What is the recommended treatment approach for surgery in cases of flexible flatfoot?

Surgical Treatment for Flexible Flatfoot

Surgery for flexible flatfoot should be reserved for severe symptomatic cases that have failed conservative management, with lateral column calcaneal lengthening (Evans-Mosca procedure) being the preferred surgical technique for adolescents and adults with persistent pain and disability. 1

Patient Selection for Surgical Intervention

When to Consider Surgery

• Surgery is indicated only in severe symptomatic cases resistant to conservative treatment 1, 2
• Key indications for surgical intervention:
  • Persistent pain under the head of the plantar flexed talus or in the sinus tarsi area
  • Failure of conservative measures (orthotics, exercises, activity modification)
  • Presence of a tight/short Achilles tendon with flexible flatfoot 2, 3
  • Significant disability affecting quality of life and mobility

Conservative Management (First-Line)

Before considering surgery, patients should undergo:

• Activity modification
• Proper footwear selection
• Custom orthoses
• Targeted exercises
• Management of comorbidities (especially obesity and ligamentous laxity) 4

Surgical Approaches

Primary Surgical Options

1. Lateral Column Calcaneal Lengthening (Evans-Mosca procedure)

   • Most effective for severe symptomatic flexible flatfoot
   • Provides satisfactory long-term correction with low complication rates
   • Improves both clinical outcomes and radiographic parameters 1

2. Achilles Tendon Lengthening

   • Often required in conjunction with other procedures
   • Essential when a tight Achilles tendon is present 2, 3
   • Failure to address this component often leads to treatment failure

3. Osteotomy

   • Fundamental procedure for deformity correction
   • Addresses structural components of the flatfoot 2

Surgical Decision Algorithm

1. Assess severity and symptoms

   • Evaluate pain location and intensity
   • Determine functional limitations
   • Confirm failure of conservative management

2. Evaluate specific anatomical components

   • Hindfoot valgus
   • Medial arch collapse
   • Achilles tendon length/tightness
   • Forefoot supination

3. Select appropriate surgical procedure(s)

   • Isolated flexible flatfoot: Evans-Mosca procedure
   • Flexible flatfoot with tight Achilles: Combined Evans-Mosca with Achilles lengthening
   • Flexible flatfoot with forefoot supination: Additional forefoot procedures may be needed

Outcomes and Complications

Expected Outcomes

• High satisfaction rates with appropriate patient selection
• Significant improvement in pain and function
• Long-term radiographic correction of deformity 1

Potential Complications

• Surgical procedures for flatfoot carry risk of serious complications 5
• Potential issues include:
  • Non-union at osteotomy sites
  • Over or under-correction
  • Midfoot arthritis (long-term)
  • Wound healing problems
  • Nerve injuries

Important Considerations

Pediatric vs. Adult Approach

• Most flexible flatfeet in children are physiologic and asymptomatic, requiring no treatment 2, 4
• Surgery should be considered only for adolescents and adults with persistent symptoms despite conservative management

Surgical Principle

• Perform the least invasive procedure that decreases pain and improves function 5
• Consider the effects of each procedure and associated morbidity when planning surgery

Monitoring and Follow-up

• Regular radiographic assessment to evaluate correction maintenance
• Long-term follow-up to monitor for development of midtarsal joint arthritis
• Assessment of functional outcomes using validated tools (AOFAS Ankle-Hindfoot Scale, FADI Score)

By following this structured approach to surgical management of flexible flatfoot, clinicians can optimize outcomes while minimizing complications in appropriately selected patients.