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

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.

Clinical outcomes of subtalar arthroereisis for the treatment of stage 1 flexible progressive collapsing foot deformity

BACKGROUND

The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD.

METHODS

A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate.

RESULTS

Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102).

CONCLUSION

Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal.

LEVEL OF EVIDENCE

IV.

Coalition excision and corrective osteotomies versus coalition excision and arthroereisis in management of pes planovalgus with talo-calcaneal coalition in adolescents: A randomized controlled trial

BACKGROUND

Talocalcaneal coalition is the most common cause of rigid flat foot in adolescents. It presents with recurrent ankle sprains, foot and ankle pain, and foot deformity. Management is still controversial. Multiple options were utilized during the last 40 years, including coalition excision only or coalition excision with hind foot arthrodesis or corrective osteotomies. However, the effect of arthroereisis after coalition excision is still questionable.

PATIENTS AND METHODS

Thirty feet in 28 patients with rigid flat foot due to talocalcaneal coalition, who presented to our institution between September 2018 and April 2020, were prospectively analyzed. Randomization was performed by random allocation using a computer-based system into two groups: group A for coalition excision and arthroereisis, group B for coalition excision and osteotomies. Functional and radiological outcomes and complications were recorded and analyzed using Statistical Package for the Social Sciences software.

RESULTS

Thirty feet in 28 patients were included in the final analysis (15 feet in each group). One patient in each group had bilateral affection. The mean age was 14.5 years, and the mean follow-up duration was 24 months. At final follow-up, the mean AOFAS was 78.8 ± 4.04 in group A and 76.73 ± 4.66 in group B, while the FAAM scores were 80 ± 5 and 79 ± 3 in groups A and B, respectively. The complication rate was higher in group A, however with no statistical significance.

CONCLUSION

The combination of talocalcaneal coalition resection with either corrective osteotomies or arthroereisis had a significant improvement of functional and radiological outcomes in the management of rigid pes planovalgus.

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.

Really Asymptomatic? Health-Related Quality of Life and Objective Clinical Foot Characteristics among 5-10-Year-Old Children with a Flexible FlatFoot

The potential effects of asymptomatic flexible flatfoot (FF) on children's health-related quality of life (QoL) and objective clinical foot characteristics have been poorly investigated in the literature. Therefore, this study aimed to analyse these indicators, comparing the children with asymptomatic FF and a control group.

METHODS

In total, 351 children were enrolled in this cross-sectional study-160 children with asymptomatic FF and 191 controls (children with normal feet). The children and their parents completed the Paediatric Quality of Life Inventory (PedsQL^TM 4.0). The objective foot characteristics included clinical foot posture measures, footprints, general hyperlaxity, and X-ray measurements.

RESULTS

Children with asymptomatic FF had a significantly lower QoL (overall and all four dimensions). The parents' assessment of the QoL of their children with asymptomatic FF in most cases was lower compared to their children's self-reported QoL. Moreover, almost all clinical foot measures also had significantly worse profiles among asymptomatic FF cases compared to the controls. This was observed with the Foot Posture Index-6 (FPI-6), the navicular drop (ND) test, the Chippaux-Smirak Index (CSI), Staheli's Index (SI), the Beighton scale, and radiological angles (except the talo-first metatarsal angle).

CONCLUSION

The findings suggest that asymptomatic FF not always reflects a normal foot development. This condition is related to decreased health-related quality of life, so the 5-10-year-old children's and their parents' complaints should be considered more closely in identification, treatment, and monitoring plans.

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.

Quality of life in flexible painful flatfoot treated by anterograde calcaneo-stop procedure: The patient's and family's perspective

PURPOSE

This study aimed to evaluate the quality of life and satisfaction about the surgical treatment in patients with symptomatic flexible flatfoot.

METHODS

The Oxford Ankle Foot Questionnaire for children (one to fill in before the surgical correction and another 6-12 months after the screw's removal), the PedsQLTM Healthcare Satisfaction Generic Module and the PedsQLTM General Well-Being Scale were administered to all patients who underwent the anterograde calcaneo-stop procedure for flexible painful flatfoot between January 2012 and December 2015.

RESULTS

One hundred forty patients were sent the questionnaires and 74 (40 male and 34 female) of them responded. The surgical correction was performed at a medium age of 11,84±1,65 years. When the Oxford Ankle Foot Questionnaire for children scores before surgical correction and after the screw removal were compared, the latter scored significantly higher for all domains. Healthcare satisfaction was good in all families. Most of the patients scored medium-high on the PedQLTM General Well-Being both when asked about themselves (mean 86,50±7,44) and in general about their health (76,06±12,32).

CONCLUSION

Our results confirmed that flexible painful flatfoot is significantly affecting the quality of life of children and that the anterograde calcaneo-stop procedure is a valuable technique, which improves their quality of life and the family wellbeing.

Presurgical Perspective and Postsurgical Evaluation of Non-Achilles Tendons of the Ankle and Retinaculum

The vast majority of non-Achilles ankle tendinopathies are related to overuse. This article discusses the clinical aspect, imaging appearance, and management of tendinopathies of the lateral, medial, and the anterior compartments with a focus on presurgical perspective and postsurgical evaluation.

Subtalar arthroeresis with peek endorthesis in juvanile flexible flafoot: Short-term results

A successful and minimally invasive treatment for adolescent flexible flatfoot is subtalar arthroeresis. This study examines the short-term results of subtalar arthroereisis with a new PEEK device (Pit'Stop®); additional research will be required to determine the device's true potential, but the preliminary findings are very encouraging, with a high success rate and a low complication rate (0.08).

Tarsal coalition resections: a long-term retrospective analysis of 97 resections in 78 patients

Background

Resection of tarsal coalitions provides good patient satisfaction scores, reduced pain, and improved long-term function in both athletic and non-athletic populations. This study aimed to determine when athletic patients undergoing resection of a tarsal coalition were able to return to their desired activity, and whether they experienced a decreased desired activity level (DDA).

Methods

Data on a total of 78 patients who underwent 97 tarsal coalition resections (49 talocalcaneal coalitions, 47 calcaneo-navicular, 14 cuboid-navicular, and three cuneo-navicular; some patients had more than one coalition) operated between January 2001 and June 2020 were prospectively collected. To subjectively assess outcomes, the Roles and Maudsley score (RM) was utilized.

Results

At an average follow-up from the index procedure of 33.6 ± 41.5 months, return to activity for the entire cohort was 18.3 ± 9.6 weeks. Post-RM was 1.3 ± 0.6.

Conclusion

Surgical excision of tarsal coalitions produced favorable results, with most patients able to return to their desired activity level.

Level of evidence

IV.

Medial column reinforcement for the correction of flatfoot deformity with accessory navicular bone

OBJECTIVES

This study aimed to evaluate the clinical effects of reinforcement of the medial column in the treatment of flatfoot deformity with accessory navicular bone.

METHODS

A retrospective analysis of 32 patients (46 feet) of flatfoot deformity with accessory navicular bone were reviewed. All patients underwent the reinforcement of their medial column in the midfoot, mainly including spring ligament repair, posterior tibial tendon reconstruction, and cotton osteotomy. Clinical evaluation adopted American Orthopaedic Foot and Ankle Society (AOFAS) score and pain visual analogue scale (VAS) was used to evaluate foot function and pain. Radiographic evaluation was performed, and Meary's angle, calcaneal pitch angle, talonavicular coverage angle (TCA), talar 2th metatarsal angle (T2MT) and calcaneal valgus angle (CVA) were measured.

RESULTS

All patients were followed up for an average duration of 24.3±3.6 months. At the final follow-up, the patient's foot pain was relieved and the foot deformity was improved. The data indicated that the mean functional AOFAS score was significantly improved and the mean VAS score was significantly decreased postoperatively at final follow-up. Additionally, Meary's angle, TCA, T2MT and CVA were all significantly decreased, and calcaneal pitch angle was significantly increased after surgery.

CONCLUSION

We found that reinforcement of the medial column can effectively maintain medial longitudinal arch, correct flatfoot deformity with accessory navicular bone.

Subtalar arthroereisis in pediatric flexible flat foot: Functional and radiographic results with 5 years of average follow-up

The aim of this retrospective study is to evaluate the clinical-functional and radiographic results in pediatric patients with painful and disabling Flexible Flat Foot (FFF) refractory to conservative treatment who underwent percutaneous subtalar arthroereisis with a Maxwell Brancheau Arthroereisis® (MBA) implant. Patients aged 8-14 years old with a minimum follow-up of 24 months were included. A pre and postoperative radiographic evaluation was carried out analyzing Meary's angle, internal Moreau-Costa-Bartani´s angle, Talar declination angle, Calcaneal Pitch, Kite's angle, Talar-1st metatarsal angle, and Talonavicular coverage angle. In those patients with more than 5 years of follow-up, the development of subtalar osteoarthritis was evaluated. A clinical-functional evaluation was carried out using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating scale. Pre and postoperative pain was evaluated using the visual analog scale (VAS). Postoperative complications were described. Fourteen patients (19 feet) met the inclusion criteria. The mean age at surgery was 12 years old with a mean follow-up of 68.26 months. All radiographic angles improved significantly. No signs of subtalar osteoarthritis were identified. The mean pre and postoperative pain according to VAS was 7.05 and 0.77 respectively. The mean pre and postoperative AOFAS was 75.42 and 97.05 respectively. One female patient had persistent pain in both feet (VAS = 4). However, she was able to do sports and daily life activities without restrictions. None of the implants needed to be removed due to intolerance or pain. Subtalar arthroereisis seems to be effective to improve the clinical-functional and radiographic parameters in moderate pediatric FFF.

Outcomes Following the Use of Subtalar Arthroereisis in the Correction of Adult Acquired Flatfoot: A Systematic Review

BACKGROUND

Adult acquired flatfoot deformity (AAFD) is a condition affecting approximately 3% of the adult population. It can lead to severe morbidity, and therefore, prompt treatment is of the upmost importance in maintaining and restoring function. Recently, the use of subtalar arthroereisis has become more widespread in the treatment of AAFD. The purpose of this systematic review is to examine the clinical and radiological outcomes of AAFD when treated with subtalar arthroereisis.

METHODS

Studies involving the use of subtalar arthroereisis for the management of AAFD were reviewed, and appropriate studies selected based on inclusion and exclusion criteria. Studies were reviewed for both clinical and radiological outcomes following the use of subtalar arthroereisis as well as reported complications.

RESULTS

Nine studies met our inclusion criteria, with most of these involving stage II AAFD. A total of 190 subtalar arthroereisis procedures were performed with all studies demonstrating improvement in both clinical and radiological scores with a low rate of complications.

CONCLUSION

Subtalar arthroereisis may have benefits when used as an adjunct to treat stage II AAFD. However, more high-quality studies are needed to establish its best use.

LEVELS OF EVIDENCE

Level IV: Systematic review.

The Role of Arthroereisis in Improving Sports Performance, Foot Aesthetics and Quality of Life in Children and Adolescents with Flexible Flatfoot

Flexible flatfoot represents one of the most common deformities of the lower limb, affecting children and adolescents. Aesthetic aspect, abnormal gait, pain and fatigue are by far the most important symptoms which determine parents to bring their children to the orthopedist. We set out to conduct a prospective study, case-controlled, including patients with symptomatic flexible flatfeet operated on by arthroereisis surgery and comparing them to a normal feet group of children age- and sex-matched (control group). Minimum follow-up time was 2 years. In total, 33 patients with bilateral arthroereisis were included and 36 patients formed the control group (12.12 +/− 1.85 years vs. 11.81 ± 2.40 years, p = 0.54). Quality of life improved postoperatively (p = 0.18) and was not different from the control group. Median running time improved postoperatively by 2.25 s (p < 0.0001) and got closer to the median running time from the control group (22.30 s compared to 20.94 s, p = 0.01). All radiological angles improved (p < 0.0001), but quality of life improvement was correlated with talonavicular coverage angle and Meary angle measurements. Flatfoot in children and adolescents may be a condition in which the quality of life and sports performance are decreased, compared to healthy children. Arthroereisis is a minimally invasive surgical procedure with a short recovery time and a short period before resumption of sport activities, which can be useful in certain types of flexible flatfoot due to its effectiveness on symptom reduction.

Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult-Acquired Flatfoot Deformity

BACKGROUND

Our aims were (a) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult-acquired flexible flatfoot deformity (AAFD); (b) to assess the STA-related complication rate.

METHODS

A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medializing calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre- and postoperative (minimum 24 weeks) radiographs by 2 observers and repeated twice by 1 observer. Inter- and intraobserver reliabilities were assessed. The association of demographic (gender, side, age, body mass index) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model.

RESULTS

Excellent inter- and intraobserver reliabilities were demonstrated for all measurements (intraclass correlation coefficient range, 0.75-0.99). Gender, side, Cotton osteotomy, and STA were included in the multivariable analysis. Regression showed that STA was the only predictor of change in talonavicular coverage angle (TNCA) (R² = 0.31; P = .03) and in calcaneo-fifth metatarsal angle (CFMA) (R² = 0.40; P = .02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1° and in CFMA by 5°. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them.

CONCLUSION

In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.

LEVELS OF EVIDENCE

Level IV: Retrospective cohort study.

Long-term clinical and radiological outcomes following surgical treatment for symptomatic pediatric flexible flat feet: a systematic review

BACKGROUND AND PURPOSE

Albeit pediatric flexible flat foot (FFF) is a common condition, only a minority of patients become symptomatic. Long-term outcomes of surgically treated pediatric patients with symptomatic FFF are largely unknown. In this systematic review, studies providing outcomes at a mean follow-up of at least 4 years after the procedure in these patients were analyzed.

MATERIAL AND METHODS

A PubMed search was undertaken involving original articles published up to July 2021 on outcome in children aged 6 to 14 with surgically treated FFF and mean (or minimum) follow-up of at least 4 years. Radiographic and clinical outcomes were analyzed.

RESULTS

Of initially 541 entries, 10 could be included in the systematic review (all level IV), involving 846 pediatric patients with 1,536 symptomatic FFF. Pooled mean radiological (n = 8) and clinical follow-up (n = 10) was 5.3 (range 0.5-15) and 7.0 (range 4.1-15) years, respectively. Surgical procedures included arthroereisis (n = 8), lateral column lengthening (n = 1), and Horseman procedure (n = 1). Overall relative frequency of implant-associated complications and wound-healing problems was 3.2% and 1.3%, as well as 2.8% and 1.6% following subtalar arthroereisis only. From preoperative to latest radiological assessment following subtalar arthroereisis (including 3 studies with radiological follow-up < 48 months), pooled median decrease in talonavicular coverage angle (TNCA; -9.2°), anteroposterior talocalcaneal angle (A-TCA; -6.5°), lateral talocalcaneal angle (L-TCA; -3.5°), talar declination angle (TDA; -14°), Moreau Costa Bertani angle (MCB; -13°), and talo-firstmetatarsal angle (L-T1MA; -10°) was observed, as was an increase in calcaneal pitch (4.5°).

INTERPRETATION

In symptomatic pediatric FFF patients, surgery is associated with a manageable complication profile, and results in satisfactory long-term clinical as well as radiological outcome. Yet scientific evidence is low, warranting larger scaled studies in the future.

Patient Outcomes Following Extra-Osseous Talo-Tarsal Stabilization for Foot Hyperpronation

The aim is to present a single-center case series of patients with symptomatic hyperpronated feet treated with arthroereisis by using a second generation extra-osseous talo-tarsal stabilization device. This case series enrolled 123 feet in 87 patients (20 [6-75] years) treated with arthroereisis, either isolated (76 cases) or combined procedure (47 cases). At their final follow-up, a patient reported questionnaire (overall satisfaction, foot stability and shape, activities of daily living, pain level, and analgesics usage) was distributed. The average postoperative follow-up period was 30 (13-55) months. Nineteen (15%) cases required at least one revision surgery: the implant was manipulated in 5 (4%), while 14 cases (11%) required definitive implant removal. The predominant reason for implant removal was pain (50%), followed by implant migration (27%). The pediatric population with isolated procedure showed lowest revision rate (5%), while adults with combined ankle/hindfoot procedures demonstrated revision rate of 50%. The overall patient satisfaction after arthroereisis was 84%. The patients' perceived improvement in foot stability was 75%, foot shape 85%, and activities of daily living 64%. Eighty-two percent of cases reported no analgesics usage in the last month and mean visual analogue scale (0-10) pain level decreased from 5.5 to 2.2 (p < .001). The subgroup analyses of patient-reported questionnaires revealed the best outcome in the pediatric-isolated cases, while adults with combined procedures reported the lowermost outcome. Extra-osseous talo-tarsal stabilization demonstrated a low rate of revisions surgery and a high satisfaction rate as an isolated procedure. Patients with conjoined procedures experienced more revisions and considerably lower satisfaction rates.

Are Pedobarographic and Gait Analyses Useful Tools to Evaluate Outcomes of Anterograde Calcaneo-Stop Procedure in Pediatric Symptomatic Flexible Flatfoot?

Background: Flexible flatfoot is a frequent condition in childhood that needs to be treated when symptomatic. The aim of this study was to analyze pedobarographic and gait outcomes of patients with painful flexible flatfoot who underwent the anterograde calcaneo-stop procedure. Methods: All patients scheduled for surgical correction of painful flexible flatfoot between April and September 2011 were offered to participate in a study of dynamic pedobarographic and gait analyses before surgery and 3, 12, and 24 months after surgery. A healthy control group of similar age and physical characteristics also underwent dynamic pedobarographic and gait analyses. Results: Fifteen patients accepted to undergo dynamic pedobarography and gait analyses. The data were compared with fifteen controls of similar age and BMI. No significant differences were found on dynamic pedobarography within patients at different endpoints, except for a decreased percentage of plantigrade phase and increased percentage of digitigrade phase at 12 months post-op in comparison with 3 months post-op, nor when compared with control. Similarly, when range of motion was taken into consideration, no significant differences were found within patients at different endpoints, nor when compared with control, except for a decrease in ankle joint range of motion 24 months post-op in comparison with the controls. The stride was significantly decreased before surgery and became like controls 24 months after the procedure. The cadence, significantly decreased 24 months after surgery in comparison with the pre-surgical set, was similar to the controls. No significant differences were seen in the walking speed within patients at different endpoints and the controls. The cycle time significantly increased 24 months after surgery when compared to the pre-op situation, and was similar to the controls. Conclusion: Dynamic pedobarographic and gait analyses were useful not only to identify the gait impairment in patients with symptomatic flexible flatfoot, but also to measure the treatment outcome through the analysis of the surgery’s impact on the gait quality.

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.

Trends in hospitalization for paediatric flatfoot: an Italian nationwide study from 2001 to 2016

Background

Flatfoot is a common condition in young patients, but usually resolves by adolescence. This study aimed to estimate annual trend hospitalizations for flatfoot in Italian paediatric population from 2001 to 2016.

Methods

Data of this study were collected from the National Hospital Discharge Reports (SDO) reported at the Italian Ministry of Health regarding the years of this paper (2001–2016). The yearly number of hospital admission for flatfoot, the percentage of males and females, the average age, the average days of hospitalization, primary diagnoses and primary procedures in the whole Italian population were calculated using descriptive statistical analyses.

Results

109,300 hospitalizations for flatfoot of young patients were performed during this period. 59.3% of patients were male and 40.7% female of the 10–14 years-old age class. The average days of hospitalization stay were 1.73 ± 1.27 days. The data highlights that the burden of flatfoot surgery is growing and affecting the healthcare system. The mean rate of hospital admissions in Italy for flatfoot in the young population was 82.14 for 100,000 inhabitants of the same age class.

Conclusions

The data highlights that the cases of flatfoot surgery increased from 2001 to 2016. The most common treatment was the “Internal Fixation Of Bone Without Fracture Reduction, Tarsals And Metatarsals followed by Subtalar Fusion and Arthroereisis. Further prospective studies on this topic may be conducted to improve the evidence of the results.

Trends in hospitalisation of Subtalar Joint Arthroereisis in Italy from 2009 to 2016

BACKGROUND

Subtalar Joint Arthroereisis (SJA) is the most used technique for the treatment of flexible flatfoot. Limited data are reported to trends of hospitalisation for SJA. This study aimed to estimate annual admissions and the geographical distribution of SJA in young Italian patients from 2009 to 2016.

METHODS

Data of this study were collected from the National Hospital Discharge Reports reported at the Italian Ministry of Health. The yearly number of SJA, sex, age and days of hospitalisation were calculated. Public and Private hospitalisations have been analysed individually.

RESULTS

1.6762 hospitalisations for SJA were performed in Italy during the study period, and the incidence increased from 8.22 to 117.08 (cases/100,000 inhabitants). Men represented the majority of young patients treated by SJA. The mean length of stay was 1.55 ± 0.818 days.

CONCLUSIONS

The prevalence of admissions of young patients for SJA increases from 2009 to 2016. The majority of the procedure was performed in public hospitals, but a shorter length of stay was reported in patients treated in private hospitals (p < 0.001). This study highlighted the limits of ICD-9; in fact, difficulties in procedure codification and heterogeneity in diagnosis and procedures performed were reported.

Arthroereisis: Treatment of Pes Planus

Arthroereisis is a surgical procedure primarily used to treat flexible pes planus (flatfoot) in pediatric and young adult patients. The principal goal of subtalar arthroereisis is to relieve pain and restore function. This is primarily done by restoring the medial foot arch without fusing the subtalar joint and without requiring a long recovery period needed after osteotomies. Although the procedure can be performed in isolation to treat flexible flatfoot, it can also be performed as an ancillary in the treatment of tarsal coalition, posterior tibial tendon dysfunction, and accessory navicular syndrome. Various implants and multiple surgical techniques exist for arthroereisis, such as the sinus tarsi implant and calcaneo-stop. The type of device and the surgical approach to proceed with are based on the surgeon’s discretion rather than an evidence-based protocol. Multiple complications can arise from subtalar arthroereisis, most commonly sinus tarsi pain. Currently, there is a dearth of quality clinical data and evidence on the long-term outcomes and complications of arthroereisis. This lack of literature for a commonly performed procedure validates the need for future studies to better guide a standard protocol, reach consensus on well-defined indications and contraindications, provide expected complications, and improve the practice of evidence-based medicine.

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.

Short Term Clinico-Radiological Outcome of Extra Osseous Talo-Tarsal Stabilization (EOTTS) in Flat Foot: An Indian Perspective

INTRODUCTION

Flexible flat foot is one of the most common foot conditions found amongst any age group across the world. One very important reason for this condition is the incongruency or partial dislocation of one or more joints within the talo-tarsal mechanism. This flexible talo-tarsal malalignment is termed as recurrent talo-tarsal joint dislocation (RTTJD).

MATERIALS AND METHODS

Between 2016 and 2018, 32 patients were advised Extra osseous talo-tarsal stabilization (EOTTS) as a standalone procedure for RTTJD following detailed clinical examination including foot posture index (FPI) scoring and weight-bearing radiographic evaluation. Subjective assessment was done through Maryland Foot Score (MFS) questionnaire. Radiological parameters like talar declination angle, talar second metatarsal angle and tibio-calcaneal valgus angle were assessed for preoperative and postoperative comparison. 15 patients (20 feet) underwent surgery and rest 17 patients (25 feet) became our control group. A retrospective record analysis of longitudinal data was done over a period of 4 years. The purpose of this study is to depict the short-term results of EOTTS procedure in terms of functional and radiological improvement and compare it with the non-surgical group.

RESULT

Significant improvement was seen in MFS from 67.31 ± 16.04 to 95.47 ± 4.36 over a mean follow-up period of 30.66 ± 7.09 months. Total FPI improved by 96.83 ± 4.80% at final follow-up of EOTTS group. Radiologically, maximum correction achieved was in coronal plane (93.07 ± 30.05%).

CONCLUSION

EOTTS, as a standalone procedure improved the foot radiological angles and restored the normal foot biomechanics significantly in presence of competent spring ligament and posterior tibial tendon. This procedure resulted in excellent patient satisfaction score as assessed by MFS questionnaire.

LEVEL OF EVIDENCE

III.

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.

Biomechanical comparison among five mid/hindfoot arthrodeses procedures in treating flatfoot using a musculoskeletal multibody driven finite element model

BACKGROUND AND OBJECTIVE

Mid/hindfoot arthrodesis could modify the misalignment of adult-acquired flatfoot and attenuate pain. However, the long-term biomechanical effects of these surgical procedures remain unclear, and the quantitative evidence is scarce. Therefore, we aimed to investigate and quantify the influences of five mid/hindfoot arthrodeses on the internal foot biomechanics during walking stance.

METHODS

A young participant with flexible flatfoot was recruited for this study. We reconstructed a subject-specific musculoskeletal multibody driven-finite element (FE) foot model based on the foot magnetic resonance imaging. The severe flatfoot model was developed from the flexible flatfoot through the attenuation of ligaments and the unloading of the posterior tibial muscle. The five mid/hindfoot arthrodeses simulations (subtalar, talonavicular, calcaneocuboid, double, and triple arthrodeses) and a control condition (no arthrodesis) were performed simultaneously in the detailed foot multibody dynamics model and FE model. Muscle forces calculated by a detailed multi-segment foot model and ground reaction force were used to drive the foot FE model. The internal foot loadings were compared among control and these arthrodeses conditions at the first and second vertical ground reaction force (VGRF) peak and VGRF valley instants.

RESULTS

The results indicated that the navicular heights in double and triple arthrodeses were higher than other surgical procedures, while the subtalar arthrodesis had the smallest values. Five mid/hindfoot arthrodeses reduced the peak plantar fascia stress compared to control. However, double and triple arthrodeses increased the peak medial cuneo-navicular joint contact pressures and peak foot pressures as well as the metatarsal bones stresses.

CONCLUSION

Although mid/hindfoot arthrodesis generally reduced the collapse of medial longitudinal arch and plantar fascia loading during the stance phase, the increased loading in the adjacent unfused joint and metatarsal bones for double and triple arthrodeses should be noted. These findings could account for some symptoms experienced by flatfoot patients after surgery, which may facilitate the optimization of surgical protocols.

Biomechanical assessment of two types and two different locations of subtalar arthroereisis implants for flexible flatfoot: A cadaveric study

BACKGROUND

Subtalar arthroereisis refers to the implantation of a sinus tarsi implant for the treatment of flexible flatfoot. The purpose of this study was to compare the ability to correct the flatfoot deformity and contact pressure of the posterior subtalar joint between two types of self-locking wedge implants and between two different positions for the same device in a cadaveric flatfoot model.

METHODS

The flatfoot model was created in ten cadaver feet through ligament sectioning and cyclic loading. Three kinds of arthroereisis procedures were evaluated: Talar-Fit (type I self-locking wedge implant) anchored in the sinus portion of the tarsal sinus (T-sinus group), Talar-Fit in the canalis portion (T-canalis group), and HyProCure (type II) in the canalis portion (H group). Corrective ability in the sagittal and transverse planes were measured with clinometers. Contact pressure was measured with pressure-sensitive films.

FINDINGS

T-canalis group provided more sagittal (mean difference for size 10 mm: 1.9°, P = 0.014; mean difference for size 11 mm: 3.1°, P = 0.037) and transverse (mean difference for size 8 mm: 1.8°, P = 0.049; mean difference for size 11 mm: 2.2°, P = 0.049) corrections than T-sinus group. The flattening process shifted the peak pressure of the posterior subtalar joint to the posteromedial side (P < 0.05) and arthroereisis helped the distribution of contact pressure restore uniformity (all P > 0.05).

INTERPRETATION

A self-locking wedge implant inserted in the canalis portion of the tarsal sinus achieved better correction than an implant inserted in the sinus portion.

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.

Lateral column osteotomy versus subtalar arthroereisis in the correction of Grade IIB adult acquired flatfoot deformity: A clinical and radiological follow-up at 24 months

BACKGROUND

Adult acquired flat foot deformity (AAFD) is a spectrum of conditions which can be progressive if untreated. Surgical correction and restoration of anatomical relationship are often required in the treatment of symptomatic Grade II AAFD after a failed course of conservative treatment. There is a paucity of literature recommending best practice-especially in the adult population. The authors aim to compare radiological and clinical outcomes of two widely employed surgical techniques in the treatment of symptomatic AAFD.

METHODS

A retrospective study of 76 patients with Grade IIB AAFD and had undergone either lateral column lengthening (LCL) or subtalar arthroereisis (STA) surgical correction of their symptomatic AAFD. Each technique was augmented with both bony osteotomy and soft tissue transfer as determined by on table assessment. Clinical and radiological outcomes were reviewed 24 months after surgery.

RESULTS

LCL and STA groups had comparable radiological outcomes at 24 months after surgery. However, LCL group demonstrated superior American Orthopaedic Foot and Ankle Society (AOFAS) midfoot (90.3 ± 12.6 vs 81.1 ± 20.6, p < 0.001) as well as Visual Analogue Scale (VAS) midfoot scores (0.5 ± 1.6 vs 1.3 ± 2.4, p < 0.001) at 24 months compared to the STA group. STA had a higher complication rate (20.6% vs 4.4%), with all cases complaining of sinus tarsi pain requiring subsequent removal of implant.

CONCLUSION

There is a role for either techniques in the treatment of symptomatic AAFD. LCL whilst more invasive has demonstrated superior outcome scores and lower complication rates at 24 months compared to STA. Patients need to be counselled appropriately to appreciate the benefits of each technique.

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 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.

Surgical Treatment of Severe Idiopathic Flexible Flatfoot by Evans-Mosca Technique in Adolescent Patients: A Long-Term Follow-Up Study

Flexible idiopathic flatfoot is very common in growing age and rarely causes pain or disability. Surgery is indicated only in severe symptomatic cases that are resistant to conservative treatment, and numerous surgical procedures have been proposed. Lateral column calcaneal lengthening as described by Evans and modified by Mosca is a widely used surgical technique for the correction of severe symptomatic flexible flatfoot. In the present study, we report the long-term clinical and radiographic results in 14 adolescent patients (mean age: 12.8 years) affected by severe symptomatic flexible flatfoot, surgically treated by Evans–Mosca procedure, for a total of 26 treated feet (12 cases bilateral and 2 unilateral). In all cases, surgery was indicated for the presence of significant symptoms resistant to nonsurgical management. Clinical evaluation was made according to the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, the Foot and Ankle Disability Index (FADI) Score, and Yoo et al.'s criteria. Radiographic evaluation was made using anteroposterior and lateral weight-bearing radiographs of the feet to evaluate Meary's angle and Costa–Bertani's angle and to evaluate possible osteoarthritic changes in the midtarsal joints. At follow-up (mean: 7 years and 7 months), we observed a satisfactory result in all patients. The mean average score of the AOFAS Ankle-Hindfoot Scale improved from 60.03 points to 95.26; the mean FADI score improved from 71.41 to 97.44; and according to Yoo et al.'s criteria, the average clinical outcome score was 10.96. At radiographic examination, nonunion of the calcaneal osteotomy was never observed. Meary's angle improved from an average preoperative value of 25° to 1.38° at follow-up; Costa–Bertani's angle improved from an average preoperative value of 154.2° to 130.9° at follow-up. In no case, significant radiographic signs of midtarsal joint arthritis were observed. According to our results, we believe that Evans–Mosca technique is a valid option of surgical treatment for severe idiopathic flexible flatfoot and allows a satisfactory correction of the deformity with a low rate of complications.

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.

Treatment for Flexible Flatfoot in Children With Subtalar Arthroereisis and Soft Tissue Procedures

Background: Children with flexible flatfoot is common in clinics and there is no unified conclusion on surgical treatment. And for some patients with severe deformities, the correction of the subtalar joint arthroereisis combine the release of the Achilles tendon or gastrocnemius muscle release is still not satisfactory. The main aim of the present study was to investigate the therapeutic outcomes of subtalar arthroereisis combined with Achilles tendon or gastrocnemius recession and medial soft tissue (spring ligament, talonavicular joint capsule, tibionavicular ligaments and tibiospring ligaments) tightening for treating flexible flatfoot with severe deformities. Methods: Thirty patients (32 feet) with pediatric flexible flatfoot who underwent subtalar arthroereisis and soft tissue procedures during January 2016 to January 2018. There were 18 males (20 feet) and 12 females (12 feet) with an average age of 9.5 years (range, 8-12 years). We used the AOFAS scores and VAS scores combined with angles measure to evaluate the pre-operative and post-operative status. Results: Thirty patients (32 feet) were followed up for 25.3 months on average (range, 18-36 months). There was no infection. Post-operative foot pain, arch collapse, and other symptoms improved. At last follow-up, the Meary angle was decreased from 17.5° ± 4.4° to 4.1° ± 1.2° (P < 0.05), the talar-first metatarsal (AP) was decreased from 15.3° ± 3.1° to 4.8° ± 1.3°(P < 0.05), The mean AOFAS score was rose from 66.6 ± 5.8 to 88.6 ± 7.9 (P < 0.05), the mean VAS score was decreased from 6.6 ± 0.6 to 1.7 ± 0.3 (P < 0.05). Conclusion: The subtalar arthroereisis combined with soft tissue procedures can effectively correct flexible flatfoot in children and it is a significant method for severe forefoot abduction reconstruction. Level of Evidence: IV.

Role of Minimally Invasive Surgery in Adult Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) as a consequence of posterior tibial tendon dysfunction is commonly divided in flexible (stages I and II) and fixed (stages III and IV) deformities. The aim of this article is to summarize the evidence available for minimally invasive surgical techniques that can be used in the treatment of flexible AAFD, including tibialis posterior tendoscopy, subtalar arthroereisis, minimally invasive calcaneal osteotomy, and medial proximal gastrocnemius recession. A treatment algorithm and technical tips have also been provided.

Flatfoot and associated factors among Ethiopian school children aged 11 to 15 years: A school-based study

BACKGROUND

The Foot health of a child plays a pivotal role in their participation in play, locomotive activities, healthy lifestyle, somatic development, and weight management. The burden of flatfoot among children in Ethiopia is not known. The objective of this study was to analyze the structure of the medial foot arch using Staheli plantar arch index and investigate its associated factors among larger sample school children, aged 11-15 years in Ethiopia.

METHODS

A school-based cross-sectional study was conducted among children aged 11-15 years from eleven randomly selected primary schools. The sample size was determined proportionally across school strength and governmental and private schools to ensure variety within the sample. Data collection consisted of physical measurements, footprint-based measures whilst full weight-bearing, and a structured questionnaire on foot pain, footwear type, and physical activity. Data were analyzed descriptively and through uni- and multivariate logistic regression model.

RESULTS

A total of 823 children participated. The overall prevalence of flatfoot was 17.6% with a significant difference between age, gender, type of school, BMI, and type of footwear. Being younger (OR 3.3, 95% CI 1.6-6.7), male (OR 1.6, 95% CI 1.0-2.4), experiencing foot pain (OR 1.9, 95% CI 1.0-3.5), wearing closed shoe (OR 4.4, 95% CI 1.6-11.9), overweight (OR 3.8, 95% CI 1.2-8.7), obese (OR 4.2, 95% CI 2.5-10.9), and low level of physical activity (OR 2.1, 95% CI 1.0-4.6) were significantly associated with flatfoot. Children who were overweight, obese, and also experiencing foot pain have a 2.8 (95% CI 1.62-5.94) and 4.1 (95% CI 2.85-8.31) times greater chance of having flatfoot respectively. The prevalence of flatfoot among 560 normal weight children was 17.5%.

CONCLUSIONS

The findings of this study demonstrated that the overall prevalence and the prevalence of flatfoot among normal-weight children are almost the same. There is a definite need to develop a screening algorithm for diagnosis and treatment indication for this children's lower extremity disorder.

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.

Comparative Study of Spring Ligament Reconstructions Using Either Hamstring Allograft or Synthetic Ligament Augmentation

BACKGROUND

Idiopathic flatfeet are usually caused by attenuation of the medial soft tissues rather than a lateral osseous deficiency. Debate continues on whether spring ligament attenuation or posterior tibial tendon (PTT) dysfunction is the initial driver for the deformity. Our comparative prospective study aimed to quantify the radiological and clinical outcomes of 2 techniques for spring ligament reconstruction using a hamstring graft or a synthetic ligament.

METHODS

Seventeen spring ligament reconstructions (SLRs) were performed in 17 patients using synthetic ligament augmentation and 16 SLRs were performed using hamstring allograft in 13 patients. Additional procedures such as gastrocnemius recession, PTT advancement, flexor digitorum longus transfer, and calcaneal osteotomy were performed as required. A minimum of 12 months of follow-up was available for all cases. Radiographic analysis was performed with standardized parameters.

RESULTS

Following SLR with synthetic ligament augmentation, all radiological parameters significantly improved (P < .05). Hamstring allograft SLR also demonstrated significantly improved radiographic parameters in all but Meary's line at final follow-up. At 12 months, patient outcome scores were significantly better in the synthetic ligament group.

CONCLUSION

Reconstruction of the spring ligament using either hamstring allograft or synthetic ligament augmentation provided significant improvements in radiological alignment; however, superior patient-reported outcomes were found in the synthetic ligament augmentation group.

LEVELS OF EVIDENCE

Level III, retrospective cohort study.

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.

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.

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.

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.

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.

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.