot angles improved significantly, except the calcaneal inclination angle which improved slightly.

Body Weight Effects on Extra-Osseous Subtalar Arthroereisis

Implant extrusion in subtalar arthroereisis is a common complication for pediatric flexible flatfoot. However, there were a limited number of articles addressing the body weight effects on implant extrusion after the procedure. We conducted a 24-month follow-up assessment after subtalar arthroereisis. Surgical patients who underwent the Vulpius procedure were retrospectively collected from May 2010 to January 2017, including 59 cases of both feet having implants in situ and 43 cases of both feet having implant extrusion. The average age of 102 patients was 9 years old. The mean body mass index (BMI) of the implant in situ group was 19.5, whilst the extrusion group was 21.2 (p = 0.035). The inter-observer correlation was excellent. There were 11 cases (39.3%) of bilateral extrusion in the overweight group (BMI ≥ 24) and 13 cases (23.2%) in the low body weight group (BMI ≤ 18.5) (p < 0.0004). Postoperative radiographic angles were corrected in both the implant in situ group and the extrusion group. Nonetheless, the implant in situ group revealed better postoperative outcomes of Meary’s angle and the talonavicular angle from an anterior-posterior view, and the talar inclination angle from a lateral view. We conclude that a higher BMI is related to implant extrusion and worse results after subtalar arthroereisis. Further prospective study to investigate whether preoperative weight loss results in improved surgical outcomes is warranted in the future.

Radiographic and Functional Results following Subtalar Arthroereisis in Pediatric Flexible Flatfoot

Introduction

Flexible flatfoot (FFF) is one of the most common skeletal disorders in children. In symptomatic patients who do not respond to conservative measures, surgery may be an option. Subtalar arthroereisis consists of limiting excessive eversion of the subtalar joint through different types of implants.

Materials and Methods

We carried out a retrospective study of 16 patients (32 feet) intervened for FFF with a subtalar device (arthroereisis), across the period of 2008-2015 with a minimum follow-up period of one year. Pre- and postoperative measures of the Moreau-Costa-Bartani angle, dorsoplantar (DP) and lateral (L) talocalcaneal angle, talonavicular coverage angle, and naviculocuboid overlap were used to evaluate correction of the deformity. Two expert surgeons from the Pediatric Orthopedics Unit took separate measurements of these angles for subsequent analysis purposes and to obtain the interobserver correlation coefficient for quantitative variables. Pre- and postoperative differences in the measurement of angles were ascertained using Student's t-test for paired samples; and a functional evaluation of the patients intervened was carried out pre- and postoperatively by administering the parent version of the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) during a clinical interview. All statistical analyses were performed using the SPSS v. 19.0 program (SPSS, Chicago, IL), with values being deemed statistically significant at p<0.05.

Results

A breakdown of the study population showed 81.25% (13 patients) males and 18.75% (3 patients) females, with mean age of 9 years (7-11). The interobserver coefficient for quantitative variables displayed a very high degree of concordance (0.7-0.9), indicating that the validity of the measures was adequate. Pre- and postoperative analysis of differences in the measurement of angles was statistically significant (p<0.005). In terms of functional evaluation, the postoperative results were positive, with statistical significance for the “school and play”, “emotional”, and “footwear” domains of the OxAFQ-C scale and no differences in the “physical” domain.

Conclusion

Subtalar arthroereisis is a valid option for the treatment of symptomatic pediatric flatfoot, with good postoperative functional and radiographic results.

Radiological outcome after treatment of juvenile flatfeet with subtalar arthroereisis: a matched pair analysis of 38 cases comparing neurogenic and non-neurogenic patients

PURPOSE

Therapy of juvenile neurogenic flatfoot (JNF) with subtalar arthroereisis (SA) is currently under critical clinical investigation. In this retrospective matched pair analysis, the radiological outcome after arthroereisis in paediatric patients with infantile cerebral palsy and JNF was compared with children with juvenile flatfeet (JF) without neurological diseases.

METHODS

From October 2007 to April 2018 80 patients with 149 flatfeet underwent surgery with SA. Inclusion criteria were: 1) JNF or JF with age at surgery ≤ 13 years; 2) treatment with SA; 3) presence of three sets of biplane radiographs (preoperative, postoperative and follow-up (FU)). The radiographs were analyzed for: 1) navicular-cuboidal-index (NCI); 2) talocalcaneal angle anteroposterior; 3) talocalcaneal angle lateral; 4) calcaneal-pitch (CP); and 5) talometatarsal-index (TMTI). Following this, 25 patients with 38 flatfeet could be included.

RESULTS

The mean age at SA of the JNF group was 9.2 years (JF group: 9.3 years) and the mean time of FU was 35.2 months (JF group: 39.4 months). In comparison with preoperatively, a significant decrease of the NCI was seen in both groups (p = ≤ 0.05 and p = ≤ 0.001) in the FU radiographs. The analysis of CP and TMTI in the JF group also resulted in a significant improvement (p = ≤ 0.001 and p = ≤ 0.05). Overall, the comparison between the JNF and JF group showed no significant differences in regard to the analyzed postoperative parameters.

CONCLUSION

Based on this data, treatment of flatfeet by SA in patient with neurological disorders shows an improvement of radiological parameters comparable with neurologically unimpaired patients and might be considered as additional treatment option.

LEVEL OF EVIDENCE

IV.

Effects of body weight on the clinical and radiological outcomes of children with flexible flatfeet managed with the 'calcaneo-stop' procedure

This study aimed to evaluate the clinical and radiological outcomes of normal, overweight, and obese children with symptomatic flexible flatfeet managed with the 'calcaneo-stop' procedure (CSP), and to determine whether any correlation exists between patient weight and outcome. One hundred and seventy-four symptomatic flexible flatfeet were managed with CSP during the study period. The patients were divided into three groups according to their BMI and weight Z-scores: normal, overweight, and obese. Their clinical and radiographic outcomes were assessed preoperatively, and at 1 and 5 years after the index procedure. Although the radiographic criteria were comparable between the three groups, the clinical outcome was worse in obese children than in normal and overweight patients (P<0.05). BMI and the Z-score affected the outcomes of obese patients treated with CSP for symptomatic flexible flatfeet. Although the radiographic outcome was similar irrespective of BMI and Z-scores, obese patients had significantly lower clinical scores than the other patients.

Reliability of a New Method to Determine Foot Arch Height for Clinicians

BACKGROUND

Arch height is an important indicator of risk of foot pathology. The current non-invasive gold standard based on footprint information requires extensive pre-processing. Methods used to obtain arch height that are accurate and easier to use are required in routine clinical practice.

METHODS

The proposed arch index diagonals (AI_d) method for determining the arch index (AI) reduces the complexity of the preprocessing steps. All footprints were first prepared as required by the Cavanagh and Rodgers method for determining the AI and then compared to the proposed diagonals method. Results were classified according to the Cavanagh and Rodgers cut-off values into three groups of low, normal and high AI. ANOVA and Tukey's post hoc tests were applied to identify significant differences between AI groups. Linear modeling was applied to determine the fit of the new AI_d method compared to the Cavanagh and Rodgers AI.

RESULTS

One hundred and ninety-six footprints were analyzed. The ANOVA indicated significant differences between the groups for AI_d (F1,194=94.49, p<0.0001) and the Tukey post hoc tests indicated significant differences between the pair-wise comparisons (p<0.001). Linear modeling indicated that the AI_d ratio classified more footprints in the high arch group compared to Cavanagh and Rodgers results (R²=32%, p< 0.01). Intra- and inter-rater correspondence was above 90% and confirmed that the AI_d results provided a better indication of arch height.

CONCLUSIONS

The proposed method simplifies current processing steps to derive the arch height.

Are there benefits of a 2D gait analysis in the evaluation of the subtalar extra-articular screw arthroereisis? Short-term investigation in children

BACKGROUND

A juvenile flexible flatfoot is a common abnormality during growth. For children with a pathological manifestation, subtalar extra-articular screw arthroereisis is a popular operative technique. Although this minimally invasive operation technique has been performed for >45 years, complications still occasionally occur. For this reason, we created this pilot study to investigate whether a two-dimensional (2D) gait analysis is able to identify functional movement deficits after surgery.

METHODS

Fourteen children (27 ft) with a mean age of 12.38 years (SD, 1.40 years) were analyzed. Biomechanics were examined before and 4 weeks after surgery using a 2D gait analysis. For this purpose, the patients were filmed on a treadmill. In focus were static and dynamic recordings of the heel angle, rearfoot angle, and the leg axis angle. In addition, the step length and self-selected speed were measured.

FINDINGS

After surgery rearfoot angle showed significant reduction (p < 0.001) from 12.49° to 3.63° under static conditions and from 12.65° to 4.58° under dynamic conditions. Heel angle responded similar (p < 0.001). There were no significant differences in self-selected speed or step length. Undoubtedly, gait analysis was able to identify intraindividual deficits, leading to a closer monitoring of five patients and an adjustment of the screw in one foot.

INTERPRETATION

By means of the 2D gait analysis, we were able to show functional improvement after subtalar extra-articular screw arthroereisis. Nonetheless, we identified a few children who still had functional abnormalities. Certainly, it is unclear whether this additional examination is able to reveal all complications that would have occurred later.

Surgical treatment of idiopathic pes planovalgus in paediatric patients

Idiopathic pes planus is common and usually physiologic. Decompensation, when it occurs, may be obvious or on the contrary difficult to identify, raising challenges in patient selection for surgical treatment. The physical examination of a child with pes planus must include an evaluation in the supine position, which helps to adjust the amount of correction during surgery. The many reported surgical procedures include repositioning (talus-reseating, subtalar implants and calcaneo-stop screw), osteotomies and joint fusions. The primary treatment goal is to achieve full architectural correction of the deformity. Selection of the procedure depends on patient age and reducibility of the deformity. The joint lines should be preserved whenever possible. Triceps surae contracture should be sought and corrected if found.

Outcomes of the calcaneo-stop procedure for the treatment of juvenile flatfoot in young athletes

PURPOSE

Flexible flatfoot (FFF) is a widespread condition in juvenile patients. If symptomatic, FFF can require surgical treatment. The calcaneo-stop procedure has shown excellent clinical and radiographic outcomes and low rates of complications. The aim of the present study was to assess the sport practice of young athletes affected by FFF having undergone the calcaneo-stop procedure.

METHODS

Between 2008 and 2016, 68 sport practitioners were bilaterally treated by the calcaneo-stop procedure, for a total of 136 FFF cases. Clinical evaluation, including the American Orthopedic Foot and Ankle Score (AOFAS), the Yoo et al score and The Foot & Ankle Disability Index (FADI) and FADI Sport scores were assessed. Radiographic evaluation was based on measurement of talar declination, Costa-Bertani's angle and calcaneal pitch.

RESULTS

Mean follow-up was 57.6 months (sd 16.8). The AOFAS score mean increased from 79.3 (sd 5.7) to 97.3 (sd 4.5) three years after surgery. The Yoo score improved from 3.1 (sd 1.0) preoperatively to 11.7 (sd 0.6) three years after surgery. The FADI Sport subscale mean improved from 74.1 (sd 10.4) preoperatively to 95.9 (sd 4.9) three years after surgery.Costa-Bertani's angle decreased from 156.1° (sd 4.2°) to 135.8° (sd 7.3°) at three years postoperatively; mean talar declination angle decreased from 44.2° (sd 6.3°) to 30.6° (sd 3.2°) at three years postoperatively and mean calcaneal pitch increased from 12.6° (sd 2.3°) to 16.3° (sd 1.3°) at three years postoperatively.

CONCLUSION

Adolescent patients who underwent the calcaneo-stop procedure reported satisfactory outcomes in terms of clinical and radiological evaluations. Moreover, our results showed an improvement of sport activity levels, with patients recovering sports activity within three months of surgery and without limitation in the execution of preferred activities.

LEVEL OF EVIDENCE

IV.

Functional evaluation of bilateral subtalar arthroereisis for the correction of flexible flatfoot in children: 1-year follow-up

BACKGROUND

Flexible flatfoot (FFF) is a common alteration of the foot diagnosed in the pediatric population causing pain and decreased quality of life. Surgical treatment via arthroereisis of the subtalar joint can be recommended when non-invasive options do not result in sufficient pain relief. While clinical outcome of subtalar joint arthroereisis is generally positive, no functional evaluation has thus far been reported following surgery.

RESEARCH QUESTION

The aim of this study was to assess the effects of two arthroereisis implants for the correction of bilateral FFF on foot and lower limb biomechanics during gait.

METHODS

This is a prospective study following 13 children affected by bilateral symptomatic FFF. The patients underwent bilateral subtalar arthroereisis during the same surgery using two types of poly-L-lactide bioabsorbable implants: an expanding endo-orthotic implant, and a calcaneo-stop screw. Radiological parameters and gait analysis were performed preoperatively and at 1 year follow-up and compared to those from an age-matched normal-arched control population. Lower limb and multisegment foot kinematic analysis, along with EMG of the main ankle flexor/extensor muscles, were performed during level walking at comfortable speed. Paired non-parametric Wilcoxon signed-rank test was used to assess differences in radiological and kinematic parameters between pre-op and post-op assessments.

RESULTS

All radiological parameters, and frontal-plane orientation of the rearfoot in double-leg standing were improved at 1-year follow-up in both implant groups (e.g calcaneo-stop: pre-op = 15 ± 7 deg; post-op = 6 ± 9 deg; p < 0.01). The endo-orthotic implant group showed significantly lower pronation/supination at the ankle and midtarsal joint. Activation of the tibialis anterior muscle was more physiological after surgery in both groups.

SIGNIFICANCE

According to the present analysis, both implants appear effective in restoring physiological alignment of the rearfoot, however the endo-orthotic implant appeared more effective in restoring a more correct frontal-plane mobility of foot joints.

Bioabsorbable Calcaneo-Stop Implant for the Treatment of Flexible Flatfoot: A Retrospective Cohort Study at a Minimum Follow-Up of 4 Years

Arthroereisis of the subtalar joint is a common surgical technique in Europe for the management of flexible flatfoot in the pediatric population. In most cases, it is performed using a calcaneo-stop metallic screw. Despite the good clinical results, screw removal is always advised after 2 to 3 years. The use of a bioabsorbable screw might overcome the need for a second operation to remove a nonabsorbable device. We report the results of a biodegradable calcaneo-stop screw at a minimum of 4 years of follow-up. Eighty-eight procedures were performed on 44 children. All patients were clinically and radiologically evaluated preoperatively and at a minimum 4-year follow-up period. Patient satisfaction and plantar collapse using Viladot's classification were recorded. Meary's talus-first metatarsal angle and talocalcaneal angle were measured on radiographs preoperatively and at the last follow-up visit. The presence of the device at the last follow-up examination was assessed by magnetic resonance imaging. The mean follow-up duration was 56 months. Of the 44 patients, 33 (75%) reported excellent clinical outcomes, 9 (20.5%) good outcomes, and 2 (4.5%) poor. Foot print improvement was registered for all patients. The mean Meary's talus-first metatarsal angle had improved from 160.6° ± 7.7° preoperatively to 170.6° ± 6.5° at the last follow-up visit (p < .001). The talocalcaneal angle had decreased from 39.9° ± 5.2° preoperatively to 29.4° ± 4° at the last follow-up examination (p < .001). At the 4-year follow-up point, the implant could be seen to have almost completely biodegraded on magnetic resonance imaging. Two screw breakages occurred. The bioabsorbable calcaneo-stop screw seems to be an effective solution for flexible flatfoot in pediatric patients. Also, owing to its biodegradable composition, the need of a second operation for implant removal will not always be necessary.

Double calcaneal osteotomy with minimally invasive surgery for the treatment of severe flexible flatfeet

BACKGROUND

Severe flexible flatfoot deformity in children and adolescents is a complex problem. Calcaneal lengthening remains the gold standard for surgical correction at this institution. However, in a minority of patients, inadequate correction of valgus is noted at surgery and a further calcaneal shift osteotomy is done.

METHODS

We have conducted a retrospective review of ten patients who received 15 combined minimally invasive calcaneal shift and calcaneal lengthening osteotomies, which were all performed by the senior author. All patients had failed conservative treatment. We describe our technique for double calcaneal osteotomy combining minimally invasive surgery (MIS) for the medial calcaneal shift with traditional open calcaneal lengthening osteotomy for treating children and adolescents with severe flexible flatfoot deformity.

RESULTS

The average shift achieved was 8.07 mm. The average improvement in Meary's angle was 14.99°. All of them had radiological and clinical union at 12 weeks. None of the patients developed sural nerve injury, wound breakdown, or infection of the MIS incision.

CONCLUSION

In double calcaneal osteotomies, the MIS calcaneal medial shift technique can be used safely with potentially lower risks of wound complications and sufficient medial shift, compared to conventional open extensive surgery.

IMPLICATIONS

MIS calcaneal shift osteotomy has an advantage over open conventional open technique in cases where the skin is under tension like in combined calcaneal lengthening osteotomy. With experience, the procedure can be faster than an open procedure.

The role of arthroereisis of the subtalar joint for flatfoot in children and adults

Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults.It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome.Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.Sinus tarsi pain is the most frequent complication, often requiring removal of the implant.To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear. Cite this article: EFORT Open Rev 2017;2:438-446. DOI: 10.1302/2058-5241.2.170009.

Bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot

Flatfoot is a common condition in growing-age patients. Despite its common presentation, nowadays surgical indications and treatments are still debated. Arthroereisis is a widely used technique, and several implants designs have been proposed over time. Despite the good results shown in the literature, the main drawback of these techniques has always been the need for a second surgery for implant removal. Bioabsorbable devices have been introduced to overcome this necessity.Correct approach to the patient, indications and contraindications and available studies on bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot were analyzed in this narrative review. Even if only a few studies have been published in the literature, bioabsorbable implants showed good clinical results comparable to non-absorbable implants and with a rare necessity for implant removal or revision. When correct indications and proper surgical technique are followed, arthroereisis with bioabsorbable implants appears to be an effective solution for the treatment of pediatric flexible flatfoot.