Research Article| Volume 61, ISSUE 2, P272-278, March 2022

Foot Typology, Dynamic and Static Weight Distribution, and Radiographic Changes After Subtalar Arthroereisis in Juvenile Symptomatic Flexible Flat Feet


      Flexible flatfoot is among the most common skeletal disorders in childhood. This study describes the dynamic and static correction effects of subtalar arthroereisis in adolescents with flexible symptomatic flatfeet in comparison to normal subjects as well as to results before and after removal of metal. Eighteen adolescents with 25 symptomatic flexible flatfeet were treated surgically with a subtalar arthroereisis at a mean of 12.5 (10-16) years. At follow-up (mean 3.9 years, range 0.4-8), patients filled out the American Orthopaedic Foot and Ankle Society questionnaire, received radiographs and were examined using dynamic and static pedobarography as well as static hindfoot axis examination. Results were compared to healthy controls (n = 13; 26 feet). Surgically treated feet (n = 25) had better questionnaire results after surgery than before, but lower scores than healthy feet. Radiological parameters improved significantly after surgery. Removal of metal did not influence post-surgical results (follow-up 2.8 years). Surgically treated feet had larger contact areas than normal feet with predominance to the midfoot region. The relative maximum force, relative peak pressure and contact time were higher in the midfoot of treated feet compared to controls. When comparing pedobarography data of treated versus untreated feet of the same patients (subgroup n = 11 feet), there were no differences. Subtalar arthroereisis was able to effectively treat symptomatic flexible flatfeet in this population. Results improved significantly evaluating a questionnaire, radiographs, dynamic and static weight distribution, but were still worse than results of healthy feet. There was no relapse after removal of metal.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • De Pellegrin M
        • Moharamzadeh D
        • Strobl WM
        • Biedermann R
        • Tschauner C
        • Wirth T.
        Subtalar extra-articular screw arthroereisis (SESA) for the treatment of flexible flatfoot in children.
        J Child Orthop. 2014; 8: 479-487
        • Mosca VS.
        Flexible flatfoot in children and adolescents.
        J Child Orthop. 2010; 4: 107-121
        • Hell AK
        • Döderlein L
        • Eberhardt O
        • Hösl M
        • von Kalle T
        • Mecher F
        • Simon A
        • Stinus H
        • Wilken B
        • Wirth T
        S2-guideline: pediatric flat foot.
        Z Orthop Unfall. 2018; 156: 306-315
        • Hösl M
        • Böhm H
        • Oestreich C
        • Dussa CU
        • Schäfer C
        • Döderlein L
        • Nader S
        • Fenner V
        Self-perceived foot function and pain in children and adolescents with flexible flatfeet—relationship between dynamic pedobarography and the foot function index.
        Gait Posture. 2020; 77: 225-230
        • Waizy H
        • Plaass C
        • Brandt M
        • Herold D
        • Stukenborg-Colsman C
        • Windhagen H
        • Claassen L
        Extra-articular arthroereisis according to Grice/Green versus calcaneal lengthening according to Evans: retrospective comparison for therapy of neurogenic pes planovalgus.
        Orthopade. 2013; 42: 409-417
        • Evans AM
        • Rome K.
        A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet.
        Eur J Phys Rehabil Med. 2011; 47: 69-89
        • Gijon-Nogueron G
        • Marchena-Rodriguez A
        • Montes-Alguacil J
        • Evans AM.
        Evaluation of the paediatric foot using footprints and foot posture index: a cross-sectional study.
        J Paediatr Child Health. 2020; 56: 201-206
        • Martínez-Nova A
        • Gijón-Noguerón G
        • Alfageme-García P
        • Montes-Alguacil J
        • Evans AM.
        Foot posture development in children aged 5 to11 years: a three-year prospective study.
        Gait Posture. 2018; 62: 280-284
        • Evans D.
        Calcaneo-valgus deformity.
        J Bone Joint Surg Br. 1975; 57: 270-278
        • Lowman C.
        An operative method for correction of certain forms of flatfoot.
        JAMA. 1923; : 1500-1502
        • Masterson E
        • Jagannathan S
        • Borton D
        • Stephens MM.
        Pes planus in childhood due to tibialis posterior tendon injuries. Treatment by flexor hallucis longus tendon transfer.
        J Bone Joint Surg Br. 1994; 76: 444-446
        • Shah NS
        • Needleman RL
        • Bokhari O
        • Buzas D.
        2013 Subtalar arthroereisis survey: the current practice patterns of members of the AOFAS.
        Foot Ankle Spec. 2015; 8: 180-185
        • Kitaoka HB
        • Alexander IJ
        • Adelaar RS
        • Nunley JA
        • Myerson MS
        • Sanders M.
        Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes.
        Foot Ankle Int. 1994; 15: 349-353
        • Kostuj T
        • Krummenauer F
        • Schaper K
        • Stief F
        • Zettersten K
        • Baums MH
        • Meurer A
        • Lieske S
        Analysis of agreement between the German translation of the American Foot and Ankle Society’s Ankle and Hindfoot Scale (AOFAS-AHS) and the Foot Function Index in its validated German translation by Naal et al. (FFI-D).
        Arch Orthop Trauma Surg. 2014; 134: 1205-1210
        • Vanderwilde R
        • Staheli LT
        • Chew DE
        • Malagon V.
        Measurements on radiographs of the foot in normal infants and children.
        J Bone Joint Surg Am. 1988; 70: 407-415
        • Flores DV
        • Mejía Gómez C
        • Fernández Hernando M
        • Davis MA
        • Pathria MN
        Adult acquired flatfoot deformity: anatomy, biomechanics, staging, and imaging findings.
        Radiographics. 2019; 39: 1437-1460
        • Thomas JL
        • Kunkel MW
        • Lopez R
        • Sparks D.
        Radiographic values of the adult foot in a standardized population.
        J Foot Ankle Surg. 2006; 45: 3-12
        • Hamel J.
        Radiologisch-dokumentierte Korrektureffekte beim kindlichen Pes planovalgus mit der Calcaneostop-Arthrorise und der Calcaneus-Verlängerungosteotomie.
        Fuß & Sprunggelenk. 2010; 8: 43-47
        • Hamel J
        • Kinast C.
        Der TMT-Index zur radiologischen Quantifizierung von planovalgus-deformitäten.
        Fuß Sprunggelenk. 2006; 4: 221-226
        • Davids JR
        • Gibson TW
        • Pugh LI.
        Quantitative segmental analysis of weight-bearing radiographs of the foot and ankle for children: normal alignment.
        J Pediatr Orthop. 2005; 25: 769-776
        • Hafer JF
        • Lenhoff MW
        • Song J
        • Jordan JM
        • Hannan MT
        • Hillstrom HJ.
        Reliability of plantar pressure platforms.
        Gait Posture. 2013; 38: 544-548
        • Murley GS
        • Menz HB
        • Landorf KB.
        A protocol for classifying normal- and flat-arched foot posture for research studies using clinical and radiographic measurements.
        J Foot Ankle Res. 2009; 2: 22
        • Ludwig O
        • Quadflieg R
        • Koch M.
        Einfluss einer Sensomotorischen einlage auf die aktivität des M. peroneus longus in der Standphase.
        Dtsch Z Sportmed. 2013; 2013: 77-82
        • Reilingh ML
        • Beimers L
        • Tuijthof GJM
        • Stufkens SAS
        • Maas M
        • van Dijk CN.
        Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view.
        Skelet Radiol. 2010; 39: 1103-1108
        • Hefti F
        • Brunner R.
        Flexible arch of the foot.
        Orthopade. 1999; 28: 159-172
        • Dars S
        • Uden H
        • Banwell HA
        • Kumar S.
        The effectiveness of non-surgical intervention (Foot Orthoses) for paediatric flexible pes planus: a systematic review: Update.
        PLoS One. 2018; 13e0193060
        • Hagen L
        • Pape JP
        • Kostakev M
        • Peterlein C-D.
        Pedobarographic changes during first month after subtalar extra-articular screw arthroereisis (SESA) operation of juvenile flexible flatfoot.
        Arch Orthop Trauma Surg. 2020; 140: 313-320
        • Ruiz-Picazo D
        • Jiménez-Ortega P
        • Doñate-Pérez F
        • Gaspar-Aparicio N
        • García-Martín V
        • Ramírez-Villaescusa J
        • Losa-Palacios S
        Radiographic and functional results following subtalar arthroereisis in pediatric flexible flatfoot.
        Adv Orthop. 2019; 20195061934
        • Vogt B
        • Toporowski G
        • Gosheger G
        • Rölfing JD
        • Rosenbaum D
        • Schiedel F
        • Laufer A
        • Kleine-Koenig MT
        • Theil C
        • Roedl R
        • Frommer A
        Subtalar arthroereisis for flexible flatfoot in children-clinical, radiographic and pedobarographic outcome comparing three different methods.
        Children (Basel). 2021; 8359
        • Kuhn H
        • Zuther W
        • Heine A
        Küster Hans-H. Die subtalare Arthrorise mittels Kalix® Implantat beim flexiblen Knick-Senkfuß.
        Fuß Sprunggelenk. 2010; 8: 48-54
      1. Arbab D, Frank D, Tingart M, Bouillon B, König DP, Abbara-Czardybon M. Ergebnisse der subtalaren schrauben-arthrorise beim kindlichen knick-senkfuß. deutscher kongress für orthopädie und unfallchirurgie (DKOU 2015). Available at: Accessed August 19, 2021.

        • Pavone V
        • Costarella L
        • Testa G
        • Conte G
        • Riccioli M
        • Sessa G.
        Calcaneo-stop procedure in the treatment of the juvenile symptomatic flatfoot.
        J Foot Ankle Surg. 2013; 52: 444-447
        • Younger AS
        • Sawatzky B
        • Dryden P.
        Radiographic assessment of adult flatfoot.
        Foot Ankle Int. 2005; 26: 820-825
        • Choi JY
        • Lee DJ
        • Kim SJ
        • Suh JS.
        Does the long-term use of medial arch support insole induce the radiographic structural changes for pediatric flexible flat foot?—a prospective comparative study.
        Foot Ankle Surg. 2020; 26: 449-456
        • Abbara-Czardybon M
        • Frank D
        • Arbab D.
        The talus stop screw arthroereisis for flexible juvenile pes planovalgus.
        Oper Orthop Traumatol. 2014; 26: 625-631
        • Megremis P
        • Megremis O.
        Arthroereisis for symptomatic flexible flatfoot deformity in young children: radiological assessment and short-term follow-up.
        J Foot Ankle Surg. 2019; 58: 904-915
        • Thometz JG
        • Liu XC
        • Tassone JC
        • Klein S.
        Correlation of foot radiographs with foot function as analyzed by plantar pressure distribution.
        J Pediatr Orthop. 2005; 25: 249-252
        • Sullivan JA.
        Pediatric flatfoot: evaluation and management.
        J Am Acad Orthop Surg. 1999; 7: 44-53