Mid-term Results of Subtalar Arthroereisis with Talar-Fit Implant in Pediatric Flexible Flatfoot and Identifying the Effects of Adjunctive Procedures and Risk Factors for Sinus Tarsi Pain

Abstract

Objectives: To (i) report the mid-term outcomes of subtalar arthroereisis using Talar-Fit implant for the treatment of flexible flatfoot patients; (ii) compare clinical and radiographic outcomes between arthroereisis with and without adjunctive operative procedures to investigate the effects of adjuncts on the outcomes; and (iii) analyze the risk factors associated with sinus tarsi pain, which is the most common postoperative complication of arthroereisis. Methods: Thirty-one flexible flatfoot children and adolescents (46 feet) treated with subtalar arthroereisis using Talar-Fit implant from June 2014 to May 2019 were retrospectively analyzed. The feet were divided into four treatment groups: (i) arthroereisis alone, (ii) arthroereisis with gastrocnemius recession, (iii) arthroereisis with Kidner procedure, and (iv) arthroereisis with gastrocnemius recession and Kidner procedure. Clinical function was evaluated based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score. The following angles were measured for radiographic evaluation: talar-first metatarsal angle, calcaneal pitch angle, and talar declination angle on the lateral view; and talar-first metatarsal angle, talocalcaneal angle, and anteroposterior talonavicular coverage angle on the anteroposterior (AP) view. The paired Student's t-test was used to compare the pre- and postoperative angular measurements and AOFAS scores. The Wilcoxon rank-sum test was undertaken to determine the outcome differences among four treatment groups. Multivariate logistic regression analysis was used to analyze risk factors for sinus tarsi pain. P value <0.05 is considered statistically significant. Results: The mean follow-up of the feet was 32.8 months (range, 10–71 months). The mean AOFAS score significantly improved from 55.5 ± 14.5 preoperatively to 86.3 ± 9.9 (P < 0.001). Comparison of radiographic outcomes showed that the lateral talar-first metatarsal angle decreased by a mean of 19.1° ± 11.9° (P < 0.001), the calcaneal pitch angle increased by a mean of 5.4° ± 3.4° (P < 0.001), the talar declination angle decreased by a mean of 14.8° ± 9.9° (P < 0.001), the AP talar-first metatarsal angle decreased by a mean of 15.6° ± 10.3° (P < 0.001), the AP talocalcaneal angle decreased by a mean of 7.2° ± 8.3° (P = 0.001), and the AP talonavicular coverage angle decreased by a mean of 20.4° ± 9.0° (P < 0.001). There were no statistically significant differences with regard to AOFAS score and all angle measurements on both the AP and lateral views among the four treatment groups. There was one dislocation case caused by a fall 6 weeks after surgery, which was treated nonoperatively. The incidence of sinus tarsi pain was 13% and logistic regression analysis indicated that patients with a longer distance from the tail end of the implant to the lateral calcaneal wall had 38.8% greater odds of developing sinus tarsi pain. Conclusions: The mid-term clinical and radiographic results were satisfactory in patients who underwent the subtalar arthroereisis procedure using Talar-Fit implant, alone or in combination with other adjuncts, for the treatment of flexible flatfoot.