Does the way of weight-bearing matter? Single-leg and both-leg standing radiographic and pedobarographic differences in pediatric flatfoot

BACKGROUND

An exact definition is lacking for the term "weight-bearing" or different standing modalities when implementing foot radiographs for children and adults; moreover, only few studies have investigated the relationship between radiographic and pedobarographic measurements.

RESEARCH QUESTION

We hypothesized that the method of weight-bearing in single-leg and both-leg standing positions could influence the measurement results in radiographs and the distribution of foot pressure.

METHODS

This prospective study evaluated 33 children (66 feet) with flexible flatfoot deformities scheduled for subtalar screw arthroereisis surgery. Radiographs in the lateral and anteroposterior (AP) views were assessed independently in the single-leg and both-leg standing positions. Static pedobarography was performed as that for measuring weight-bearing. Standardized radiographic angles and pedobarographic data were analysed and correlated.

RESULTS

There were differences in radiographic measurements between the single-leg and both-leg standing positions, including the AP talocalcaneal angle (p = 0.032), AP talus-first metatarsal base angle (p = 0.003), AP talus-first metatarsal angle (p = 0.003), lateral calcaneal pitch angle (p = 0.001), talus-first metatarsal index (p = 0.004), and talocalcaneal index (p = 0.029). Moreover, differences between these two standing modalities were found in most of the static pedobarographic data, including the contact area (p = 0001), maximal force (p = 0.001), and peak pressure (p = 0.007). Overall, medial foot pressure increased more in both-leg standing than in the single-leg standing position, whereas radiographic measurements showed a more pronounced flatfoot deformity in the single-leg standing position. The AP talus-first metatarsal angle was the only angle or index with a significant association to some pedobarographic measurements in both standing modalities.

SIGNIFICANCE

As there are significant differences between single-leg standing and both-leg standing radiographic and static pedobarographic values, observers have to be precise in the definition of "weight-bearing" to gain reproducible and comparable study values in children and adults. We recommend acquiring both-leg standing foot radiographs because children with flexible flatfeet can stand more steadily in this position than in the single-leg standing position.

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.

Quality of Life after Flatfoot Surgery in the Pediatric Population

Flatfoot is a common deformity in the pediatric population and has a multitude of causes. Sometimes, it can be a normal finding in children, and treatment should not be guided only based on the appearance, but rather after thoroughly assessing the patient and the impact it has on the child’s daily life. In this paper, we describe the quality of life that the patients are experiencing after the surgical treatment of this pathology. We made a comparison between the most used techniques for correcting flatfoot and insisted on the postoperative comfort of the patient, rehabilitation, and the time it took to get back to their daily routine. The comparison was made between Mosca calcaneal lengthening osteotomy, Grice extraarticular arthrodesis, arthroereisis and triple arthrodesis of the foot. All of the surgeries were performed by the same doctor at “Grigore Alexandrescu” Emergency Hospital for Children in Bucharest. From the data collected, we propose that newer, minimally invasive techniques could be used in treating this pathology in order to help the patient feel better in the postoperative period and avoid some of the complications regularly encountered when using the old techniques.

Functional evaluation of bilateral subtalar arthroereisis for the correction of flexible flatfoot in children: 1-year follow-up

BACKGROUND

Flexible flatfoot (FFF) is a common alteration of the foot diagnosed in the pediatric population causing pain and decreased quality of life. Surgical treatment via arthroereisis of the subtalar joint can be recommended when non-invasive options do not result in sufficient pain relief. While clinical outcome of subtalar joint arthroereisis is generally positive, no functional evaluation has thus far been reported following surgery.

RESEARCH QUESTION

The aim of this study was to assess the effects of two arthroereisis implants for the correction of bilateral FFF on foot and lower limb biomechanics during gait.

METHODS

This is a prospective study following 13 children affected by bilateral symptomatic FFF. The patients underwent bilateral subtalar arthroereisis during the same surgery using two types of poly-L-lactide bioabsorbable implants: an expanding endo-orthotic implant, and a calcaneo-stop screw. Radiological parameters and gait analysis were performed preoperatively and at 1 year follow-up and compared to those from an age-matched normal-arched control population. Lower limb and multisegment foot kinematic analysis, along with EMG of the main ankle flexor/extensor muscles, were performed during level walking at comfortable speed. Paired non-parametric Wilcoxon signed-rank test was used to assess differences in radiological and kinematic parameters between pre-op and post-op assessments.

RESULTS

All radiological parameters, and frontal-plane orientation of the rearfoot in double-leg standing were improved at 1-year follow-up in both implant groups (e.g calcaneo-stop: pre-op = 15 ± 7 deg; post-op = 6 ± 9 deg; p < 0.01). The endo-orthotic implant group showed significantly lower pronation/supination at the ankle and midtarsal joint. Activation of the tibialis anterior muscle was more physiological after surgery in both groups.

SIGNIFICANCE

According to the present analysis, both implants appear effective in restoring physiological alignment of the rearfoot, however the endo-orthotic implant appeared more effective in restoring a more correct frontal-plane mobility of foot joints.

Patient-perceived outcomes after subtalar arthroereisis with bioabsorbable implants for flexible flatfoot in growing age: a 4-year follow-up study. Eur J Orthop Surg Traumatol. 2018;28:707-712. [PMID: 29299766 DOI: 10.1007/s00590-017-2119-1]

PURPOSE

Results of subtalar arthroereisis in flexible flatfoot have been mainly reported in the literature using clinical or radiographical findings. However, the aim of this study is to evaluate the patient-perceived quality of life using self-reported questionnaires after subtalar arthroereisis using a bioabsorbable implant.

METHODS

Italian modified FFI and the SEFAS scores were submitted to a consecutive series of 173 patients who underwent surgical treatment for flatfoot deformity using a bioabsorbable endo-orthotic implant. Postoperative complication rates were assessed. Time needed to resume normal sports activities was recorded.

RESULTS

Mean population age was 11.2 years with slight variability between males and females. At a mean follow-up of 4 years, arthroereisis with bioabsorbable implants showed excellent results for the perception of the quality of life with an average result for FFI score of 4.5 and an average SEFAS score of 47.19. Time needed to resume sport activities was 4.7 months ± 0.2 with almost no difference between the groups. Four patients needed a second procedure for implant removal.

CONCLUSION

Arthroereisis using a bioabsorbable implant offers good results in terms of satisfaction and quality of life with a negligible rate of failures and patient complaints based on self-reported questionnaires. The patient reported high degrees of satisfaction, and their quality of life was not compromised at all by the procedure.

Congenital talotarsal joint displacement and pes planovalgus: evaluation, conservative management, and surgical management

The diagnosis of and preferred treatment regimens for pediatric flatfoot, a complex and ambiguous deformity, continues to be debated. Incongruence of the talotarsal joint, whether flexible or rigid, is always present in pes planovalgus. However, it is important to note that talotarsal dislocation can occur without a flatfoot. The displacement of the talus on the hindfoot bones serves as the apex of the deformity. External measures, such as conservative care, are limited in providing correction to this internal deformity. Extraosseous talotarsal stabilization provides a minimally invasive internal option that should be considered before more radical surgical intervention is decided upon.