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

Effects of Preoperative Abnormality of Posterior Tibial Tendon on the Surgical Outcomes of Medial Osteochondral Lesion of the Talus

BACKGROUND

Although surgical treatment for osteochondral lesion of the talus (OLT) can obtain good clinical outcomes, the rate of return to sports is variable. It is reported that medial OLT unrelated to trauma has abnormal structures in the medial aspect, which may induce the medial OLT due to the medial instability. The posterior tibial tendon (PTT) plays an important role in the stabilization of the foot, and high mechanical stress may be added to the PTT to compensate for medial instability in medial OLT. We investigated whether abnormal PTT findings on preoperative magnetic resonance imaging (MRI) in patients with OLT affect clinical outcomes after surgery.  Methods: Eighty-one ankles in 74 patients who were treated surgically for OLT were included in this study (41 men and 33 women; mean age, 26.0 years). Abnormalities of the PTT were evaluated using preoperative MRI. The Japanese Society for Surgery of the Foot (JSSF) scale, arch height, and ankle activity score (AAS) on standing plain radiogram were compared between patients with and those without preoperative PTT abnormalities.

RESULTS

Twenty-five ankles (30.9%) had PTT abnormalities on preoperative MRI. All patients with preoperative PTT abnormalities were medial OLT. There were no significant differences in the preoperative JSSF scale in the procedures for OLT. The postoperative JSSF scale and arch height were significantly lower in patients with preoperative PTT abnormalities than those without them. AAS in patients with preoperative abnormalities significantly decreased at the final follow-up.  Conclusion: PTT abnormalities on preoperative MRI may affect clinical outcomes even in preoperative asymptomatic patients in the medial OLT unrelated to trauma.

Foot Posture Index Does Not Correlate with Dynamic Foot Assessment Performed via Baropodometric Examination: A Cross-Sectional Study

BACKGROUND

Clinicians employ foot morphology assessment to evaluate the functionality of the method and anticipate possible injuries. This study aims to correlate static foot posture and the dynamic barefoot evaluation in a sample of healthy adult participants.

METHODS

The foot posture was evaluated using the Foot Posture Index-6 (FPI-6) and the dynamics were evaluated through baropodometric examination. Two operators independently assessed the participants' foot posture through FPI-6, and then a dynamic evaluation was performed by asking them to walk 8 times across a platform. One hundred participants (mean age: 32.15 ± 7.49) were enrolled.

RESULTS

The inter-rater agreement between the two assessors was found to be excellent. The majority of the feet belonged to the 0 < FPI < 4 class (32%), followed by the 4 < FPI < 8 (31%) and the FPI > 8 ranges (19.5%). Our "area of contact" analysis showed a significant poor correlation between FPI and total foot, midfoot, and the second metatarsophalangeal joint (MTPJ) (-0.3 < r < 0). Regarding "force" parameters, the analysis showed a poor correlation between the midfoot, hallux, and the second toe (-0.2 < r < 2); finally the "pressure" analysis showed a poor correlation between FPI, the fourth MTPJ, and the second toe (-0.2 < rs < 0.3) and a moderate correlation between the hallux (r = 0.374) and the fifth MTPJ (r = 0.427).

CONCLUSIONS

This study emphasizes the constrained correlation between static foot posture observation and dynamic barefoot examination.

Comparison of 2 Conservative Treatment Approaches for the Flat Foot in Children Aged 5 to 10: Foot Orthoses Versus Foot Orthoses Supplemented With Zukunft-Huber Manual Therapy

The aim was to find if foot orthotics alone can improve flat feet in children and analyze how the addition of Zukunft-Huber manual therapy and corrective bandaging changes the outcome. Forty-nine children aged 5 to 10 with asymptomatic flexible flat feet were divided into 2 groups. The first was treated with foot orthoses alone, in the second wearing foot orthoses was supplemented with Zukunft-Huber manual therapy and corrective bandaging. Pedobarography during gait was performed before the therapy and after a year. In the first group decrease in arch index, width, force, and area of midfoot, increase in force MH2 and area hindfoot was found, in the second decrease in arch index, width, force, and area of midfoot, increase in force under metatarsal head second, third, fourth, and fifth, area metatarsal head fourth and area hindfoot. Both methods showed positive changes, but foot orthoses with additional intervention were more effective.

Magnitude of flat foot and its associated factors among school-aged children in Southern Ethiopia: an institution-based cross-sectional study

BACKGROUND

Flat foot, also known as pes planus, is a common condition among primary school children and is a leading cause of all clinical visits related to foot problems worldwide. It can cause skeletal problems and joint misalignment. This study aimed to assess the magnitude of flat foot and its associated factors among public primary school children.

METHODS

An institutional-based cross-sectional study was conducted on 1072 school children aged 11 to 18 years. A structured questionnaire was used for data collection and the footprints were used to calculate the plantar arch index. Data were entered into Epi data version 4.6, and analyzed by STATA version 15. Bivariable and multivariable binary logistic regressions were conducted. Adjusted odds ratios (AORs) with corresponding 95% confidence intervals (CIs) were calculated. Statistical significance was declared at a P-value < 0.05.

RESULT

Out of 1022 participants, 105(10.27%) 95%CI: 8.5-12) had a flat foot. Being male (AOR = 2; 95%CI:1.22-3.30), living in highland altitude (AOR = 8.83; 95% CI: 4.64-16.79), living in midland altitude (AOR = 3.32;95% CI:1.75-6.29), living in an urban area (AOR = 2.42;95% CI:1.15-5.09), insufficient physical activity (AOR = 8.78;95% CI: 4.42-12.3), wearing closed-toe shoes (AOR = 2.33;95%CI:1.27-4.28), obesity (AOR = 6.30;95% CI:3.31-11.9), and foot pain (AOR = 3.52;95%CI:2.08-6.27) had a higher likelihood of flat foot as compared to their counterparts.

CONCLUSION

One in every ten children had a flat foot. Altitude, residence, sex, physical activity, foot pain, body mass index, and type of footwear were found to be factors statistically associated with flat foot. Integrated interventions for children to have sufficient physical activity, wearing sandals, maintaining a healthy body mass index, and flatfoot screening and monitoring are recommended.

Effect of flatfoot correction on the ankle joint following lateral column lengthening: A radiographic evaluation

OBJECTIVES

The effects of foot deformities and corrections on the ankle joint without osteoarthritis has received little attention. This study aimed to investigate the effect of flatfoot correction on the ankle joint of patients without osteoarthritis.

METHODS

Thirty-five patients (24 men and 11 women; mean age 17.5 years) who underwent lateral column lengthening for flatfoot deformities were included. The mean postoperative follow-up period was 20.5 months (standard deviation [SD]: 15.7 months). Radiographic indices were measured pre- and postoperatively, including anteroposterior (AP) and lateral talo-first metatarsal angles, naviculocuboid overlap, position of the articulating talar surface, and lateral talar center migration. Postoperative changes in the radiographic indices were statistically analyzed.

RESULTS

There was significant postoperative improvement in flatfoot deformity in terms of AP and lateral talo-first metatarsal angles (p<0.001 and p<0.001, respectively) and naviculocuboid overlap (p<0.001). On lateral radiographs, the talar articulating surface dorsiflexed by 7.3% (p<0.001), and the center of the talar body shifted anteriorly by 0.85 mm (p<0.001) postoperatively.

CONCLUSIONS

Flatfoot correction using lateral column and Achilles tendon lengthening caused dorsiflexion and an anterior shift of the articular talar body in patients without osteoarthritis. Correction of flatfoot deformity might affect the articular contact area at the ankle joint. The biomechanical effects of this change need to be investigated further.

The effect of biological maturation on foot morphology, and their relation to postural stability performance in male footballers

BACKGROUND

Biological maturity (BM) and foot morphology (FM) can independently alter neuromuscular loading on the ankle-foot complex, potentially causing stability deficits and injury predisposition. However, the influence of BM on FM, and how much both explain neuromuscular performance in postural stability (PS) tests, has been understudied. This study aimed to investigate the effect of BM on FM, and then discover to what extent both factors explain the variance in PS performance in adolescent footballers.

METHODS

Over one season, 399 three-dimensional foot scans were gathered from 72 footballers (U12-U15). PS was measured by center of pressure (COP) displacement in bilateral and unilateral stance. The Khamis and Roche equation determined maturity status (MS), while formulae from Mirwald and Khamis and Roche estimated timing of biological maturation (TBM). Principal component analysis determined nine principal components that explained the most variance in FM. An ANCOVA determined the effect of TBM on FM principal components, with covariates of age, height, weight, playing position, and foot preference. Step-wise linear regression determined the explanation of COP displacement by the above-mentioned predictors.

RESULTS

There was significantly increased foot pronation during and after peak height velocity/puberty. MS and four foot principal components (foot arch and width, great toe width and length) were significant predictors in all PS tests (R2: 0.105-0.180).

CONCLUSIONS

TBM had a significant effect on FM presentation, and should be a part of adolescent foot assessment. While they only explained a small amount of variance, determining MS and FM may identify those requiring additional PS attention.

Anatomical Features of the Tarsal Sinus in Patients with Pes Planus: Implications for Clinical Management

BACKGROUND In the treatment of pes planus, if the implant does not match the anatomical structures of the sinus tarsi, synovitis can develop, causing pain symptoms. In the interest of making clinical recommendations for extra-osseous talotarsal stabilization, the goal of the present study was to characterize the anatomical characteristics of the sinus tarsi in patients with pes planus using magnetic resonance imaging (MRI) scans. MATERIAL AND METHODS This was a retrospective study involving 56 pes planus patients and 56 healthy volunteers from January 2014 to May 2022. The sinus tarsi was measured for length and width, for angle with the coronal and sagittal axes, and for length of the subtalar implant. RESULTS All examined metrics showed a difference between pes planus patients and healthy participants, with the exception of the subtalar implant's length. The average sinus tarsi length and width among pes planus patients were 19.23 mm and 2.91 mm, respectively. The angle between the sinus tarsi and the coronal and sagittal axes was 21.418° and 25.077°, while the length of approach was 33.06 mm and 0.76°. The only gender differences that were statistically significant were in the length and width of the sinus tarsi. There were no notable variations between the left and right sides. CONCLUSIONS Sinus tarsi morphology may be impacted by pes planus. When treating patients with pes planus, clinicians should take these anatomical factors into consideration since they might more completely characterize the anatomical features of the sinus tarsi.

Efficacy of Personalized Foot Orthoses in Children with Flexible Flat Foot: Protocol for a Randomized Controlled Trial

Pediatric flat foot (PFF) is a very frequent entity and a common concern for parents and health professionals. There is no established definition, diagnostic method, or clear treatment approach. There are multiple conservative and surgical treatments, the implantation of foot orthoses (FO) being the most used treatment. The evidence supporting FO is very thin. It is not clearly known what the effect of these is, nor when it is convenient to recommend them. The main objective of this protocol is to design a randomized controlled trial to determine if personalized FO, together with a specific exercise regimen, produce the same or better results regarding the signs and symptoms of PFF, compared to only specific exercises. In order to respond to the stated objectives, we have proposed a randomized controlled clinical trial, in which we intend to evaluate the efficacy of FO together with strengthening exercises, compared to a control group in which placebos will be implanted as FO treatment along with the same exercises as the experimental group. For this, four measurements will be taken throughout 18 months (pre-treatment, two during treatment and finally another post-treatment measurement). The combination of FO plus exercise is expected to improve the signs and symptoms (if present) of PFF compared to exercise alone and the placebo FO group. In addition, it is expected that in both conditions the biomechanics of the foot will improve compared to the initial measurements.

Pediatric Flatfoot: Is There a Need for Surgical Referral?

Pediatric foot deformities are a common finding, concerning up to 44% of preschool aged children. The absence of accepted international guidelines, as well as heterogeneity in definitions and measurements, makes management of pediatric flatfoot a challenge, and decisions surrounding specialized care referral confusing and biased. The objective of this narrative review is to provide guidance to primary care physicians treating these patients. A non-systematic review of the literature regarding the development, etiology, and clinical and radiographic assessment of flatfeet using the PubMed and Cochrane Library databases was performed. The exclusion criteria for the review were adult populations, papers detailing the outcome of a specific surgical procedure, and publications prior to 2001. The included articles showed great heterogeneity in definition and proposed management, which makes the study of pediatric flatfoot challenging. Flatfoot is a common finding in children under 10 years old, and should not be considered pathological unless stiffness or functional limitation are present. Surgical referral should be reserved to children with stiff or painful flatfoot, while simple observation is indicated for flexible, asymptomatic flatfeet.

Efficacy of Plantar Orthoses in Paediatric Flexible Flatfoot: A Five-Year Systematic Review

Paediatric flexible flatfoot (PFF) is a very common condition and a common concern among parents and various healthcare professionals. There is a multitude of conservative and surgical treatments, with foot orthoses (FO) being the first line of treatment due to their lack of contraindications and because the active participation of the child is not required, although the evidence supporting them is weak. It is not clear what the effect of FO is, nor when it is advisable to recommend them. PFF, if left untreated or uncorrected, could eventually cause problems in the foot itself or adjacent structures. It was necessary to update the existing information on the efficacy of FO as a conservative treatment for the reduction in signs and symptoms in patients with PFF, to know the best type of FO and the minimum time of use and to identify the diagnostic techniques most commonly used for PFF and the definition of PFF. A systematic review was carried out in the databases PubMed, EBSCO, Web of Science, Cochrane, SCOPUS and PEDro using the following strategy: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) on child patients with PFF, compared to those treated with FO or not being treated, assessing the improvement of signs and symptoms of PFF. Studies in which subjects had neurological or systemic disease or had undergone surgery were excluded. Two of the authors independently assessed study quality. PRISMA guidelines were followed, and the systematic review was registered in PROSPERO: CRD42021240163. Of the 237 initial studies considered, 7 RCTs and CCTs published between 2017 and 2022 met the inclusion criteria, representing 679 participants with PFF aged 3-14 years. The interventions of the included studies differed in diagnostic criteria, types of FO and duration of treatment, among others. All articles conclude that FO are beneficial, although the results must be taken with caution due to the risk of bias of the included articles. There is evidence for the efficacy of FO as a treatment for PFF signs and symptoms. There is no treatment algorithm. There is no clear definition for PFF. There is no ideal type of FO, although all have in common the incorporation of a large internal longitudinal arch.

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet

Introduction

Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.

Methods

This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.

Results

The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.

Conclusion

Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.

Level of evidence: IV, Case series.

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Flatfoot is a frequent reason for consultation in pediatric orthopedics.

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Orthopedic management was recommended up to 9 years old.

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Knowing how to choose the feet to be operated on is important.

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Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.

Pediatric Flat Feet: A 2020 Guide for Clinicians to Identify the Boomerangs

The pediatric flatfoot has long occupied a place in the medical literature, with concerns about the significance of its appearance. At the end of the first decade of the 21st century, an article in this journal provoked active debate about the pediatric flatfoot as part of development, and proposed a considered titration of presenting cases in an effort to justify treatment and appreciated the range and expected change in normal foot posture with growth. A decade later, the availability of normative pediatric foot posture data, and the prospective findings to confirm lessening flat feet with age, encourage a structured and considered approach to this frequent primary care presentation. The pragmatic concept of the "boomerang" is built on the research identifying pediatric flat feet likely to be symptomatic, thus requiring intervention, and filtering from those likely to remain asymptomatic. Differential diagnoses are advisedly considered, and gait remains the hallmark outcome. In this contemporary guide, an eight-step strategy has been developed to improve the approach to community pediatric flatfoot concerns. Furthermore, the three boomerang flat feet factors delineating symptomatic from asymptomatic flat feet, and applicable cutoff levels, are availed for practical reference and use. Given the recognized state of overdiagnosis and resulting unnecessary treatment that pervades the 21st century, it is timely for clear 20/20 vision for the presentation of pediatric flatfoot.

The effects of pediatric flat foot on the frontal alignment of proximal segment

The purpose of this study was to determine the effects of flat foot on the frontal alignment of calcaneus and tibia in 23 children with flat feet, aged 7-9 (7.43±0.58 years old). To evaluate the foot, the Foot Posture Index-6 (FPI 6) was used, while the posture of the calcaneus and the tibia was analyzed using the Global Postural System 400. The statistical results indicate strong intensity links between flat foot and the frontal alignment of the calcaneus and the tibia, as follows: FPI 6 right foot score and calcaneus - right foot angle (r= 0.824; p < 0.001), tibia - right foot angle (r= 0.588; p < 0.001); FPI 6 left foot score and calcaneus - left foot angle (r= 0.824; p < 0.001), tibia - left foot angle (r= 0.853; p < 0.001). Our study demonstrates that pediatric flat foot has the capacity to significantly influence the values of the angle of the calcaneus and tibia in a frontal plane. Keywords: pediatric flat foot, Foot Posture Index-6,proximal segments

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.

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.

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.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.