Original article 345

Prospective comparison of subtalar arthroereisis with lateral

column lengthening for painful flatfeet
David Y. Chonga, Bruce A. Macwilliamsb, Theresa A. Hennesseyb,
Noelle Teskeb and Peter M. Stevensb,c

We prospectively compared subtalar arthroereisis with alternative to lateral column lengthening that merits further
lateral column calcaneal lengthening for the treatment investigation. J Pediatr Orthop B 24:345–353 Copyright ©
of painful flatfeet. Twenty-four feet (mean age of patients 2015 Wolters Kluwer Health, Inc. All rights reserved.
12.8 years) were treated. Kinematic motion analysis, Journal of Pediatric Orthopaedics B 2015, 24:345–353
pedobarometry, and radiography were performed, and the
Oxford Ankle–Foot Questionnaire for Children was Keywords: calcaneal osteotomy, kinematic motion analysis,
lateral column lengthening, painful flatfoot, pedobarometry, planovalgus foot,
administered for each patient before surgery and at the subtalar arthroereisis
1-year follow-up. We found statistically significant a
University of Oklahoma, Department of Orthopedic Surgery and Rehabilitation,
improvements in both groups, with no difference in their Oklahoma City, Oklahoma, bShriners Hospital for Children and cPrimary Children’s
outcomes. Both groups showed significantly improved Hospital, University of Utah, Salt Lake City, Utah, USA

hindfoot and midfoot motion and positioning. Hindfoot Correspondence to David Y. Chong, MD, OUHSC Department of Pediatric
range of motion was preserved. Radiography and Orthopedics, 940N.E. 13th Street, Suite 2009/MRI 2000, Oklahoma City,
OK 73104, USA
pedobarometry also revealed significant improvements. Tel: + 1 405 271 6458; fax: + 1 405 271 1502; e-mail: [email protected]
Subtalar arthroereisis is a valid and potentially less-invasive

Introduction procedure may have resulted in overuse, with question-

Flatfoot is a common complaint presenting at the clinic. able indications.
During weight-bearing, the midfoot pronates, the medial
Opponents of subtalar arthroereisis have cited high
arch sags, and the hindfoot moves into valgus. An
complication rates and an implant removal rate of up to
asymptomatic, flexible flatfoot does not require any
40% [19–21]. The reported incidence of implant loos-
treatment [1,2], and if there are symptoms, most resolve
ening or breakage has reduced since the introduction of
with conservative treatment. Some children have persis-
titanium implants [22]. Other complications include
tent pain, and it is reasonable to offer surgical correction.
overcorrection and undercorrection of the hindfoot varus,
Various surgical techniques have been reported without a
sinus tarsi pain, cortical erosion, inflammatory synovitis,
clear consensus of treatment [3–5], which demonstrates
talar avascular necrosis, and calcaneus fractures [23–27].
the need for a better understanding of subtalar instability There is also concern toward the possible loss of hindfoot
and its optimal management. mobility. Metcalfe et al. [28] reviewed the literature and
found that most studies consisted of case reports or ret-
Evans [6] introduced the concept of lateral column
rospective case series. Although estimates of patient
lengthening in 1975, and the procedure has been further
satisfaction were between 79 and 100%, very few studies
developed by Mosca [7]. Good results have also been
had validated outcome measures. They also found dis-
reported in the population with neuromuscular diagnoses
crepancy and lack of transparency in how radiographic
[8,9]. However, complication rates of up to 69% have
measurements were made. Reporting of complications
been reported, with significant problems from delayed
was also erratic, with little explanation on how the
unions or nonunion [10]. There is also potential for
researchers determined whether a foot was overcorrected
damage to the articular facets from the osteotomy [11]
or undercorrected.
and for calcaneocuboid subluxation [12,13].
The purpose of this prospective, nonrandomized study was
Chambers [14] first introduced the concept of subtalar to evaluate two different surgical treatments for sympto-
arthroereisis in 1946, elevating the floor of the sinus tarsi matic planovalgus feet: lateral column lengthening osteot-
with an autogenous bone block to prevent eversion. omy and subtalar arthroereisis. Our goal was to compare the
Arthroereisis has since evolved into a wide range of outcomes of these two surgeries and determine whether
implants. Staples, silicone, thermoplastic, and titanium both treatments resulted in clinical improvement. This was
implants have all been studied, but most with short-term accomplished through preoperative and postoperative
follow-up and nonvalidated outcome measurements [15, kinematics, pedobarography, radiographic measurements,
16]. The population with neuromuscular diagnoses has and validated outcome measures. We were particularly
met with mixed results [16–18]. The simplicity of the interested in analyzing the kinematic changes to quantify
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/BPB.0000000000000179

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

346 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4

the changes in foot mobility and alignment during ambu- Transplant Foundation). The foot was assessed intraopera-
lation, as they have not been previously studied to our tively for improved talonavicular coverage and recreation of a
knowledge. Our hypothesis was that both procedures satisfactory medial arch. Gastrocnemius recessions were
would yield significant improvement and be equivalent in performed in three patients and three feet; peroneal tendon
their results. transfers were performed bilaterally in one patient. Staples
were used in three feet for graft stability. Patients were
Methods placed in non-weight-bearing below-knee casts for 1 month.
We obtained institutional review board approval for a Following cast removal, ambulation was permitted in cam-
prospective investigation, performed at the Primary walker type boots for an additional month. Radiographs
Children’s Medical Center and Shriners Hospitals for were obtained to check allograft incorporation before
Children in Salt Lake City, Utah, from 2010 to 2011. The weight-bearing.
trial was registered in a public trials registry (http://www.
Patients were evaluated preoperatively through weight-
ClinicalTrials.gov, NCT02055495). A total of 15 patients
bearing anteroposterior (AP) and lateral radiographs of
(24 feet) without underlying neuromuscular diagnoses
their ankles and feet. Radiographic measurements of the
were enrolled. All participants and their parents gave
calcaneal pitch, lateral talocalcaneal angle, AP and lateral
informed consent for participation. Patient ages ranged
talo-first metatarsal angle, and AP talonavicular coverage
from 8 to 17 years (mean 12.8 years) at the time of sur-
were obtained as described by Davids et al. [29].
gery. Inclusion criteria were planovalgus deformity,
Postoperative radiographs were obtained at a mean of
painful symptoms refractory to conservative treatment for
12.9 months after surgery.
at least 6 months, and independent ambulation without
assistive devices. We excluded patients taking medica- Kinematic studies were performed on each patient pre-
tion affecting motor control and those unable to follow operatively. Reflective markers were placed on the
directions or participate in a gait lab study. Patients patient’s legs, following a protocol to collect both standard
enrolled at the Primary Children’s Medical Center were lower extremity data and multisegment foot data [30].
treated with arthroereisis by a single surgeon. Patients Marker trajectories were recorded at 100 Hz as the patient
enrolled at Shriners Hospitals for Children were treated walked through a calibrated volume using a 10-camera
with lateral column lengthening by three different sur- motion capture system (Vicon, Centennial, Colorado,
geons. We consider this a single-center study, as all USA). Force plates (AMTI, Watertown, Massachusetts,
attending surgeons are faculty of the University of Utah. USA) within the volume recorded ground reaction forces.
All surgeries were performed at Shriners Hospitals for Hindfoot varus/valgus, hindfoot flexion/extension, mid-
Children, because of financial limitations on using foot inversion/eversion, midfoot flexion/extension, mid-
arthroereisis screws. The number of arthroereisis foot abduction/adduction, and ankle power were
implants available was limited because of financial con- calculated from the model. Patients then walked over a
straints, and as such, we were only able to enroll a small pedobarograph mat (RSScan, Paal, Belgium), which
sample of patients in the arthroereisis group. recorded data at 100 Hz. Analysis of the foot pressures
focused on timing and the medial/lateral position of the
Seven patients and 13 feet were enrolled in the arthroer-
center of pressure. To assess outcomes, data were com-
eisis group (six bilateral, one unilateral). These patients
pared with those from a set of typically developing chil-
received Vilex titanium implants (McMinnville,
dren (34 feet from 17 individuals, mean age 10.2 years)
Tennessee, USA) with outpatient surgery. A 1 cm lateral
collected from a previous study [31,32]. Kinematic studies
incision was centered over the sinus tarsi and a cannulated
were repeated postoperatively at a mean of 12.7 months.
system was used to implant the conical screw. Fluoroscopy
confirmed appropriate placement and deformity correction. The Oxford Ankle–Foot Questionnaire for Children
Care was taken to avoid overcorrection of the hindfoot into (OxAFQ-C) is a child and parent reported outcome
varus. The gastrocnemius was intraoperatively assessed for measure used for children [32,33]. It has been proven to
tightness after placement of the implant, but it was not be valid and reliable in evaluating the effectiveness of
lengthened for any patient in this study. Patients were interventions for foot and ankle problems in children
placed in below-knee walking casts for 3 weeks to mini- [34]. The OxAFQ-C contains 15 questions, with five-
mize possible implant loosening. Following cast removal, point scales to calculate scores in physical and emotional,
unrestricted activities were encouraged. and school and play domains [31,32]. This questionnaire
was administered to both parents and children before and
Eight patients and 11 feet were enrolled in the lateral col-
after surgery, at the same time as their kinematic studies
umn lengthening group (three bilateral, five unilateral). One
(mean follow-up 12.7 months).
patient had a calcaneocuboid fusion, and seven patients
underwent an anterior calcaneal osteotomy as described by
Evans [6]. A 4 cm lateral incision was made over the distal Statistics
calcaneus, where an opening wedge osteotomy was made, A paired one-tailed Student t-test was used to compare
inserting a wedge of cadaveric bone (Musculoskeletal preoperative and postoperative results. Two-tailed t-tests

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Subtalar arthroereisis for painful flatfeet Chong et al. 347

were used to compare the two groups. Mann–Whitney altering calcaneal pitch. The midfoot flexion/extension
U-tests were performed on nonparametric OxAFQ- range of motion was only decreased in the arthroereisis
C data. group, from about 23° to 19°. Both groups showed sta-
tistically significant decreases in midfoot abduction (7°-
Results –8°). The mean supination [35] statistically improved in
Radiographic measures both groups. The arthroereisis group showed a significant
In our analysis of radiographic measurements, we found improvement in the range of motion, with an increase in
no statistical difference between the two groups pre- the adduction peak of the midfoot during toe-off.
operatively, except for the AP talo-first metatarsal angle, Measurements of ankle power showed no changes post-
which was greater in the lengthening group by 9.3°. In operatively for both groups. No significant differences
both groups, we found statistically significant post- were found between the outcomes of both groups.
operative decreases in the lateral talocalcaneal angle, AP
and lateral talo-first metatarsal angle, and AP talonavi- Pedobarometry
cular coverage (Table 1 and Fig. 1). The difference in the Analysis of foot pressures showed statistically significant
outcomes of the two groups was found to be statistically improvements in both groups. Compared with controls,
significant only for an increase in calcaneal pitch in the both groups had increased time on the hindfoot and
lengthening group. This is consistent with the previous decreased time on the midfoot preoperatively, as well as
literature finding that arthroereisis does not change cal- medialization of the center of pressure. Postoperatively,
caneal pitch [32], as well as with the fact that a proportion both groups had decreased time on the hindfoot and
of the lengthening group underwent gastrocnemius increased time on the midfoot. However, only the
recessions. arthroereisis group reached statistical significance
(P = 0.01) with reduced time on the hindfoot. Both
Kinematics groups also showed a statistically significant lateralization
Kinematic analysis (Figs 2 and 3) demonstrated statisti- of both the hindfoot and the midfoot center of pressure
cally significant postoperative improvements in both measurements (P < 0.01). No differences were seen
groups, but no difference between the two outcomes. In between the groups preoperatively or on comparing
the hindfoot, both groups demonstrated a 4° decrease in outcomes between the two groups (Fig. 4).
mean valgus, with preservation of subtalar range of
motion. The mean hindfoot dorsiflexion was improved
only in the lengthening group by 8°, which is consistent Oxford ankle–foot questionnaire
with our radiographic findings. Both groups showed improvements in their Oxford
scores, but only the arthroereisis group achieved statis-
In the midfoot, both groups showed a 3–4° decrease in tical significance (Fig. 5). In the arthroereisis group, the
mean inversion. The mean midfoot flexion in relation to mean parental scores increased from 55.5 to 82.9
the hindfoot was significantly improved, by 8°, in the (P = 0.017), and the mean child scores improved from
lengthening group only; this finding is also explained by 54.4 to 86.7 (P =0.014). In the calcaneal lengthening
the differences in the two approaches with regard to group, the mean parental scores improved from 47.9 to
70.1, and the mean child scores improved from 59.6 to
Table 1 Radiographic measurements and comparison of 86.7. Two patients in this group did not fill out pre-
arthroereisis and calcaneal lengthening operative Oxford questionnaires, which may be why we
Mean were unable to achieve statistical significance in this arm.
Mean pre- post-op Change P-value (pre-op P-value (post-
op (deg.) (deg.) (deg.) vs. post-op) op AR vs. CL)
Calcaneal pitch Complications
AR 13.0 11.7 − 1.3 0.08 0.01* We encountered two complications within the lateral
CL 12.0 14.4 2.4 0.02*
Lateral TC column lengthening group. One patient had partial
AR 52.9 43.8 − 9.1 0.004* 0.62 extrusion of the graft and staple; upon hardware removal,
CL 52.7 45.2 − 7.4 0.0002*
Lateral T-1MT
the graft was stable and the patient did well clinically and
AR 23.8 12.3 − 11.5 0.001* 0.85 radiographically. One patient had a wound dehiscence
CL 23.4 11.2 − 12.2 0.00002* that was managed conservatively. Of note, the same
AP T-1MT
AR 18.9 8.3 − 10.6 0.0003* 0.30 problem occurred 1 year later in the contralateral side.
CL 28.2 13.4 − 14.8 0.0005* We encountered two complications within the subtalar
AP talonavicular
AR 31.0 19.1 − 11.9 0.0001* 0.07
arthroereisis group. Two patients developed implant-
CL 39.0 17.7 − 21.3 0.0005* related pain and subsequently underwent removal at 24
and 31 months after surgery, respectively. Both clinically
AP, anteroposterior; AP-1MT, anteroposterior talo-first metatarsal angle; AR,
arthroereisis; CL, calcaneal lengthening. retained their foot position, with improvement of their
*Statistically significant with P<0.05. pain after surgery (Fig. 6).

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

348 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4

Fig. 1

(a)

Pre-op Post-op

(b)

Pre-op 50 Post-op

Lossy: 20:1

80 mm

80 mm

Clinical photographs and radiographs of the (a) subtalar arthroereisis group and (b) the lateral column lengthening group.

Discussion objectively and subjectively. Neither method yielded

Both methods of surgical correction of the painful, flex- outcomes that were superior to the other method. The
ible flatfoot yielded significant improvements, both focal point of this study was kinematic analysis, and by

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Subtalar arthroereisis for painful flatfeet Chong et al. 349

Fig. 2

Ankle complex in/eversion Ankle complex flexion extension Ankle power

30 60 6
In Typical DF Gen
CL pre-op
CL post-op 45
15 AR pre-op 4
AR post-op 30
Degrees

Degrees

W/kg
0 15 2
0
−15 0
−15
Ev PF Abs
−30 −30 −2
0 25 50 75 100 0 25 50 75 100 0 20 40 60 80 100

Supination index Mid-foot flexion/extension Mid-foot ab/adduction

30 30 30
Sup P1 Ad
15
15 0 15
Degrees

Degrees

Degrees
−15
0 0
−30
−45
−15 −15
−60
Pro Cv Ab
−30 −75 −30
0 25 50 75 100 0 25 50 75 100 0 25 50 75 100
% Gait cycle % Gait cycle % Gait cycle

Kinematic plots of both groups (arthroereisis in blue, calcaneal lengthening in red) compared with typical samples (green).

using a multisegment foot model, we found a statistically stimulating the patients to dynamically correct their flat-
significant improvement in kinematic measurements and feet. An interesting support to this argument is that De
pedobarometry results in both groups. Pellegrin et al. [38] and Richter and Zech [40] reported
that some patients in their case series spontaneously
The two treatments that we studied may affect the flatfoot corrected the contralateral foot after a single side was
complex differently. Arthroereisis may only minimally affect corrected. In addition, they both also reported main-
midfoot transverse plane deformities, which may be better tenance of the correction after the screw was removed,
addressed with lateral column lengthening or medial column which has also been reported in the subtalar implant lit-
shortening. If a patient’s forefoot has significant varus, then a erature [44–47]. The proposed mechanism is likely similar
subtalar arthroereisis may push the forefoot into even more in nature to the concept of the implant used in our study.
varus deformity [36]. Conversely, lateral column lengthen- Future long-term studies would help determine the
ing may not affect naviculocuneiform sag [37]. In our study, longevity of the correction for either method.
however, there were no significant changes seen between
the two groups to recommend one over the other. Although we did find significant changes in our radio-
graphic measurements, we feel that clinical outcomes are
Importantly, we found no loss of hindfoot mobility in not necessarily correlated to radiographic outcomes.
either group. This contradicts the common concern that Although our measurements were made by a single
arthroereisis stiffens the mobility of the hindfoot. Three physician, interobserver variability has been found to be
patients showed qualitative improvement in subtalar low [6,12]. However, radiographic measurements can also
motion on physical examination. This points toward an be unreliable on the basis of their technique and the
effect greater than a simple mechanical block in the sinus severity of deformity. Most radiographs of severe flatfoot
tarsi. A proprioceptive mechanism has been proposed in deformity do not have a true lateral of the foot, leading to
the recent literature describing the calcaneo-stop screw some measurement error, especially when determining
method, in which a screw is placed into the sinus tarsi, the axis of the talus. Talar tilt exceeding 10° can cause an
either in the talus or in the calcaneus [38–43]. Authors apparent increase in the talocalcaneal angle, even if the
have reported large case series with good results similar to relationship is normal [48].
those from subtalar implants, and this method is also
minimally invasive and reversible. It is proposed that the The results of our Oxford scores reveal that both parents
screw not only acts to mechanically prop up the talus, but and children in both groups felt significant improvement
that it also modifies the proprioception of the foot, postoperatively. There was a statistically significant

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

350 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4

Fig. 3

30 30 Pre 5
Post
25 Typical
4
Mean hindfoot flexion (deg.)

Peak hindfoot power (W/kg)

Hindfoot flexion ROM (deg.)
20 20
3
15

2
10 10

1
5

0 0 0
AR CL TD AR CL TD AR CL TD

5 P = 0.021
40 15
P = 0.007
P = 0.027

Mean midfoot abduction (deg.)

0
Mean midfoot flexion (deg.)

30 10
Mean supination (deg.)

−5
20 5
−10

P = 0.004
10 0
−15
P = <0.001

−20 0 −5
AR CL TD AR CL TD AR CL TD

20 40 15

P = 0.030
Midfoot abduction ROM (deg.)
Midfoot flexion ROM (deg.)

15 30
Supination ROM (deg.)

10

10 20

5
5 10

0 0 0
AR CL TD AR CL TD AR CL TD

Hindfoot and midfoot kinematic changes and analysis. Both groups show significantly decreased hindfoot valgus, while maintaining range of motion
(ROM). Both groups show decreased midfoot abduction and inversion. AR, arthroereisis; CL, calcaneal lengthening; TD, typically developing.

improvement only in the arthroereisis group; however, The groups were not randomized and, although the two
our sample size was too underpowered on the calcaneal groups were closely matched in initial kinematics, pedo-
lengthening side to draw any definite conclusion. barography, and Oxford scores, the lengthening group did

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 Subtalar arthroereisis for painful flatfeet Chong et al. 351

Fig. 4

(a) Arthroereisis Pre-op Calcaneal lengthening

Arthroereisis Post-op, 1 year Calcaneal lengthening

(b)
P = 0.001
40 25 60 Pre 35
Hindfoot center of pressure excursion

P = 0.006
Midfoot center of pressure excursion

P < 0.001 Post

P = 0.009 Typical
35 30
% Stance time on hindfoot

% Stance time on midfoot

P = 0.019 20
30
P = 0.004 25
40
25 P = 0.006
(% stance)

(% stance)

15 20
20 P = 0.013
10 15
15
20
10
10
5
5 5

0 0 0 0
AR CL AR CL AR CL AR CL AR CL TD AR CL TD
>2 SD medial >1 SD medial >2 SD medial >1 SD medial

(a) Pedobarometry clinical photographs and pressure studies of both groups. Notice the lateralization of the center of pressure in both groups
postoperatively. (b) Pedobarometry analysis. Upper plots are the percentage of stance time for the hindfoot (top left plot) and midfoot (top right plot),
where the center of pressure is either medially shifted to be outside of 1 SD from normal or 2 SD from normal. Bottom plots show percentage of
stance time on the hindfoot (bottom left) and midfoot (bottom right), with comparison with typically developing feet, with both groups showing
significant improvement. AR, arthroereisis; CL, calcaneal lengthening; TD, typically developing.

have a greater preoperative radiographic deformity. This lengthening. Arthroereisis is performed as an outpatient
may be due to a difference in patient populations at the two surgery, with smaller incisions and earlier weight-bearing,
hospitals at which enrollment took place. The discrepancy and it avoids the risks of allograft failure. If the implant
makes it difficult to prove that one treatment is superior. loosens or symptoms persist, the implant may be easily
However, our data does suggest that both procedures were removed, possibly maintaining correction. If both proce-
successful in achieving kinematic, radiographic, and clinical dures offer similar results, it is reasonable for parents to
improvement. Finally, the results reported here are short- choose a less-invasive method first. Unfortunately, most
term results and the conclusion may change if these patients insurance carriers currently deny reimbursement on the
are re-evaluated after several years. grounds that arthroereisis is an experimental procedure.
This restricts the serious evaluation of the potential risks
It is important to note that the morbidity and recovery time and benefits of arthroereisis, and it limited the sample size
for arthroereisis is significantly less than those for calcaneal in this study. We feel that this work is important to validate

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

352 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 4

Fig. 5

100 P = 0.014 100

P = 0.017

80 80

OxAFQ parent questionnaire

OxAFQ child questionnaire

60 60

40 40
Pre
Post
Typical

20 20

0 0
AR CL TD AR CL TD

OxAFQ results. Both groups showed improvement, but only the arthroereisis group showed statistical significance. AR, arthroereisis; CL, calcaneal
lengthening; OxAFQ, Oxford Ankle–Foot Questionnaire; TD, typically developing.

Fig. 6

WT bearing

Lossy: 20:1

Complications. Loosening of the arthroereisis implant (left) and calcaneal staple (right), both necessitating hardware removal.

the outcomes of subtalar arthroereisis, making it available flexible planovalgus feet. No differences were found between
for further randomized and long-term studies. the outcomes of both groups. Neither procedure caused any
loss of hindfoot mobility. The less-invasive nature and lower
Conclusion potential morbidity suggest that judicious use of arthroereisis
Both lateral column lengthening and subtalar arthroereisis implants is appropriate for some patients. However, further
significantly improved kinematic, radiographic, and subjective investigation and long-term outcome studies are warranted to
clinical outcome measures in the surgical treatment of painful, demonstrate the efficacy, safety, and cost-effectiveness of

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

 Subtalar arthroereisis for painful flatfeet Chong et al. 353

subtalar implants, as compared with the more accepted 22 Brancheau SP, Walker KM, Northcutt DR. An analysis of outcomes after use
method of calcaneal osteotomy and allograft. of the Maxwell–Brancheau arthroereisis implant. J Foot Ankle Surg 2012;
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