Surgical Treatment for Painful Pediatric Pes Planovalgus: How Does Subtalar Extra-articular Screw Arthroereisis Compare to the Standard Technique of Modified Evans Reconstruction?

BACKGROUND

A subset of patients with flexible pediatric pes planovalgus (PPV) will have recalcitrant symptoms and functional impairment despite maximizing nonoperative methods and seeking surgical care. The primary aim of this study was to compare the clinical course and radiographic improvement including final alignment for patients who underwent the minimally invasive corrective subtalar extra-articular screw arthroereisis (SESA) technique compared with the traditional modified Evans reconstruction (MER) technique for flexible PPV correction.

METHODS

Forty-five feet in 31 PPV patients aged 10 to 19 years treated at a single institution with (1) SESA +/- Vulpius or accessory navicular or tarsal coalition excision (22 feet) or (2) MER +/- Vulpius (23 feet) from 2010 to 2022 were identified. Patients with no weight-bearing postoperative x-rays were excluded. Comprehensive preoperative and postoperative radiographic measurements were obtained from standing radiographs. Radiographic outcomes were evaluated across treatment groups using noninferiority analysis. Comparisons in clinical characteristics were conducted using mixed-effects regression modeling to account for the correlation between bilateral measurements within the same patient.

RESULTS

Surgery was performed at an average age of 13.7 years (SD, 1.9); the cohort was 53% male. There were no differences in age, BMI, or laterality between the SESA and MER cohorts. The SESA cohort had a significantly shorter operative time compared with MER (51 vs. 167 min; P<0.001). One patient in the MER cohort required a return to the operating room for hardware removal in the setting of pseudoarthrosis, and another for a buried pin. Time to weightbearing in the SESA cohort was a median 3 weeks earlier than the MER cohort (P=0.004). The SESA procedure was found to be noninferior to MER with respect to postoperative radiographic alignment as well as in the improvement in alignment from preoperative to postoperative measurement (all P<0.05).

CONCLUSIONS

For painful pediatric pes planovalgus (PPV), subtalar extra-articular screw arthroereisis (SESA) offers a less invasive approach with noninferior outcomes compared with modified Evans reconstruction (MER). Our study found similar radiographic improvements and deformity correction in adolescents treated with SESA versus MER, along with shorter procedures and earlier weightbearing. No major complications were observed. Long-term follow-up and patient-reported outcome studies are needed, especially postscrew removal.

LEVEL OF EVIDENCE

Therapeutic case-control study, level III.