Extraartikuläre Arthrorise nach Grice/Green vs. Kalkaneusverlängerungsosteotomie nach Evans

Foot Typology, Dynamic and Static Weight Distribution, and Radiographic Changes After Subtalar Arthroereisis in Juvenile Symptomatic Flexible Flat Feet

Flexible flatfoot is among the most common skeletal disorders in childhood. This study describes the dynamic and static correction effects of subtalar arthroereisis in adolescents with flexible symptomatic flatfeet in comparison to normal subjects as well as to results before and after removal of metal. Eighteen adolescents with 25 symptomatic flexible flatfeet were treated surgically with a subtalar arthroereisis at a mean of 12.5 (10-16) years. At follow-up (mean 3.9 years, range 0.4-8), patients filled out the American Orthopaedic Foot and Ankle Society questionnaire, received radiographs and were examined using dynamic and static pedobarography as well as static hindfoot axis examination. Results were compared to healthy controls (n = 13; 26 feet). Surgically treated feet (n = 25) had better questionnaire results after surgery than before, but lower scores than healthy feet. Radiological parameters improved significantly after surgery. Removal of metal did not influence post-surgical results (follow-up 2.8 years). Surgically treated feet had larger contact areas than normal feet with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of treated feet compared to controls. When comparing pedobarography data of treated versus untreated feet of the same patients (subgroup n = 11 feet), there were no differences. Subtalar arthroereisis was able to effectively treat symptomatic flexible flatfeet in this population. Results improved significantly evaluating a questionnaire, radiographs, dynamic and static weight distribution, but were still worse than results of healthy feet. There was no relapse after removal of metal.

Radiological outcome after treatment of juvenile flatfeet with subtalar arthroereisis: a matched pair analysis of 38 cases comparing neurogenic and non-neurogenic patients

PURPOSE

Therapy of juvenile neurogenic flatfoot (JNF) with subtalar arthroereisis (SA) is currently under critical clinical investigation. In this retrospective matched pair analysis, the radiological outcome after arthroereisis in paediatric patients with infantile cerebral palsy and JNF was compared with children with juvenile flatfeet (JF) without neurological diseases.

METHODS

From October 2007 to April 2018 80 patients with 149 flatfeet underwent surgery with SA. Inclusion criteria were: 1) JNF or JF with age at surgery ≤ 13 years; 2) treatment with SA; 3) presence of three sets of biplane radiographs (preoperative, postoperative and follow-up (FU)). The radiographs were analyzed for: 1) navicular-cuboidal-index (NCI); 2) talocalcaneal angle anteroposterior; 3) talocalcaneal angle lateral; 4) calcaneal-pitch (CP); and 5) talometatarsal-index (TMTI). Following this, 25 patients with 38 flatfeet could be included.

RESULTS

The mean age at SA of the JNF group was 9.2 years (JF group: 9.3 years) and the mean time of FU was 35.2 months (JF group: 39.4 months). In comparison with preoperatively, a significant decrease of the NCI was seen in both groups (p = ≤ 0.05 and p = ≤ 0.001) in the FU radiographs. The analysis of CP and TMTI in the JF group also resulted in a significant improvement (p = ≤ 0.001 and p = ≤ 0.05). Overall, the comparison between the JNF and JF group showed no significant differences in regard to the analyzed postoperative parameters.

CONCLUSION

Based on this data, treatment of flatfeet by SA in patient with neurological disorders shows an improvement of radiological parameters comparable with neurologically unimpaired patients and might be considered as additional treatment option.

LEVEL OF EVIDENCE

IV.

Pediatric flatfoot: cause, epidemiology, assessment, and treatment

PURPOSE OF REVIEW

The current review includes the most up to date literature on the cause, epidemiology, diagnosis, and treatment of pediatric flatfeet.

RECENT FINDINGS

Recent systematic reviews concur that the evidence supporting the use of orthotics in pediatric flexible flatfeet is poor. Multiple studies have recently reported on the results of arthroereisis, yet these are mostly retrospective and do not include a comparative group or long-term follow up. Other options for symptomatic flatfeet may include osteotomies and/or fusions, but similarly high quality comparative studies are lacking.

SUMMARY

Pediatric flatfeet range from the painless flexible normal variant of growth, to stiff or painful manifestations of tarsal coalition, collagen abnormalities, neurologic disease, or other underlying condition. Most children with flexible flatfeet do not have symptoms and do not require treatment. In symptomatic children, orthotics, osteotomies, or fusions may be considered. Arthroereisis has gained popularity in Europe, but has not been widely adopted in North America. Children with asymptomatic rigid flatfeet may not require treatment, whereas those with pain or functional deficits may benefit from orthotics, osteotomies, or fusions. A careful history, clinical exam, and selective diagnostic testing can be used to determine the appropriate treatment option for each child.