What is the treatment approach for a child with flexible flatfoot, possibly requiring calcaneal osteotomy and FDL (Flexor Digitorum Longus) tendon transfer?

Surgical Management of Flexible Flatfoot in Children

For children with symptomatic flexible flatfoot that has failed conservative management, a combination of calcaneal osteotomy and flexor digitorum longus (FDL) tendon transfer is recommended to correct deformity and improve function.

Assessment and Initial Management

• Most children with flexible flatfoot are asymptomatic and require no treatment 1, 2
• Flexible flatfoot is typically a normal variant of foot shape in children
• Surgical intervention should only be considered when:
  • Pain persists despite conservative management
  • Deformity interferes with normal activities
  • Pain occurs under the medial midfoot and/or sinus tarsi
  • Associated contracture of the Achilles tendon is present

Surgical Approach for Symptomatic Flexible Flatfoot

Timing of Surgery

• Surgery should be performed only after maximizing medical treatment for at least 12 months 3
• Consider the child's age in decision-making:
  • Guided growth techniques require at least 2-3 years before skeletal maturity
  • Osteotomy complications reduce when performed later in childhood or after skeletal maturity 3

Recommended Surgical Procedure

1. Calcaneal Osteotomy:

   • Lengthening osteotomy of the calcaneus helps correct hindfoot valgus
   • Improves talo-1st metatarsal index and pedographic parameters 4
   • Addresses the lateral column of the foot

2. FDL Tendon Transfer:

   • Transfers the flexor digitorum longus tendon to support the medial arch
   • Provides dynamic support along the medioplantar aspect of the foot 5
   • Helps restore normal foot mechanics

Evidence Supporting This Approach

• Combined lengthening osteotomy and FDL transfer has shown:
  • Improved clinical outcomes with AOFAS score increases from 47 to 92 points 5
  • Correction of radiographic parameters (talo-1st metatarsal angles) 4
  • Low complication rates with predictable correction 4

Important Considerations

Surgical Expertise

• Surgery should be performed by a surgeon with expertise in pediatric foot deformities 3
• The surgeon should be familiar with both bony and soft tissue procedures

Post-Surgical Management

• Regular clinical and functional assessments should be made following surgery
• Radiographic evaluation at 12 months post-surgery or earlier if deformity worsens 3
• Physical therapy is recommended following surgery to improve range of motion, muscle strength, and gait 3

Potential Complications

• Wound healing delay (reported in 9% of cases) 4
• Possible need for revision surgery (rare)
• Risk of overcorrection leading to cavus foot
• Risk of undercorrection with persistent symptoms

Contraindications and Cautions

• Asymptomatic flexible flatfoot should not undergo surgical correction
• No evidence supports the use of insoles or shoe modifications to change foot shape 2
• Avoid surgery in very young children when possible, as complications are more common

This approach provides a comprehensive solution addressing both the bony deformity through calcaneal osteotomy and the dynamic support through FDL tendon transfer, resulting in improved foot alignment and function in children with symptomatic flexible flatfoot.