SLR - September 2020 - Joyann E. Oakman

Operative Versus Nonoperative Treatment in Children with Painful Rigid Flatfoot and Talocalcaneal Coalition

Reference: Luigi Di Gennaro G, Stallone S, Olivotto E, Zarantonello P, Magnani M, Tavernini T, Stilli S, Trisolino . Operative Versus Nonoperative Treatment in Children with Painful Rigid Flatfoot and Talocalcaneal Coalition. BMC Musculoskelet Disord. 2020 March 24; 21: 185.

Scientific Literature Review

Reviewed By: Joyann E Oakman, DPM
Residency Program: Hoboken University Medical Center - Hoboken, NJ

Podiatric Relevance: The management protocols for symptomatic rigid flatfoot (RFF) with associated talocalcaneal coalition (TCC) typically begin with conservative treatment, with surgery reserved for if this fails. Historically, ubtalar or triple arthrodesis has been recommended, but recently good results have been reported with coalition resection and tissue interposition. Studies have also stressed the vitality of correcting the hindfoot alignment for improved function, pain level, and subtalar joint (STJ) motion. The purpose of this study was to compare nonoperative and operative treatments in children with TCC and RFF.

Methods: This is a Level IV retrospective comparative study of patients with painful RFF with TTC confirmed by T, between 2005 and 2015 at a single center for pediatric orthopedics. A total of 55 children made up two cohort groups: A) nonoperative manipulation under anesthesia and casting for five weeks followed by custom shoe inserts (34 children; 47 feet); B) operative TCC resection, allograft interposition and STJ arthroereisis with a nonresorbable crew (21 children; 34 feet). Follow-up was at least three years, and data were collected and analyzed by two independent observers. The American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS-AHS), and the Foot and Ankle Disability Index (FADI) were used for clinical evaluation at the latest follow-up visit. On CT, heel valgus, coalition area, STJ space narrowing and STJ osteoarthritis (OA) were assessed. Postoperative radiographs were limited, thus the preoperative and postoperative radiographic angle differences were not analyzed.

Results: The mean age at treatment was 11.8 years. The mean follow-up was significantly longer in the nonoperative group (7.8 versus 4.7 years). Return to regular sport averaged 10 months for operative and seven months for nonoperative. There were no differences between groups concerning age at treatment, gender, bilaterality, baseline AOFAS-AHS, or radiographic features. In all cases, the coalition involved less than 50 percent of the STJ and no OA was observed. At latest follow-up, the AOFAS-AHS significantly increased in both groups, with more improvement in the operative group. The FADI score was better in the operative group at 93 points, versus 81 points in the nonoperative group. There were no reported complications in either group. Six patients were unsatisfied with the nonoperative treatment and required surgery two to four years later.

Conclusions: The authors found that 15 percent of the cases in the nonoperative group eventually required surgery and the functional scoring was in favor of the operative group, thus concluding that the proposed operative treatment may be a better direct option for these cases. The nonoperative management of RFF with TCC can be costly and time-consuming, and often unsatisfactory for the patient if pain is present. Therefore, children with pain could be addressed directly with surgical treatment, keeping in mind the goal to eliminate pain and improve function; this can be obtained via hindfoot alignment with arthroereisis and improvement in STJ motion via coalition excision and interposition. Further high level studies are needed to confirm this and identify the best out of all of the surgical options to treat this condition.

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