SLR - August 2019 - Paris M. Payton

Radiological Outcome After Treatment of Juvenile Flatfeet with Subtalar Arthroereisis: A Matched Pair Analysis of 38 Cases Comparing Neurogenic and Non-Neurogenic Patients

Reference: Kubo H, Krauspe R, Hufeland M, Lipp C, Ruppert M, Westhoff B, Pilge H. Radiological Outcome Af¬ter Treatment of Juvenile Flatfeet with Subtalar Arthroereisis: A Matched Pair Analysis of 38 Cases Comparing Neurogenic and Non-Neurogenic Patients. J Child Orthop 2019;13.

Scientific Literature Review

Reviewed By: Paris M. Payton, DPM
Residency Program: St. Vincent Charity Medical Center – Cleveland, OH

Podiatric Relevance: The pediatric flatfoot is a common issue encountered by practicing podiatrists on a daily basis. There are a number of conservative and surgical treatment options for management of juvenile flatfoot deformity, including minimally invasive subtalar arthroereisis (SA). The main benefit of SA in the pediatric population is that it is reversible and allows for more complex reconstructive procedures down the line if the deformity progresses into adulthood. Neurological disease in children can complicate the management of a pes planus deformity, and little literature is available to guide surgical treatment in these patients. SA, although commonly performed in the pediatric flatfoot, may not be the best surgical treatment option for patients who have neurologic conditions, and management of the juvenile neurogenic flatfoot (JNF) with SA is controversial.

Methods: This Level IV retrospective matched pair study evaluated 25 patients with 38 flatfeet who underwent SA between October 2007 and April 2018. The patients included in the study all had JNF or juvenile flatfoot (JF) and underwent SA at 13 years of age or younger. They each had at least three sets of biplane radiographs (preoperative, postoperative, and follow-up) and these radiographs were analyzed for: 1) Navicular-cuboidal index (NCI); 2) Talocalcaneal angle anteroposterior; 3) Talocalcaneal angel lateral; 4) Calcaneal-pitch (CP), and; 5) Talometatarsal-index (TMTI).  To further evaluate the outcome of SA, the patients were split into two groups: those with infantile cerebral palsy and/or JNF and those without neurological disease. In cases of additional equinus deformity, when dorsiflexion of the ankle was <5°, gastrocnemius recession or tendo-Achilles lengthening were performed in conjunction to SA. A total of 14 cases were treated solely with SA, 4 with SA and a Baumann procedure, and 1 case with SA and Achilles tendon lengthening. Post-operative complications were not reported.

Results: The mean age of SA in both groups were similar, at 9.2 years in the JNF group as compared to 9.3 years in the JF group. Compared to pre-operative findings, there was a significant decrease in the NCI seen in both groups in follow up radiographs. In the JF group alone, there was a significant improvement noted to the CP and TMTI. Overall, both groups showed no significant differences in regard to the analyzed post-operative parameters. Ultimately, this matched-pair study demonstrates that SA results in significant improvement of flatfoot deformity in children with and without neurological impairment.  

Conclusions:This study demonstrates that SA can be an effective treatment for juvenile neurogenic flatfoot as it shows an improvement in radiological parameters comparable with neurologically unimpaired patients. A major limitation of the study was the small patient population based upon strict inclusion criteria. Additionally, the impact of adjunctive soft tissue procedures was not analyzed. In future studies, clinical scores, gait analysis, pedobarography, and energy consumption can be reviewed to better determine the outcome of SA in JNF and JF patients.

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