SLR - November 2018 - Meghan Hurley

Patient-Perceived Outcomes After Subtalar Arthroereisis with Bioabsorbable Implants for Flexible Flatfoot in Growing Age: A Four-Year Follow-Up Study

Faldini C, Mazzotti A, Panciera A, Persiani V, Pardo F, Perna F, Giannini S. Patient-Perceived Outcomes after Subtalar Arthroereisis with Bioabsorbable Implants for Flexible Flatfoot in Growing Age: A Four-Year Follow-Up Study. European Journal of Orthopaedic Surgery & Traumatology. 2018 May; 28(4): 707–712.

Scientific Literature Review

Reviewed By: Meghan Hurley, DPM
Residency Program: North Colorado Medical Center Podiatric Medicine and Surgery, Greeley, CO

Podiatric Relevance: Treatment of flexible pes planus has been widely studied over the decades. However, research rarely focuses primarily on patient quality of life and self-reported outcomes post treatment. Arthroereisis is a debated topic among foot and ankle specialists in the United States; however, it is readily used and supported in many other countries. Historically, metallic arthroereisis devices have been utilized. However, in an effort to avoid secondary procedures for removal, bioabsorbable implants are becoming more popular. The aim of this study was to evaluate the patient-perceived quality of life after undergoing an arthroereisis by means of bioabsorbable implant using self-reported questionnaires.

Methods: Flexible flatfoot patients between the ages of eight and 15 treated with polymeric endo-orthotic implants between 2010 and 2012 completed questionnaires by phone. One hundred seventy-three patients were included in the study. Originally, 182 patients were involved, but nine were lost to follow-up. Patients were evaluated using the Italian FFI and SEFAS scoring systems. Exclusion criteria were neuromuscular disorders, synostosis, clubfoot, patients who underwent tendoachilles lengthening and individuals with joint hyperlaxity. A clinical evaluation was performed to assess laxity level. Surgical treatment involved an 8 mm endo-orthotic device placed into the sinus tarsi through a small lateral approach. Postoperatively, patients were nonweightbearing in a protective boot for two weeks, followed by weightbearing as tolerated.

Results: In total, 283 feet were treated out of the 173 patients included. Patient average age was 11 years old. Notably, four patients required a secondary procedure to remove the implant: three patients suffered from premature implant breakdown, and one experienced a local inflammatory response. The need for implant removal did not have a statistically significant impact on questionnaire scores. Mean follow-up time was 49.5 months. Average male FFI score was 5.3; females reported an average of 3.7. SEFAS scores were 47.0 and 47.3, respectively. Return-to-sports time was around 4.5 months on average. Prior to surgery, patients reported early fatigue and some degree of pain, especially after athletic activities. Mean follow-up was four years after surgery.

Conclusions: The use of bioabsorbable arthroereisis for the treatment of flexible pes planus in pediatric patients had a very low failure rate of 1.41 percent in this study. Explantation of the device did not have a significant influence on foot position and resulted in good clinical outcomes according to the authors. Advantages compared to metallic implants were reported to be a reduction in the number of patients requiring implant removal and earlier return to sports. This study could have been improved by having patients complete preoperative questionnaires in addition to postoperative surveys. It would be interesting to see if patients noted a remarkable reduction in time to fatigue and discomfort when performing athletic activities after surgical intervention. Although not the primary aim of the study, correlation between radiographic evaluation and patient satisfaction several years after implantation could add validity to their procedural choice. 

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