2016 AWARD WINNER

Flexible flatfoot in children is a topic of debate, and little agreement exists with regard to the need for surgery and the timing and techniques for management. Currently, surgical procedures most commonly advocated for the management of flatfoot in patients who are skeletally immature include lateral column lengthening (ie, calcaneal lengthening osteotomy, calcaneal-cuboid-cuneiform osteotomy) and subtalar arthroereisis. Osteotomies aim to rebalance the length of the medial and lateral column of the foot, whereas the goal of arthroereisis is to properly relocate the talus over the calcaneus. In children with flexible flatfoot, subtalar arthroereisis may allow a correct relationship to develop between the talus and the calcaneus, resulting in correct remodeling of the subtalar joint during growth. The mechanism by which arthroereisis improves foot alignment remains unclear. Often, other surgical procedures should be performed in combination with subtalar arthroereisis to achieve complete correction of the flatfoot, such as in patients with Achilles tendon tightness and patients with an accessory navicular bone who have tibialis posterior impairment. In addition, subtalar arthroereisis requires a flexible deformity; therefore, tarsal coalitions, if present, must be removed. Bioabsorbable implants have been described for subtalar arthroereisis and avoid the need for implant removal.

The goal of this video is to describe surgical management of flexible flatfoot in a skeletally immature child via subtalar arthroereisis with the use a bioabsorbable implant made of poly-L-lactic acid with a half-life of at least 24 months. The video also describes surgical procedures that can be performed in combination with subtalar arthroereisis, including percutaneous Achilles tendon lengthening (Hoke technique), removal of an accessory navicular bone with tensioning of the tibialis posterior tendon, and removal of a talocalcaneal coalition. In our series, subtalar arthroereisis with the use of a bioabsorbable implant afforded satisfactory midterm results via a minimally invasive approach. In addition, the technique can be easily performed in combination with other procedures to correct flatfoot in skeletally immature children.