Health Problem: Flatfoot (FF) refers to a progressive developmental or acquired deformity characterized by plantar medial rotation of the talus, decrease in medial arch height, and abduction of the forefoot. In children, FF may be an isolated clinical entity or it may be found with neuromuscular disorders (e.g., cerebral palsy [CP]). Untreated, FF may lead to pain, abnormal gait, decreased function, and increased risk of injury. Flexible flatfoot (FFF) is commonly seen in pediatric orthopedic clinics and estimates of its prevalence range from ≥ 2.7% to 18%, differing between age groups.
Technology Description: Subtalar arthroereisis (SA) is a surgical option for treating children with symptomatic FF deformity that does not respond to conservative measures and that negatively impacts the patient’s ability to function in activities of daily living. SA involves limitation of subtalar joint pronation by surgical placement of an implant into the sinus tarsi, which prevents abnormal rotation of the tarsus. It shifts loads from the medial to lateral column and decreases the movement of the talonavicular joint compared with a flattened foot without the implant. Correction is achieved by stimulation of proprioceptive foot receptors, allowing active inversion of the foot and normal subtalar joint motion while blocking excessive pronation. Surgery is performed with locoregional or general anesthesia and the implant may be removed after correction. SA is performed with a variety of devices, alone or in conjunction with adjunct procedures such as Achilles tendon lengthening, bunionectomy, and others.
Controversy: Debate continues regarding the necessity of treatment and the appropriate treatment options for FF. However, it is generally accepted that symptomatic FF, rigid FF, progressive FF, or withdrawal from physical activity due to FF merit detailed evaluation and accurate diagnosis. When conservative measures fail to produce symptomatic relief, surgical management may be indicated. Although no well-accepted objective parameters for surgical indications exist, there are several options, such as soft tissue plication, tendon lengthening, osteotomy, and SA.
Key Questions: Key questions regarding SA for treatment of pediatric FF include:
Does SA provide long-term correction of FF deformity, reduce symptoms, and increase functionality?
How does SA compare with other well-established surgical approaches such as joint fusions and osteotomies?
Is SA safe in children with FF?
Have definitive patient selection criteria for the use of SA in the treatment of FF been established?
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