Published online Jun 18, 2021. doi: 10.5312/wjo.v12.i6.433
Peer-review started: December 1, 2020
First decision: February 15, 2021
Revised: March 21, 2021
Accepted: May 8, 2021
Article in press: May 8, 2021
Published online: June 18, 2021
Flexible flatfoot (FFF) is a very common condition in children, characterized by the loss of the medial arch and by an increase in the support base with valgus of the hindfoot. Arthroereisis (AR) procedures are widely performed corrective surgeries and are classified as subtalar AR and calcaneo-stop (CS).
We investigated the literature published in the last 5 years with the aim of providing an update on the evidence related to AR treatment in FFF patients. We report the principal findings of subtalar AR and CS procedures concerning clinical and radiological outcomes and complication rates in the general population, young athletes, and obese people according to material device.
Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review of studies published in the past 5 years and included the PubMed and Science Direct databases was performed on May 6, 2020. The research string used was (pediatric OR children OR Juvenile NOT adult) AND (flexible NOT rigid) AND (flat foot OR pes planus) AND (calcaneo-Stop OR arthroereisis OR subtalar extra-articular screw OR SESA OR subtalar arthroereisis OR endosinotarsal). The risk of bias assessment was performed using the Dutch checklist form for prognosis.
A total of 47 articles were found. Ultimately, after reading the full text and checking reference lists, we selected 17 articles that met the inclusion and exclusion criteria. A total of 1864 FFFs were identified. Eight studies concerned the subtalar AR (47.1%) and nine concerning CS (52.9%). The average age of patients at start of treatment was 11.8 years, the average follow-up of the studies was 71.9 mo (range 29.1-130). Globally, complications occurred in 153 of the 1864 FFF treated, with a rate of 8.2%.
Both AR procedures are valid surgical techniques for treating FFF. Surgeon experience, implant cost, and cosmetic correction are the most common considerations included in the orthopedic device decision-making process. In obese patients, the subtalar AR is not recommended. In adolescents who need to improve sports performance, the CS screw had better results compared with other implants.
Core Tip: Arthroereisis (AR) procedures are widely performed corrective surgeries for juvenile flexible flatfoot. The AR procedures include impact blocking devices and self-locking implants. Impact blocking devices include subtalar extra-articular calcaneo-stop (CS) screws that have a stem and a head and interfere with the talus. Self-locking implants (subtalar AR) are inserted in the sinus tarsi along its main axis. Surgeon experience, implant cost, and, cosmetic correction are the most common criteria included in the orthopedic decision-making process. Both AR procedures improved clinical and radiological parameters. Considering the complications, calcaneo-stop screws had a slightly better rate than subtalar AR.