Flexible Flatfoot In Children Research Articles

A Combined Reconstructive Procedure with Rerouting of Tibialis Anterior Tendon in Management of Severe Flexible Flatfoot in Children in Damietta

A Combined Reconstructive Procedure with Rerouting of Tibialis Anterior Tendon in Management of Severe Flexible Flatfoot in Children in Damietta

Lečenje bolnog ravnog stopala kod dece korišćenjem minimalno invazivne hirurške procedure nakon neuspelog konzervativnog lečenja

Introduction/Aim: Flexible flatfoot (FFF) is one of the most common skeletal deformities in the pediatric population, especially in preadolescence. This retrospective observational study evaluates results of a calcaneal subtalar extra-articular arthrodesis (subtalar arthroereisis) with one cannulated screw for the treatment of painful flexible flatfoot in children, after previously failed conservative treatment. Material and Methods: Preadolescent and adolescent pediatric patients were observed at the Department of Pediatric Orthopedic Surgery. The study included 28 feet of 15 children (5 girls and 10 boys) during a 6-year period, from 2016 to 2021 (average 36 months). The average age was 11.46 years (range 8-15 years). We performed the same operative technique under fluoroscopy for all patients. Radiographic parameters were taken before, after operative treatment, and after hardware removal. The following radiological parameters were measured: talo-calcanear (TC), talo-navicular (TN), talo-first metatarsal bone (T1MT) and calcanear pitch (CP) angles, in the anteroposterior and/or lateral views. Functional outcomes (extension and eversion of the foot) before surgery and after hardware removal were compared. Results: After operative treatment, the midfoot radiographic parameters were not statistically significantly altered; however, the subtalar joint and forefoot were statistically significantly improved: both radiologically and clinically. The range of extension and eversion of the foot were remarkably reduced without disturbing the morphological and functional aspects of the talocrural and subtalar joints. Conclusion: Extra-articular arthrodesis, using a cannulated screw is a minimally invasive technique, represents an optimal method for the operative treatment of symptomatic flexible flatfoot in children. This technique is simple, efficient and does not disrupt the anatomy of the foot.

Arthroereisis with a Talar Screw in Symptomatic Flexible Flatfoot in Children

Background: Pes planovalgus, or flexible flatfoot, deformity is a common problem in pediatric orthopedic patients. There is no consensus on using the technique of arthroereisis in the treatment of symptomatic pes planovalgus. The aim of our study was to prospectively assess the functional outcomes following symptomatic pes planovalgus treatment with the use of the Spherus talar screw. Methods: Twenty-seven patients (11 females, 16 males), at a mean age of 10.5 years (7–14 years) were included in the prospective study. We assessed the level of physical activity (including sports) based on the University of California, Los Angeles (UCLA) activity scale, a 10-point level-of-activity VAS scale, and the Grimby physical activity scale. Pain was assessed based on a VAS pain scale; foot function was assessed with the revised Foot Function Index (FFI-R); and ankle joint mobility was measured. Results: The mean follow-up period was 18 months (14–26 months). There was a significant improvement in VAS-measured physical activity scores from 5.47 to 7 at follow-up, p = 0.048. There was a significant improvement in UCLA activity scale scores from 4.78 to 6.05 at follow-up, p = 0.045. Pain levels decreased from a mean VAS score of 4.73 prior to surgery to a mean score of 2.73 at follow-up, p = 0.047. The functional FFI-R scores showed a significant improvement from 140 points prior to surgery to 97.75 points at follow-up, p = 0.017. Comparison of the preoperative and follow-up values of the range of plantar flexion, adduction, and abduction in the operated limb also showed no significant changes in those individual parameters. The mean values of dorsiflexion, plantar flexion, adduction, and abduction at the ankle joint at follow-up, compared individually between the operated and non-operated foot showed no statistically significant differences. Conclusions: The use of a talar screw in the treatment of symptomatic pes planovalgus helps reduce pain and improve functional outcomes after treatment. Foot function assessments showed diminished pain, improved levels of physical and sport activity, and no effect on the range of motion after surgery in comparison with preoperative data. Arthroereisis with a talar screw is a valid surgical technique for the treatment of symptomatic pes planovalgus.

Corrective shoes and inserts as treatment for flexible flatfoot in infants and children

We performedaprospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment withaHelfet heel-cup; or Group IV, treatment withacustom-molded plastic insert. All of the patients in Groups II, III, and IV hadaminimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstratedasignificant improvement in all groups (p 0.01), including the controls, and no significant difference between the controls and the treated patients (p 0.4).
 We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

Tibialis anterior rerouting combined with calcaneal lengthening osteotomy as a single-stage reconstruction of symptomatic flexible flatfoot in children and adolescents

BackgroundSymptomatic flexible flatfoot in children and adolescents should be surgically managed only if conservative measures have failed. The aim of this study was to assess functional and radiological results of tibialis anterior rerouting combined with calcaneal lengthening osteotomy as s single-stage reconstruction of symptomatic flexible flatfoot.MethodsThe current study was a prospective study of patients with symptomatic flexible flatfoot treated by single-stage reconstruction in the form of tibialis anterior tendon rerouting combined with calcaneal lengthening osteotomy. The American Orthopaedic Foot and Ankle Society score (AOFAS) was utilized to evaluate the functional outcomes. The evaluated radiological parameters included the standing anteroposterior (AP) and lateral talo-first metatarsal angle, talar head coverage angle, and calcaneal pitch angle.Results The current study included 16 patients (28 feet) with a mean age of 11.6 ± 2.1 years. There was a statistically significant improvement in the mean AOFAS score from 51.6 ± 5.5 preoperatively to 85.3 ± 10.2 at final follow-up. Postoperatively, there was a statistically significant reduction in the mean AP talar head coverage angle from 13.6 ± 4.4° to 3.9 ± 3°, the mean AP talo-first metatarsal angle from 16.9 ± 4.4° to 4.5 ± 3.6°, and the mean lateral talo-first metatarsal angle from 19.2 ± 4.9° to 4.6 ± 3.2°, P < 0.001. Additionally, the mean calcaneal pitch angle increased significantly from 9.6 ± 1.9° to 23.8 ± 4.8°, P < 0.001. Superficial wound infection occurred in three feet and was treated adequately by dressing and antibiotics.Conclusion Symptomatic flexible flatfoot in children and adolescents can be treated with combined lateral column lengthening and tibialis anterior rerouting with satisfactory radiological and clinical outcomes.Level of evidence Level IV.

Foot orthoses for flexible flatfeet in children and adults: a systematic review and meta-analysis of patient-reported outcomes

BackgroundThis systematic review and meta-analysis examined the effectiveness of orthoses for flexible flatfeet in terms of patient-reported outcomes in children and adults.MethodsEMBASE, Medline (OvidSP), Web-of-Science, Scopus, CINAHL, Cochrane Central Register of Controlled Clinical Trials, i.e., Cochrane Centraland Pubmed were searched to identify relevant studies since their inception up to February 2021. We included randomized controlled trials (RCT) and prospective studies in which patient reported outcomes at baseline and follow-up in an orthoses group were compared with a no orthoses or sham sole group. Methodological quality of the studies was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). A meta-analysis was performed where there were multiple studies with the same outcome measures, which was the case for the Visual Analogue Scale (VAS) for pain in adults.ResultsIn total nine studies were included: four RCT in children (N = 353) and four RCT and one prospective study in adults (N = 268) were included. There was considerable heterogeneity between studies. A meta-analysis demonstrated that pain reduction between baseline and follow-up was significantly larger in the orthoses (N = 167) than in the control groups in adults (N = 157; − 4.76, 95% CI [− 9.46, − 0.06], p0.05).ConclusionDue to heterogeneity in study designs, we cannot conclude that foot orthoses are useful for flexible flatfoot in children and adults. However, based on the meta-analysis orthoses might be useful in decreasing pain in adults.The authors did not receive support from any organization for the submitted work.

Mosca's Technique in Surgical Treatment of Symptomatic Flexible Flat Foot in Children and Adolescents

Mosca's Technique in Surgical Treatment of Symptomatic Flexible Flat Foot in Children and Adolescents

Short-term Effects of Using Arch Supporting Insoles on Balance and Symptoms of Flexible Flat Foot in Children

Background and Aims One of the treatment methods for Pediatric Flexible Flat Foot (PFFF) is to use medical insoles. The current study aimed to investigate the Short-term effects of arch supporting insoles on balance and symptoms of flexible flat foot in children. Methods Twenty children aged 6-11 years with a flexible flatfoot complication were purposefully selected after applying Inclusion and exclusion criteria. Participants were randomly assigned to two intervention (n=10) and control groups (n=10). The intervention group used insoles supporting the longitudinal arch of the foot in their shoes for 12 weeks, but the control group did not use them. To measure the balance and symptoms of flexible flat foot in children, a sensory organization test of dynamic posturography apparatus, medial longitudinal arch height, and footprint were used in the pre-posttest. The intervention group used insoles supporting the longitudinal arch of the foot in their shoes for 12 weeks, but the control group did not. Data analysis was performed in two descriptive (mean and standard deviation) and inferential (covariance analysis) sections using SPSS software v. 25 at a significance level of α&lt;0.05. Results The results showed that short-term use of medical insoles led to improved balance in conditions of normal vision and fixed support (P=0.047), absent vision and fixed support (P=0.1010), sway referenced vision and fixed support (P=0.004), normal vision and fixed support (P=0.004), absent vision and sway referenced support (P=0.001) and sway referenced vision and sway referenced support (P=0.001). The results also showed that medical insoles improved the medial longitudinal arch of the foot (P=0.001) and footprint (P=0.001). Conclusion According to the results of the present study, educators and parents of children with flexible flat foot are advised to use supportive medical insoles to improve children’s motor function, balance, and symptoms of flexible flat foot.

Effects of extraosseous talotarsal stabilization on the biomechanics of flexible flatfoot subtalar joints in children: a finite element study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Objective of the study was to generate an experimental foundation for the clinical application of extraosseous talotarsal stabilization (EOTTS) in treatment of flexible flatfeet in children by investigating the biomechanical characteristics of flexible flatfoot and the effects of EOTTS on hindfoot biomechanics.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Three-dimensional finite element models of the foot and ankle complex were generated from computer tomography images of a volunteer’s left foot in three states: normal, flexible flatfoot, and post-EOTTS. After validation by X-ray, simulated loads were applied to the three models in a neutral position with both feet standing.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In the flexible flatfoot model, the contact stress on the subtalar joint increased and contact areas decreased, resulting in abnormal stress distribution compared to the normal model. However, following treatment of the foot with EOTTS, these parameters returned to close to normal. Subtalar joint instability leads to a flexible flat foot. Based on this study, it is proposed that EOTTS can restore the normal function of the subtalar joint in and is an effective treatment for flexible flatfoot in children. We and many clinical data studies provide evidence for sinus tarsi implants in pediatric patients. It is showed that the formation of flexible flatfoot is induced by subtalar joint instability.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Because of the EOTTS provides the best biomechanical solution to subtalar joint instability, the EOTTS became an effective form for subtalar joint instability treatment.&lt;/p&gt;

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

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.

Functional and radiographic comparison of subtalar arthroereisis and lateral calcaneal lengthening in the surgical treatment of flexible flatfoot in children.

One of the most widespread diseases of children's orthopaedic problems is flatfoot. If conservative therapy failed, surgical treatment would be indicated. Lateral calcaneal lengthening (LCL) and subtalar arthroereisis (SA) are two types of operations used to correct symptomatic flexible flatfoot (FFF). The purpose of this study is to compare the functional and radiographic features of these two surgical procedures. In this prospective randomized clinical trial study, we recruited 66 patients between 2018 and 2019. For clinical assessment, American Orthopedics Foot and Ankle Society (AOFAS), visual analog scale (VAS), subtalar motion, presence of medial longitudinal arch, and family satisfaction were measured. Evaluation of radiographic angles was based on AP (AP Tal-1Met) and Lat (Lat Tal-1Met) view of Talus-1st metatarsal angle (Meary's angle) and calcaneal pitch. There was no significant difference between the two types of surgery regarding Lat Tal-1Met and AP Tal-1Met. The significantly larger angle in the LCL group was calcaneal pitch (P value < 0.001). AOFAS significantly increased from 68.71 ± 5.70 to 87.87 ± 7.14 (P value < 0.001) and from 67.28 ± 6.01 to 86.14 ± 7.56 (P value < 0.001) in LCL and SA respectively. Family satisfaction was significantly higher in the SA (8.14 ± 0.97) comparing to LCL (7.29 ± 0.86) at the latest follow-up (P value < 0.001). While both groups have substantial improvement in clinical and radiographic aspects, the SA technique is less-invasive, rapid symptom relief, and has early weight-bearing capacity. IRCT20180823040853N1.

Long-term results of subtalar arthroereisis for the treatment of symptomatic flexible flatfoot in children: an average fifteenyear follow-up 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). Thirty-four pediatric patients who underwent STA with a bioabsorbable implant were enrolled and radiographic measurements, clinical outcomes, and patients' satisfaction were evaluated. 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. 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.

Calcaneal lengthening for correction of symptomatic flexible flat foot in children.

calcaneal lengthening for correction of symptomatic flexible flat foot in children.

Calcaneal Lengthening For Correction of Symptomatic Flexible Flat Foot in Children

Background ; The purpose of this study was to evaluate the clinical, functional and radiological outcome of calcaneal lengthening osteotomy for the treatment of symptomatic flatfoot deformity in children. Methods; A prospective multicentre study on 29 feet of 23 patients who underwent lateral calcaneal lengthening for symptomatic flatfoot in children in the period between October 2015 and June 2017. Inclusion criteria were symptomatic flexible flatfoot in children with failed non operative treatment. During the study period, 29 feet of 23 patients with symptomatic flatfoot underwent calcaneal lengthening osteotomy. All patients met the inclusion criteria and were available for clinical and radiological follow-up. The percentage male were (62%)–female were (38%), The mean age at time of surgery was 10.4 years old (7 – 17 years old) and their mean follow up period was 26.2months.The mean functional American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score had improved from 43.45 (31-55) preoperatively to 85.52 (68-92) postoperatively at last follow up (P value < 0.001) using paired t-test as a significance test for evaluation of pre and post-operative AOFAS score Conclusions; The results of this study support the combination of lateral column lengthening and soft tissue reconstruction for treatment of Plano-valgus foot deformity, The adopted technique revealed satisfactory result both in children and adolescents.

Functional evaluation of bilateral arthroereisis of subtalar joint and simultaneous gastrocnemius lengthening in symptomatic flexible flatfoot in children

The aim of this study was to report the radiological and pedobarographic results of 10 children’s 20 feet with symptomatic flexible flat foot, who were treated with gastrocnemius lengthening with arthroereisis of subtalar joint. A total of 10 children’s 20 feet (5 boys and 5 girls between 9-14-year-old) with painful feet due to the flatfoot were treated in our clinic between August 2016 and December 2018. Bilateral gastrocnemius lengthening and arthroereisis of subtalar joint was performed simultaneously. Radiological evaluation was performed by measuring calcaneal pitch angle and Meary’s talusfirst metatarsal angles, pedobarographic evaluation by static and dynamic plantar heel and forefoot pressure data. The mean calcaneal pitch angle increased from 8° ± 0.93° preoperatively to 16.5° ± 1.14° postoperatively, and the mean Meary’s talus-first metatarsal angle decreased from 7.5° ± 1.14°preoperatively to 0.5° ± 0.51° postoperatively. The mean heel peak pressure and the forefoot peak pressure ascended from 11.5 ± 1.14 (N/cm2) and 10.5 ± 1.14 (N/cm2) preoperatively to 17.5 ± 1.14 (N/cm2) and 15.5 ± 1.14 (N/cm2) postoperatively, respectively. Clinical evaluation revealed that 9 patient had painful feet, while 1 patient had discomfort since the implant had been inserted.Arthroereisis of subtalar joint with simultaneous gastrocnemius lengthening provides painful feet and seems to be an effective, simple and safe solution for symptomatic flexible flatfoot in pediatric patients.

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

BackgroundThe 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. MethodsA 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. ResultsIntra- 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. ConclusionThis 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 EvidenceIII, retrospective comparative study.

Subtalar Arthroereisis for Correction of Flexible Flatfoot in Children: A Retrospective Comparative 5- Year Follow-Up Study

Category:HindfootIntroduction/Purpose:Subtalar arthroereisis for the treatment of flexible flatfoot in children is controversial. Self-locking implants are utilised worldwide aiming to limit subtalar joint movement and foot pronation. Recently two reviews have focused on the lack of comparative studies in literature and the poor-quality evidence available regarding these devices. In this study, performed on children diagnosed with flexible flatfoot and treated with subtalar arthroereisis, the two aims were: 1) to compare pre and postoperative radiographic measurements in order to assess the efficacy of arthroereisis in the correction of flatfoot; 2) to compare clinical outcomes between patients operated and normal controls at mid-term follow-up. Our hypothesis was that subtalar arthroereisis achieves flatfoot correction and that at the longest follow-up patients operated do not differ from normal controls.Methods:This is a single-centre single-surgeon retrospective comparative study, ethics committee approved. Fortysix feet from 24 continuous patients (5 females; 22 left and 24 right) treated at mean age of 11 years (range 8 to 15) with subtalar arthroereisis for flexible flatfoot were reviewed at a follow up of 51 months (range, 25 to 73) and compared with 23 feet from 13 controls (ratio 2:1, matched by age and body mass index). Radiographically, the following measurements were recorded and compared on pre and postoperative films: talonavicular coverage angle and talocalcaneal divergence angle on dorsoplantar view; Dijan-Annonier angle, Méary line, calcaneal pitch and talocalcaneal divergence angle on lateral views. Clinically, a goniometric assessment of ankle and hindfoot range of motion, AOFAS score and VAS-FA score were utilised in patients operated and normal controls (mean values ± standard deviation). Paired 2-tailed Student t tests were used to assess differences.Results:All radiographic measurements demonstrated improvement after surgery (p .001), except for the talonavicular coverage angle (p .812). At longest follow-up, patients and controls had 35.8° ± 3.8 vs 44.1° ± 2.8 of plantarflexion (p .092), 13° ± 1.7 vs 14.5° ± 2 of dorsiflexion (p .312), 16.5° ± 2 vs 18.7° ± 1.6 of inversion (p .124) and 10.6° ± 1.6 vs 11.8° ± 1.3 of eversion (p .073). AOFAS values were similar at 94.7 points ± 3.9 (patients) and 99.3 points ± 1.3 (controls) (p .083). All the items from VAS-FA showed no differences in two groups, except for frequency and intensity of pain during physical activity (p .053 and p .032, respectively) and ability to stand on leg for long time (p .004).Conclusion:Our study showed that subtalar arthroereisis significantly improves flexible flatfoot deformity, with a satisfactory correction of hindfoot alignment and longitudinal arch but no significant amelioration of the foot abduction. Although at 4 years of time patients do clinically well, they may still experience some limitations compared to normal individuals. It is therefore crucial to consider these anatomical and functional elements when counseling young patients and family about surgery, in order to address preoperatively and realistically their expectations.

Calcaneal lateral column lengthening osteotomy for symptomatic flexible flatfoot in children and adolescents: a systematic review.

Flexible flatfoot is a common condition in small children, which shows a strong tendency to spontaneously correct with their growth or to become moderate or mild in adults, which will not cause future problems. However, in a small number of cases, this condition is more severe, does not improve spontaneously, which may cause mechanical impairment, deformity, and, eventually, pain. In such cases, surgical treatment should be considered. The aim of this systematic review was to evaluate the literature results on the treatment of the symptomatic flexible flatfoot in children or adolescents through a very frequent procedure: calcaneal lateral column lengthening osteotomy, A systematic electronic search in PubMed, Web of Science, Cochrane, CINAHL, SciELO, SCOPUS and LILACS databases was performed. We searched articles published between March 1975 and September 2016. After applying the eligibility criteria, the selected publications were evaluated in relation to their clinical and radiographic results and complications. We found 341 articles in the mentioned databases, but selected only eight studies, according to the inclusion and exclusion criteria. These studies included a total of 105 patients and 167 treated feet. Only three authors performed prospective studies, but without case-control or randomization. The majority of publications were descriptive studies or case series (level of evidence III or IV), with great methodological variations, but with a high satisfaction rate on the part of both patients and surgeons in relation to the results. However, more prospective and randomized studies are required, with adequate control groups and validated evaluation criteria.

Pathology and management of flexible flat foot in children

We describe the pathology and treatment of flexible flat foot in children. The flexible flat foot is seen in the overly flexible foot and usually involves hypermobility of the subtalar joint. It typically occurs in childhood and may continue to adulthood. The arch develops spontaneously during the first decade of life in most children and comes within the normal range observed in adult feet. We prescribed orthoses for the treatment of flexible flat foot patients. Lateral weight-bearing radiographs and ultrasonography were helpful for the evaluation of the flat foot. Bleck recommended the UCBL shoe insert in cases of flexible flat foot if the standing or lateral rentgenogram demonstrates a talar plantar flexion angle (TPF) of 45° or greater. Bordelon suggested that cases of flexible flat foot should be treated if the standing or lateral roentgenogram demonstrates a Meary's talo-1st metatarsal angle (T1-MTA) of −15°or greater. However, the radiograph of a young child's foot poses some difficulties in making an accurate evaluation, because of the radiolucent cartilage zone. In this situation, a sagittal image obtained by ultrasonography has proved to be a powerful aid to evaluate the type of the flat foot. We classified the flat foot into three types: talo-navicular sag (T-N sag), naviculo-cuneiform sag (NC sag) and talo-navicular and naviculo-cuneiform sag (Mixed sag) following the criteria of Tachdjian. We recommended the NC sag and Mixed sag groups to be treated by using orthoses, while we kept a status of watchful waiting for the T-N sag group. However, we should consider the increasing complaints of children and their parents during the orthotic treatment. A through discussion between the parents of patients and the pediatric orthopedic doctors is necessary before orthotic treatment is started.