Long-Term Results of the "Horseman" Procedure for Severe Idiopathic Flatfoot in Children: A Retrospective Analysis of 41 Consecutive Cases With Mean 8.9 Year Duration of Follow-Up

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.

PEDIATRIC FLEXIBLE VALGUS FLATFOOT CORRECTION BY ARTHROEREISIS

Objective:

This article aimed to evaluate the efficacy of arthroereisis using synthetic polyethylene implants to correct excessive valgus deformity in pediatric patients with flexible valgus flatfoot.

Methods:

Retrospective study of 20 pediatric patients with flexible valgus flatfoot, totaling 23 feet, between five and 14 years old, operated between January 2009 and July 2016. Clinical evaluations were performed by the Valenti podoscopic classification and the American Orthopaedic Foot & Ankle Society criteria, based on radiographic images and podoscopic analysis. These patients underwent surgical treatment with the introduction of a synthetic implant in the sinus tarsi. Multiple linear regression analysis with Backward selection of variables, angles of pre and postoperative of radiographic images of the patients submitted to arthroereisis were performed.

Results:

The arthroereisis with interposition of synthetic material was satisfactory, considering that 91% of the cases presented clinical and radiographic improvement, with correction of angles and improvement in deformity degrees. Two cases presented implant loosening. The variables of the Bordelon and Pitch angles significantly influenced (p < 0,05) the improvement of the correction of deformity degrees.

Conclusion:

The arthroereisis with the interposition of synthetic polyethylene material showed to be an effective technique for flexible flatfoot in symptomatic pediatric patients. Level of Evidence II, Prognostic studies - Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

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.

Midterm assessment of subtalar arthroereisis for correction of flexible flatfeet in children

BACKGROUND

The role of subtalar arthroereisis (STA) for treating flexible flatfoot (FFF) in children is controversial. We hypothesized that (1) STA provided significant radiographic correction of low longitudinal arch and forefoot abduction in paediatric FFF and that (2) mid-term clinical outcomes were satisfactory and comparable to a normal population.

METHODS

A retrospective comparative study was performed of paediatric patients with symptomatic FFF who underwent STA between 2012 and 2015. Multiple measurements on preoperative and latest follow-up radiographs were recorded by two observers and compared to assess for correction of the FFF. Intra- and inter-observer reliability was also assessed. Ankle and hindfoot range of motion (ROM), AOFAS hindfoot score and VAS-FA score were compared with controls without foot symptoms or deformity. From 70 consecutive feet, 62 (31 patients) treated at 10.5 years of age were identified and compared to 48 controls (24 patients). Mean follow-up was 62 months.

RESULTS

Intra- and inter-observer reliability was excellent for all angles (range, 0.81-0.97). Radiographic measurements demonstrated significant improvement after surgery (p<0.001) but significance was not reached in talonavicular coverage angle (p=0.49) and calcaneo-fifth metatarsal angle (p=0.53) on dorsoplantar view. At latest follow-up, patients had less hindfoot inversion than controls (15.1̊ vs. 19.3̊, p=0.03), lower AOFAS scores (94.1 vs. 99.6 points, p=0.01), due to pain (p=0.01) and alignment (p=0.006) subscores. Using the VAS-FA score, patients were found to demonstrate higher pain at rest (prange, 0.02-0.03) and during activity (p=0.009), and felt limited when standing on one leg (p range, 0.01-0.03) and running (p=0.04). No loss of correction was found after removal of the implant.

CONCLUSION

This study showed that STA corrected the low longitudinal arch in symptomatic paediatric FFF, but did not correct forefoot abduction in relation to the hindfoot. Mid-term assessment revealed STA provided satisfactory ankle and hindfoot ROM, pain and function levels, but limitations are witnessed compared to unaffected individuals. This aspect should be considered when counselling patients and their parents or caregivers to allow for realistic expectations.

LEVEL OF EVIDENCE

III, retrospective comparative study.

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.