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

Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up

BACKGROUND

Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF.

METHODS

Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively.

RESULTS

Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01).

CONCLUSIONS

SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF.

LEVEL OF EVIDENCE

IV.

Gait Analysis in Patients with Symptomatic Pes Planovalgus Following Subtalar Arthroereisis with the Talus Screw

Background

Pes planovalgus is one of the most common pediatric skeletal deformities. There have been no studies to analyze in detail the spatiotemporal variables of gait following arthroereisis.

Purpose of the study

The purpose of our study was to assess gait parameters in patients with symptomatic flexible flatfoot following treatment with the talus screw.

Methods

This was a prospective study assessing the 22 patients treated surgically due to symptomatic flexible flatfoot with the talus screw. Patients underwent gait assessment with a G-Sensor. We analyzed the following gait parameters: gait cycle duration, step length, support phase duration, swing phase duration, double support duration, single support duration, cadence, velocity, step length.

Results

The post-operative gait parameter assessment for the operated and non-operated foot showed a significant difference only in terms of step length. Cadence increased from the pre-operative mean of 82.29 steps/min to a post-operative mean of 102.94 steps/min. Gait velocity increased significantly from 0.81 m/s before to 0.96 m/s after surgery.

Discussion

Arthroereisis with the talus screw helps improve gait parameters following surgery. Post-operatively, we observed increased gait velocity and cadence and decreased gait cycle duration in the operated limb.

Conclusion

Short-term biomechanical outcomes of pes planovalgus treatment with the talus screw are good.

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.

Short-Term and Medium-Term Radiological and Clinical Assessment of Patients with Symptomatic Flexible Flatfoot Following Subtalar Arthroereisis with Spherus Screw

BACKGROUND

There have been no reports on arthroereisis screw insertion into the talus in patients with flexible flatfoot. We aimed to conduct a clinical and radiological assessment in patients with symptomatic pes planovalgus deformity treated with a talar screw.

METHODS

This study involved a prospective assessment of 27 patients treated surgically for symptomatic flexible flatfoot deformity in the period 2021-2022. The following parameters were assessed in this study: Meary's angle, the Costa-Bartani angle, the calcaneal pitch angle, surgery duration, the length of hospital stay, patient satisfaction, patients' retrospective willingness to consent to the treatment they received, postoperative complications, and the use of analgesics.

RESULTS

The mean follow-up period was 14.76 months. Meary's angle decreased from 18.63° before surgery to 9.39° at follow-up (p = 0.004). The Costa-Bartani angle decreased significantly from 154.66° before surgery to 144.58° after surgery (p = 0.012). The calcaneal pitch angle changed from 16.21° before to 19.74°. Complications were reported in three patients (11.11%). The mean surgery duration was 32 min. The mean hospital stay was 2.2 days. Fourteen patients (51.85%) were highly satisfied with the treatment, and 12 patients (44.44%) were quite satisfied with treatment. Twenty-five (92.59%) of the evaluated patients would choose the same type of treatment again. Six patients (22.22%) needed to use analgesics prior to surgical treatment, whereas none of the patients needed to use them by the final follow-up.

CONCLUSION

Spherus screw arthroereisis helps improve radiological parameters in patients with flexible flatfoot. We observed good clinical outcomes after treatment with a talar screw, with a majority of patients reporting moderate-to-high levels of satisfaction with treatment. Both short- and medium-term treatment outcomes of pes planovalgus treatment with the use of Spherus screw are good.

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.

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.

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.

Arthroereisis in juvenile flexible flatfoot: Which device should we implant? A systematic review of literature published in the last 5 years

BACKGROUND

Flexible flatfoot (FFF) is a very common condition in children, characterized by the loss of the medial arch and by an increase in the support base with valgus of the hindfoot. Arthroereisis (AR) procedures are widely performed corrective surgeries and are classified as subtalar AR and calcaneo-stop (CS).

AIM

We investigated the literature published in the last 5 years with the aim of providing an update on the evidence related to AR treatment in FFF patients. We report the principal findings of subtalar AR and CS procedures concerning clinical and radiological outcomes and complication rates in the general population, young athletes, and obese people according to material device.

METHODS

Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review of studies published in the past 5 years and included the PubMed and Science Direct databases was performed on May 6, 2020. The research string used was (pediatric OR children OR Juvenile NOT adult) AND (flexible NOT rigid) AND (flat foot OR pes planus) AND (calcaneo-Stop OR arthroereisis OR subtalar extra-articular screw OR SESA OR subtalar arthroereisis OR endosinotarsal). The risk of bias assessment was performed using the Dutch checklist form for prognosis.

RESULTS

A total of 47 articles were found. Ultimately, after reading the full text and checking reference lists, we selected 17 articles that met the inclusion and exclusion criteria. A total of 1864 FFFs were identified. Eight studies concerned the subtalar AR (47.1%) and nine concerning CS (52.9%). The average age of patients at start of treatment was 11.8 years, the average follow-up of the studies was 71.9 mo (range 29.1-130). Globally, complications occurred in 153 of the 1864 FFF treated, with a rate of 8.2%.

CONCLUSION

Both AR procedures are valid surgical techniques for treating FFF. Surgeon experience, implant cost, and cosmetic correction are the most common considerations included in the orthopedic device decision-making process. In obese patients, the subtalar AR is not recommended. In adolescents who need to improve sports performance, the CS screw had better results compared with other implants.

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.

Long-term results of subtalar arthroereisis for the treatment of symptomatic flexible flatfoot in children: an average fifteen year follow-up study

AIM OF THE STUDY

The aim of this study is to report the long-term outcomes of a homogenous series of patients who underwent subtalar arthroereisis (STA) for the treatment of symptomatic flexible flatfoot (FFF).

METHODS

Thirty-four pediatric patients who underwent STA with a bioabsorbable implant were enrolled and radiographic measurements, clinical outcomes, and patients' satisfaction were evaluated.

RESULTS

At a mean 180 months follow-up, radiographic measurements showed significant improvement. A physiological footprint and a proper hindfoot alignment were shown in more than 70% of patients. Mean AOFAS score was 90.4 ± 9.2 (72-100), mean SF-12 was 44.7 with 30 out of 34 patients (88.2%) satisfied with the procedure.

CONCLUSION

STA with a bioabsorbable implant showed satisfactory long-term results. Based on the data subgroup analysis, nine to 11.5 years for female and nine to 13.5 years for male appeared to be the most appropriate age for surgery.

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.

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.