Adolescent Flatfoot Research Articles

Coalition Excision and Corrective Osteotomies versus Coalition Excision and Arthroereisis in the Management of Pes Planovalgus with Talocalcaneal Coalition in Adolescents: A Randomized Controlled Trial

Abstract Level of evidence: ΙΙ Background Talocalcaneal coalition is the most common cause of rigid flat foot in adolescents. It presents with recurrent ankle sprains, ankle pain, and foot deformity. Management is still controversial. Multiple options were utilized during the last 40 years, including arthroerisis; however, the role of arthroerisis in the management of rigid pes planovalgus remains 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 November 2020 were prospectively analyzed. Randomization was performed by random allocation using a computer- based system into two groups: group A for arthroereisis and coalition excision and group B for osteotomies and coalition excision. Functional and radiological outcomes and complications were recorded and analyzed using Statistical Package for Social Sciences software. Results Thirty feet in 28 patients were included in the final analysis (group A, 15 feet; group B, 15 feet). The mean age and follow-up duration of the participants were 14.5 years and 24 months, respectively. The mean AOFAS and foot and ankle ability measurement scores were 78.8±4.04 and 76.73±4.66 and 80±5 and 79±3 for groups A and B, respectively. The complication rate was higher in group A; however, this difference did not reach statistical significance. No difference was found regarding functional outcomes. Conclusion We believe that the combination of talocalcaneal coalition resection with either corrective osteotomies or arthroerisis resulted in a significant improvement of functional and radiological outcomes with no difference between both in the management of rigid pes planovalgus.

Is a keystone Bone Anomaly the Main Cause of Flatfoot (Pes Planus)?

Flatfoot (pes planus) is a decrease or loss of longitudinal medial arch height. The cause of symptomatic flatfoot occurring in adolescents is still unclear. In this study, the relationship between adolescent pes planus and foot bone shape was investigated. For this purpose, the volume and superficial area data of the foot bones of adolescent individuals with flatfoot deformity and individuals without any foot deformity were compared. Between September 2022 and June 2023, 30 individuals with adolescent pes planus with a medial arch angle greater than 145 degrees and 30 individuals without any foot deformity were included in the study. Computed tomography (CT) images of the participants' feet were obtained with a General Electric brand IQ model 32 detector CT device with a section thickness of 0.625mm in accordance with the bone protocol. Using the 3D Slicer program on CT images, foot bones were segmented and the volume and surface area ratios of each foot bone were determined. Cuneiforme mediale and cuneiforme intermediale volume ratios in individuals with flatfoot deformity decreased by 14% and 24%, respectively, compared with the control group ( P <0.05). Cuneiforme mediale and cuneiforme intermediale superficial area ratios were found to be 10% and 30% lower in the flatfoot group compared with the control group, respectively ( P <0.05). There was no difference in the volume and superficial area ratios of other foot bones between the groups ( P >0.05). The study results suggest that symptomatic adolescent flatfoot deformity may be associated with developmental anomalies of the os cuneiforme mediale and os cuneiforme intermedium.

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

BackgroundTalocalcaneal 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 methodsThirty 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. ResultsThirty 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. ConclusionThe 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.

Pediatric and Adolescent Flatfoot: A Questionnaire Based Middle East and North Africa Study.

Flatfoot is commonly seen in the community and is a common cause of concern for parents because it could become symptomatic and lead to decreased quality of life. One of the most used management approaches is foot orthoses, although no clear evidence supports their use. We aimed to study flatfoot symptoms' prevalence, effect on activities of daily living, and the use and effectiveness of orthoses. This was a cross-sectional study that included five countries from the Middle East and North Africa region (Jordan, Palestine, Syria, Egypt, and Iraq). Data were collected using an online questionnaire directed toward parents of children aged 0 to 16 from September to December 2020. The demographic factors were expressed as frequencies (percentages) using standard descriptive statistical parameters, and Pearson's chi-square test was used to examine the relationship between study factors. 1256 participants were recruited using this online survey. The majority (29.6%) of children were diagnosed in the age group of 0 to 2. The abnormal appearance of the foot was the most common (78.7%) complaint. Overall, 54.2% of patients were prescribed orthoses, of which 36.8% noticed improvement in flatness and 37.6% reported relief of symptoms. This study demonstrated that most participants have no or minimal symptoms and that there is a mismatch between participants' expectations and the actual effectiveness of orthoses. Taking into consideration that there is no clear evidence to support the corrective effect of orthoses, we recommend that physicians prescribing them adhere more to their proper indications and spend more time and effort counseling and addressing patients' and parents' concerns about this developmental stage.

Correlation between flat foot and patellar instability in adolescents and analysis of related risk factors.

Flatfoot and patellar instability are both developmental limb deformities that occur frequently in adolescents. A high number of patients with both diseases can be seen in clinic, and there are no studies showing a correlation between the two. The goal of this study is to investigate the association between developmental patellar instability and flat feet in adolescents and its associated risk factors. This experiment uses a cross-sectional study to select 74 adolescent patients with flat foot from a randomly selected middle school in this city since December 2021 and obtain relevant data. SPSS26.0 statistical software was used for data analysis. Quantitative data were expressed as mean ± standard deviation, and Pearson correlation coefficient was used for analysis. p < 0.05 indicates a statistically significant difference. A total of 74 people (40 men and 34 women) were included in this study. The correlation coefficients between Meary angle, Pitch angle, calcaneal valgus angle, CSI, BMI, and Beighton scores and knee joint Q angle are 0.358 (p < 0.01), -0.312 (p < 0.01), 0.403 (p < 0.01), 0.596 (p < 0.01), 0.427 (p < 0.01), and 0.293 (p < 0.05), respectively, indicating that flat foot, overweight, and Beighton scores are all correlated with Q angle. The correlation coefficients between Meary angle, Pitch angle, calcaneal valgus angle, CSI, and BMI were 0.431 (p < 0.01), -0.399 (p < 0.01), 0.319 (p < 0.01), and 0.563 (p < 0.01), respectively, indicating a correlation between flat foot and BMI. The correlation coefficients between Meary's angle, Pitch's angle, calcaneal valgus angle, CSI, and Beighton's score were 0.207 (p > 0.05), -0.240 (p < 0.05), 0.204 (p > 0.05), and 0.413 (p < 0.01), respectively, indicating a correlation between flat foot and Beighton's score. We believe that there is a significant correlation between adolescent flatfoot and patellar instability. Excessive weight and ligamental laxity during adolescent development are among the risk factors for flatfoot and patellar instability.

Lateral column lengthening osteotomy in idiopathic adolescent flatfoot A systematic review

Lateral column lengthening osteotomy in idiopathic adolescent flatfoot A systematic review

Comparing Validity and Diagnostic Accuracy of Clarke's Angle and Foot Posture Index-6 to Determine Flexible Flatfoot in Adolescents: A Cross-Sectional Investigation.

ObjectiveClinically, the foot posture index-6 (FPI-6) and Clarke’s angle (CA) are widely utilized to assess static foot posture; however, due to scarcity of scientific evidence, clinicians continue to debate the validity and diagnostic accuracy of these measures in children and adolescents. This study aimed to evaluate and compare the validity and diagnostic accuracy of the FPI-6 and CA in determining adolescents’ flexible flatfoot between ages of 12 and 18 years, considering radiographic investigation as a reference standard measure.DesignCross-sectional study.SettingGovernmental hospitals.Participants and MethodsA sample of 460 people (920 feet) with flexible flatfoot between the ages of 12 and 18 (15.23 ± 0.84 years) was enrolled in the study. The findings of the investigated measures were compared to the reference standard radiographic measure and plotted on the receiver operating characteristic (ROC) curve. The area under the ROC curve (AUC) was determined as a measure of FPI-6 and CA diagnostic accuracy. Intra-rater reliability, sensitivity, specificity, predictive values, and likelihood ratios of FPI-6 and CA were calculated and compared. The post-test probability of flatfoot was determined using the Fagan nomogram.ResultsCA had a substantially higher intra-rater reliability (ICC=0.99) than the FPI-6 (ICC=0.96), with p-value of 0.001. CA has greater sensitivity (98%) than FPI-6, as well as a superior specificity (99%), positive predictive value (98%), negative predictive value (98.9%), positive likelihood ratio (97), and a lower negative likelihood ratio (0.02). CA had such an area under ROC curve of 0.98 with a 95% confidence interval of 0.95–1.00, while FPI-6 had an area under ROC curve of 0.80 with a 95% confidence interval of (0.77–0.85).ConclusionFPI-6 and Clarke’s angle are both valid and diagnostically accurate clinical tests for flatfoot detection, with Clarke’s angle outperforming FPI-6 in adolescents aged 12 to 18 years with a normal BMI.

Preliminary Outcomes of Calcaneal Lengthening in Adolescent Flatfoot in Müller-Weiss Disease.

Müller-Weiss disease (MWD) remains a controversial painful foot condition without consensus on its pathogenesis or a gold standard treatment modality. The aim of the study was to evaluate the outcomes of calcaneal lengthening in adolescent patients with symptomatic MWD with flatfoot. The study included 13 feet of 7 patients including 5 females and 2 males who were treated from March 2012 until June 2015 by calcaneal lengthening. The mean age was 15.6 years. The mean duration of symptoms was 13.5 months. The body mass index (BMI) averaged 28.9 kg/m2 at presentation. The patients were followed up for a mean of 37.8 months. The osteotomy healed in all cases after a mean of 7.2 weeks. The second foot was operated on after an average of 11.5 months. The mean talometatarsal-1 angle improved from 39.8 degrees preoperatively to 5.9 degrees. The mean preoperative calcaneal pitch angle of 7.5 degrees increased to an average of 17.8 degrees postoperatively. The mean American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was improved from 61.9 preoperatively to 94.2 postoperatively. Four patients had occasional exertional pain. Four feet had mild residual forefoot abduction. Arthrodesis was not needed in any case by the last follow-up. Early diagnosis of MWD with flatfoot was important and allowed for nonfusion treatment options. Calcaneal lengthening osteotomy in selected MWD cases achieved satisfactory outcomes with pain control, deformity correction, and improvement of the functional results. Level IV, retrospective case series.

Short- to Mid-Term Outcomes Following the Use of an Arthroereisis Implant as an Adjunct for Correction of Flexible, Acquired Flatfoot Deformity in Adults.

The use of an arthroereisis implant for the treatment of adolescent flatfoot deformity has been described. However, data that address the outcomes of patients treated with an arthroereisis implant in adults are limited. The purpose of this study was to investigate the radiographic and clinical outcomes and complications following the use of a subtalar arthroereisis implant as an adjunct for correction acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. A retrospective case-control study was performed querying all patients undergoing surgical flatfoot correction between January 1, 2010 and January 1, 2015. The experimental group included patients undergoing arthroereisis augmentation at the time of flatfoot correction. Patients undergoing the same flatfoot correction without the use of an arthroereisis implant were used as controls. Radiographic measurements were evaluated preoperatively and at final radiographic follow-up and included talonavicular (TN) coverage angle, and lateral talar-first metatarsal angle (T1MA). Patient-reported outcomes were assessed using preoperative visual analog scale (VAS) pain scores and postoperative Short Form-36, VAS, and satisfaction at final orthopedic follow-up. A total of 15 patients underwent flatfoot correction and were augmented with an arthroereisis implant and were matched with 30 controls. Postoperative, mid-term T1MA and regional analysis was found to be improved in the experimental group versus control. Patients undergoing adjunct subtalar arthroereisis demonstrated an increased likelihood of achieving radiographically normal talonavicular coverage <7° compared with our control group at follow-up. The adjunct use of an arthroereisis implant resulted in improved and maintained radiographic and clinical measurements in patients undergoing stage II flatfoot. These results suggest utility of a subtalar arthroereisis implant as an adjunct to flatfoot correction with little additional risk of harm to the patient. Level III: Case-control study.

Surgical treatment results for flexible flatfoot in adolescents

ObjectiveIdiopathic flexible pes planus (IFPP) is a common foot problem in adolescents and young adults. Hypothesis for the present study was that combination of procedures for IFPP can achieve results in adolescents and young adults that are as good as those seen in adult-acquired pes planovalgus (AAPP) treatment in adults. MethodsA total of 21 feet of 18 patients (10 boys, 8 girls) with mean age of 15.6 years underwent surgical reconstruction for flatfoot deformity. Symptomatic patients who had been unresponsive to conservative treatment were included in study group. Mean follow-up time was 39.2 months. American Orthopedic Foot and Ankle Society (AOFAS) scores were calculated for all patients, and based on final results, all families were asked whether or not they would elect to have the surgery again in same circumstances. ResultsAll procedures were performed by the same surgeon: lateral column calcaneal lengthening osteotomy on 21 feet; percutaneous lengthening or gastrocnemius recession for Achilles tendon on 21 feet; medializing calcaneal osteotomy on 15 feet; flexor digitorum longus tendon transfer on 15 feet; medial cuneiform opening wedge osteotomy on 5 feet, spring ligament plication on 3 feet, and accessory navicular bone excision on 2 feet.Preoperative mean AOFAS score increased significantly from 56.76 to 95.29. All parents stated that they were satisfied with surgery results and would choose to have the same surgery performed again. ConclusionSoft tissue and bony procedures used for reconstruction of AAPP can be used safely for IFPP in adolescents and young adults. Level of clinical evidenceLevel IV, Therapeutic study.

Management of symptomatic flexible flatfoot in adolescents by Mosca's lateral calcaneal lengthening

Introduction There is considerable debate as to the ideal procedure for the treatment of symptomatic flexible flatfoot (FFF) that is not followed by recurrence and that minimizes complications. The purpose of the present study was to evaluate the results of calcaneal lengthening using Mosca's technique in adolescents with FFF in whom conservative treatment had been applied for more than 1 year but had failed. Patients and methods Calcaneal lengthening osteotomy was performed using Mosca's technique in 14 patients including ten males and four females. Five cases were bilateral making the total of 19 feet. The mean age at surgery was 13.53 (range 11.5–16) years. All FFF patients were evaluated as idiopathic. Bilateral cases were operated on at two sessions with an average interval of 15.6 (range 12–21) months. The American Orthopaedic Foot and Ankle Society ankle-hind foot scale was used for clinical assessment, and radiographic assessment was based on six parameters on standard anteroposterior and lateral radiographs. Results The mean follow-up period was 27.89 (range 18–44) months. The mean American Orthopaedic Foot and Ankle Society score increased from 57.53 preoperatively to 96.32 postoperatively. All radiographic parameters significantly improved. Four patients had mild occasional pain. There was no nonunion nor secondary subsidence of the arch. All patients stated that they were satisfied with the procedure. Conclusion Correction of FFF deformity with Mosca's lateral calcaneal lengthening was an effective and reproducible method to restore normal foot alignment and good function.

Peroneal spastic flatfoot in adolescents with accessory talar facet impingement: a preliminary report.

This study analyzed imaging, arthroscopic findings, and treatment responses for peroneal spastic flatfoot (PSFF) caused by talocalcaneal impingement at the accessory anterolateral talar facet (AALTF) (accessory talar facet impingement) in 13 adolescents without histories of trauma and tarsal coalition. The AALTF was determined with computed tomography and MRI. Focal abutting bone marrow edema (FABME) on MRI around the AALTF was confirmed. In seven patients who underwent AALTF resection, subtalar arthroscopy was performed. All experienced alleviation PSFF after treatment; reduction in FABME was observed. AALTF resection alone is beneficial for PSFF caused by accessory talar facet impingement when peroneal spasms are restored by an injection of local anesthesia.

Lateral column lengthening by the calcaneal osteotomy for adolescent flatfoot: a case report

Lateral column lengthening by the calcaneal osteotomy for adolescent flatfoot: a case report

Management of the Painful Adolescent Flatfoot

Management of the Painful Adolescent Flatfoot

Reconstruction of the Symptomatic Idiopathic Flatfoot in Adolescents and Young Adults

The surgical indications, timing, and procedure for flexible flatfoot reconstruction in young patients remains controversial. This retrospective study reports the clinical results of reconstruction of flexible, idiopathic, symptomatic flatfoot in adolescent and young adults indicated for surgery by persistent pain and functional limitations. The hypothesis was that the results of these procedures allow patients to return to sports activities with minimal discomfort or pain. Sixteen consecutive idiopathic flatfeet in ten patients with a mean age of 15.6 years at the time of surgery (range, 10 to 22) were assessed at a final followup visit at average of 5.2 (range, 2 to 10) years. Reconstruction included combined medializing calcaneal osteotomy and lateral column lengthening in all 16 patients. Flexor digitorum longus transfer (nine), medial column stabilization (eight), and gastroncnemius recession (eight) were carried out as needed. The AOFAS, SF-36, and FAOS questionnaires were completed. Sports activity and patient satisfaction were also assessed. Standard preoperative and postoperative radiographic parameters were measured. The mean AOFAS score increased on average from 49.1 to 93.4. Only one patient reported a postoperative restriction in sports. The satisfaction level was excellent in 15 feet and good in one foot. Significant improvement in radiographic parameters was noted for the AP talonavicular coverage angle (p < 0.001) and lateral talar-first metatarsal angle (p < 0.001). Flexible flatfoot reconstruction in a cohort of symptomatic adolescent and young adult patients achieved a reduction of pain and improved functional outcome including the ability to participate in sporting activities.

Reconstruction of the Symptomatic Idiopathic Flatfoot in Adolescents and Young Adults

Reconstruction of the Symptomatic Idiopathic Flatfoot in Adolescents and Young Adults

Double Calcaneal Osteotomy

Posterior calcaneal displacement and anterior calcaneal distraction osteotomies have been recommended for surgical management of flexible flatfoot deformity. We combined these procedures for surgical management of adolescent flatfoot and late stage II posterior tibial tendon dysfunction in the adult. Lateral column distraction has been shown to reduce rearfoot valgus and forefoot abduction by stabilizing the midtarsal joint. Posterior calcaneal displacement osteotomy, which results in medial translation of the tuberosity, converts the posterior muscle group from an everter to an inverter. A supinatory moment, therefore, is created about the subtalar joint axis, which results in supination during the midstance phase of gait. These procedures may be considered when calcaneal valgus, forefoot abduction, and midtarsal joint instability are clinically significant. We also include rearfoot alignment radiographs, long leg calcaneal axial radiographs, and malleolar valgus indices to further evaluate alignment of the foot, ankle, and leg. Ideal realignment is achieved when the heel is vertical in resting calcaneal stance position, the forefoot is parallel to the rearfoot in the frontal plane, and the medial column is stabilized, with elimination of forefoot abduction.

Subcapital talar osteotomy to correct transverse plane structural flatfoot deformities

Subcapital talar neck adductory wedge osteotomies have significant benefits in the correction of angular deformities of the talar head in the pediatric flatfoot. Reconstruction of a severe flatfoot may include an Evans opening calcaneal osteotomy, a modified Young's tenosuspension with a posterior tibial and spring ligament advancement and a tendo Achillies lengthening. Talar neck osteotomies should also be considered in the presurgical evaluation of the pediatric and adolescent flatfoot with severe transverse plane deformity.