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Surgical Treatment of Flexible Flatfoot in Children
A FOUR-YEAR FOLLOW-UP STUDY
BY SANDRO GIANNINI, MD, FRANCESCO CECCARELLI, MD, MARIA GRAZIA BENEDETTI, MD, FABIO CATANI, MD, AND CESARE FALDINI, MD Definition lexible flatfoot in children is one of the most common disorders in orthopaedics1,2. Despitenumerous papers published in the literature, the definition and etiology of flexible flatfoot; the level of disability that it may cause; and the opportunity for, appropriate time of, and efficacy of its treatment are still open to debate3,4. In fact, if the foot is only morphologically flat, characterized by a lower medial arch and a broadening of the footprint, it can be well toleratedthroughout the person’s life. If, however, the foot is also functionally flat—that is, a foot that during weight-bearing and walking stays in a prevalent or persistent pronation—can cause secondary problems5,6. Materials and Methods wenty-one children, ranging in age from eight to fifteen years, with bilateral functional flexible flatfoot were included in the study. The diagnosis of functional flexibleflatfoot was made by clinical examination, radiographic examination, and, in doubtful cases, gait analysis in order to confirm functional impairment. Clinical diagnosis was based on restriction of dorsiflexion of the ankle joint after manual correction of the deformity, increased heel valgus at rest and during the tiptoe standing test, footprint enlargement at rest and during the Jack test, and thepresence of discomfort (slight pain and fatigue). These parameters were measured before surgery and four years after it. Preoperative and postoperative data were compared by statistical analysis with the Student t test and the chi-square test (level of significance, p < 0.001). Standard lateral and dorsoplantar radiographs were made before surgery
Functional Consequences ersistentpronation of the subtalar joint during the propulsive phase of gait is mostly responsible for major deformities in adult life7. Hallux valgus, metatarsalgia, tarsal tunnel syndrome, posterior tibial tendon dysfunction, and osteoarthritis of the subtalar and midtarsal joints are often the consequences and the “natural history” of this deformity8,9. In order to avoid these problems, surgical correctionof the deformity during growth is recommended10. The goal of surgical treatment is to correct the subtalar pronation, thereby restoring the appropriate relationship between the talus and the calcaneus11. The procedures that have been described are arthrodesis, osteotomy, and arthroereisis1,2,8,11,12. While arthrodesis is indicated in adults with degenerative changes in the subtalar joint,osteotomy and arthroereisis are the two principal options for children9.
Aim of the Study he aim of this study was to evaluate the outcomes four years after correction of flexible flatfoot, in growing children, with arthroereisis of the subtalar joint with use of a bioreabsorbable implant made of poly-L-lactic acid (PLLA) approved by the European Community (Stryker Howmedica) (Fig. 1).T
Figs. 2-14 The surgical procedure (see text).
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORG VO L U M E 83-A · S U P P L E M E N T 2, P A R T 2 · 2001 S U R G I C A L TR E A T M E N T O F F L E X I B L E F L A T F O O T I N C H I L D RE N
and at the time of follow-up. Meary’s line was measured in all cases. Gait analysis consisted ofkinematic, kinetic, and electromyographic measurements. All patients were followed for four years. Surgical Treatment urgical treatment is performed under general anesthesia. A tourniquet is applied proximally to the lower limbs. Patients are placed in a supine position with the foot internally rotated. A 1-cm incision over the sinus tarsi is performed. The extensor retinaculum is opened to the cuboid...