A retrospective cohort study comparing the therapeutic efficacy of three surgical interventions for pediatric flexible flatfoot.

Background: This retrospective study evaluated clinical and radiological outcomes of three surgeries for children's flexible flatfeet. A consensus on the most effective surgical approach is lacking, but it's crucial for improving affected children's function and quality of life. Methods: From June 2013 to August 2019, a total of 31 children (49 feet) with flexible flatfoot were treated. Consecutive patients aged 6-18 years with symptomatic flexible flatfoot (failure of ≥6-month conservative therapy) were included. Exclusion criteria included neuromuscular disorders or prior foot surgery. Surgical allocation was based on surgeon expertise and anatomical severity: subtalar extra-articular screw arthroereisis (SESA) group (10 feet), HyProCure implantation at tarsal sinus (HyProCure group) (21 feet), calcaneo-cuboid-cuneiform (Triple C) osteotomy group (18 feet). The general data, preoperative imaging data, postoperative imaging data, and final follow-up imaging data were recorded. Baseline characteristics were comparable across the three groups, including age, sex, and preoperative American Orthopedic Foot and Ankle Society (AOFAS) scale. Clinical outcomes were assessed using the modified AOFAS. A total of six parameters on anteroposterior (AP) and lateral X-rays of the foot in weight loading were measured and compared. Results: The operative time and intraoperative blood loss in the SESA group and HyProCure group were significantly lower than those in the Triple C osteotomy group (P<0.05). However, the duration of correcting flatfoot in the Triple C osteotomy group was better than that in the other two groups (P<0.05). The postoperative follow-up lasted for at least 32 months, with an average of 41 months. The AOFAS scores of all three groups showed significant improvement compared to preoperative scores (P<0.05). As for postoperative imaging measurement indexes among all three groups, AP talo-first metatarsal angle, lateral talo-first metatarsal angle, AP talocalcaneal angle, Talonavicular coverage angle, and calcaneal pitch angle had significantly improved from preoperatively measured values (P<0.05). There was no significant difference observed between clinical outcomes or imaging measurement indexes among these three groups. The incidence rate of tarsal sinus pain was 10% in the SESA group while 14.3% was observed in the HyProCure group; no patient underwent removal of internal fixation due to obvious pain symptoms. In the SESA group, 10% incidence rate was observed for fibular muscle contracture while 16.7% incidence rate was seen for wound pain after the Triple C osteotomy procedure. Conclusions: Compared to the other two groups, the Triple C osteotomy group corrects flatfoot deformities quicker but has a longer surgery and more bleeding. SESA, HyProCure implantation at tarsal sinus, and Triple C osteotomy achieve satisfactory results for symptomatic flexible flatfeet. But due to the study's retrospective nature, more randomized controlled trials are needed to confirm the findings. Level of Evidence: IV retrospective study.