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Surgical Treatment Of Flexible Flatfoot In Children: Subtalar Arthroereisis and Combined Surgical Procedures

February 19, 2016

Contributors: Cesare Faldini, MD; Francesco Traina, MD; Matteo Nanni, MD; Daniele Fabbri, MD; Raffaele Borghi, MD; Fabrizio Perna; Ilaria Sanzarello, MD; Federico Pilla, MD; Sandro Giannini, MD

Flexible flatfoot in children still represents a debated topic and there is still little agreement about the need for surgery as well as the timing and the techniques for its treatment. Surgical procedures most commonly advocated nowadays for treatment of flatfoot in patients during growing age are lateral column lengthening (i.e. calcaneal lengthening osteotomy, calcaneo-cuboid-cuneiform osteotomy) and subtalar arthroereisis. Osteotomies aim to rebalance the length of the medial and the lateral column of the foot, whereas the purpose of arthroereisis is to properly relocate the talus over the calcaneus. In case of flexible flatfoot observed in children, subtalar arthroereisis may give the foot the chance to develop a correct relationship between the talus and the calcaneus producing the condition of a correct remodeling of the subtalar joint during growth, with a minimally invasive surgery, even if the mechanism by which the arthroereisis improves foot alignment still remains in part unclear. Sometimes other surgical procedures should be combined to subtalar arthroereises in order to obtain complete correction of the flatfoot, such is case of Achilles tendon tightness, or in presence of accessory navicular bone with tibialis posterior impairment. Moreover, subtalar arthroereisis requires a flexible deformity, therefore if tarsal coalitions are present, they must be removed. Bioabsorbable implants have been described for subtalar arthroereisis and they offer the advantage to avoid the need of a second surgery for implant removal. The aim of this video is to present surgical treatment of flexible flatfoot during growing age with subtalar arthroereisis using a bioabsorbable implant made of poly-L-lactic acid with a half-life demonstrated of at least 24 months. This video also presents surgical procedures that can be combined with subtalar arthroereisis: percutaneous Achilles tendon lengthening (Hoke's technique); removal of accessory navicular bone with tensioning of tibialis posterior tendon and removal of a talocalcanear coalition. In our series, subtalar arthroereisis using bioabsorbable implant allowed satisfactory results at mid-term follow up, with a minimally invasive surgery. Also, this technique could be easily combined with other procedures in the correction of flatfoot during growing age.

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