J Korean Orthop Assoc.  2022 Aug;57(4):291-299. 10.4055/jkoa.2022.57.4.291.

Surgery for Flatfoot Unresponsive to Conservative Treatment in Children and Adolescents

  • 1Department of Orthopaedic Surgery, College of Medicine, Pusan National University, Busan, Korea


Simple flatfoot is common in children and adolescents, and usually does not require treatment. On the other hand, symptoms can occur when underlying abnormalities are present and continue even after treatment. This study examined the accompanied abnormalities in a flatfoot unresponsive to conservative treatment.
Materials and Methods
Forty-six symptomatic flatfeet in 31 patients (15 bilateral; 16 unilateral; 11 females and 20 males) who undergone multiprocedural surgical treatment (mean age at the time of surgery, 10.9 years), were studied retrospectively. The accompanying comorbidities were evaluated: BMI (obesity>95%tile), joint laxity and hypermobility by the Beighton score (5 or more points of the Beighton score), Achilles tendon or gastrocnemius muscle tightness by the Silfverskiöld test, and bony malalignment (genu valgum or femoral and tibial torsion) and other foot disorders by computed tomography and magnetic resonance imaging. The surgical results for 23 feet (follow-up period after surgery>2 years) were evaluated by Oxford Ankle Foot Questionnaire for Children (OxAFQC) and mid- and hindfoot American Orthopaedic Foot Ankle Society (AOFAS) scores.
Of 31 patients 11 had soft-tissue hypermobility, and seven had obesity. Of 46 symptomatic flatfeet, comorbidities included Achilles tendon (or gastrocnemius muscle) tightness (42 feet), symptomatic accessory navicular (16), lower extremity malalignment (11) (seven decreased femoral anteversion, and four increased tibial external torsion), and genu valgum (six in three patients). Achilles tendon lengthening (43 feet) and femoral and tibial rotational osteotomy (12), and temporary hemiepiphysiodesis (six) were performed. For the flatfoot, peroneal tendon lengthening (three feet), posterior tibial tendon advancement (8), calcaneal varus osteotomy (10), and calcaneuscuboid-cuneiform (3C) osteotomy (24) were performed. For 23 feet, changes in mean OxAFQC scores before and after surgery were significant (p<0.05). The midfoot and hindfoot AOFAS scores at the last follow-up were 94.9±7.7 and 96.0±6.7, respectively.
Symptomatic flatfoot unresponsive to conservative treatment can involve a concomitant abnormality in children and adolescents. Hence, a thorough systemic evaluation is required to understand the pathophysiology and for successful treatment after surgery.


flatfoot; children; adolescents; surgery
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