SLR - May 2019 - Samantha A. Miner

Outcomes of the Calcaneo-Stop Procedure for the Treatment of Juvenile Flatfoot in Young Athletes

Reference: Pavone V, Vescio A, Di Silvestri CA, Andreacchio A, Sessa G, Testa G. Outcomes of the Calcaneo-Stop Procedure for the Treatment of Juvenile Flatfoot in Young Athletes. J Child Orthop. 2018;12:582–589.

Scientific Literature Review

Reviewed By: Samantha A. Miner, DPM
Residency Program: Mount Auburn Hospital, Cambridge, MA

Podiatric Relevance: While only a small proportion of children with flexible flatfoot (FFF) are symptomatic, this group constitutes a major source of pediatric clinic visits to foot and ankle surgeons. Sports activities are considered an important factor in mental and physical development. However, FFF may limit an affected child’s participation in such activities. Many studies have shown that arthroereisis is a valid, effective and safe technique when surgical treatment is warranted for FFF. Subtalar arthroereisis may be performed with an intra-articular implant, or with an extra-articular screw, also known as the calcaneo-stop procedure. The purpose of this study was to assess the clinical and radiographic outcomes, as well as sport activity levels of young athletes undergoing the calcaneo-stop procedure for juvenile FFF.

Methods: This is a level IV retrospective cohort study of 68 patients (136 feet) undergoing the calcaneo-stop procedures bilaterally for symptomatic juvenile FFF between 2008 and 2016. In addition to skeletal immaturity and bilateral treatment, all patients had participated in sports for at least three hours per week preoperatively. The calcaneo-stop procedure was performed with a 4.5 mm cortical screw inserted into the calcaneus with the screw head impinged against the lateral aspect of the talus to prevent eversion of the subtalar joint. Clinical outcomes were evaluated before surgery and at one and three years postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, Yoo et al’s clinical criteria, the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C), the Foot and Ankle Disability Index (FADI) and FADI Sport scores. Radiographic outcomes were evaluated at the same time points using measurements of Kite’s angle, Costa-Bertani’s angle, talar declination and calcaneal pitch. Finally, hours per week of sport practice was assessed before surgery and at one and three years postoperatively.

Results: All patients had statistically significant improvement and maintenance of clinical outcomes at one and three years postoperatively based on the AOFAS, Yoo et al, OxAFQ-C, FADI and FADI Sport scoring criteria. More than 97 percent of the patients were satisfied with the treatment. Statistically significant improvements were also seen in the radiographic assessments of Kite’s angle, Costa-Bertani’s angle, talar declination and calcaneal pitch at one year postoperatively. These values were maintained at three years postoperatively. The mean level of sports activities per week prior to surgery was 2.5 hours. This increased to 5.6 hours at one year and to 5.7 hours at three years postoperatively. Minor complications (painful scar, superficial infection, screw loosening) were seen in 12.5 percent (17 patients). One case of screw breakage was reported.

Conclusions: Satisfactory clinical and radiographic outcomes can be obtained with the extra-articular calcaneo-stop procedure in juvenile FFF. The results of this study also show an advantage of increased sport activity levels postoperatively in young athletes undergoing the procedure, although it is unclear if this is a direct result of the procedure itself. Another limitation of this study is its retrospective design. Higher-level studies may be needed to further evaluate surgical outcomes with this procedure in young athletes.

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