Journal of Foot and Ankle Surgery (Asia Pacific)

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2023 | April-June | Volume 10 | Issue 2

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Mandeep S Dhillon

Understanding and Treating Flatfoot in the Young

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:1] [Pages No:47 - 47]

   DOI: 10.5005/jp-journals-10040-1300  |  Open Access |  How to cite  | 



Ratna S Maheshwari, Ashok N Johari

Which Foot is at Risk? Understanding the Evolution of the Pediatric Flatfoot

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:8] [Pages No:48 - 55]

Keywords: Achilles tendon, Flatfoot, Hindfoot, Pediatric flatfoot, Recurrent talotarsal joint dislocation

   DOI: 10.5005/jp-journals-10040-1292  |  Open Access |  How to cite  | 


Few subjects in orthopedics have had varied and diverse opinions expressed about every aspect of the condition, from etiology to treatment, as has the flexible flatfoot (FFF). FFF is common in infants and children, and the majority of them resolve by the 1st decade of life. Thus, FFF has been described as physiologic because it is usually flexible and painless and has been thought to be of no functional consequence. However, there is a mounting body of literature that persistent flat feet may not be as benign in terms of long-term function as was once thought to be. Despite being one of the most common concern scenarios encountered in the pediatric orthopedic outpatient department, there is an absence of a standard definition for pediatric flatfoot and a lack of clarity on the natural history of untreated persistent FFF. Looking at the precariousness surrounding flatfoot literature, we need to reevaluate if we can be confident of pain-free adulthood in untreated children with persistently severe flat feet. Excessive hindfoot motion in this entity can have far-reaching effects on the musculoskeletal chain distally and proximally. With this article, we will look deeper into the biomechanics of FFF, summarize our understanding of the literature on this entity with regard to evolution, and identify “red flag signs” in persistent FFF where intervention might be beneficial.



Zhi Hao Tang, Keen Wai Chong

Use of HyProCure in Correcting Flatfoot in Adolescent and Adult Asians: A Radiographic Study Using a New Method of Measuring Hindfoot Alignment

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:5] [Pages No:56 - 60]

Keywords: Arthroereisis, Deformity correction, Flexible flatfoot, Hindfoot, Pes planus

   DOI: 10.5005/jp-journals-10040-1238  |  Open Access |  How to cite  | 


Aim: Extraosseous talotarsal stabilization (EOTTS) is increasingly popular as a surgical treatment for adult symptomatic flexible pes planus. This can be performed alone or combined with medializing calcaneal osteotomies with or without medial column stabilization. The aim of our radiographic study is to evaluate the changes in various radiographic parameters of a pes planus deformity including hindfoot alignment after EOTTS. We hypothesize that EOTTS can demonstrate improvement in radiographic parameters, including hindfoot alignment. Materials and methods: A total of 12 feet from nine patients who had undergone EOTTS using the HyProCure implant were analyzed. Weight-bearing radiographs were used to measure the pre- and postoperative talar-second metatarsal, lateral Meary's, calcaneal inclination, talar declination angles. Hindfoot alignment was measured using fibular axis calcaneal offset (FACO) method. Results: Our results showed significant improvement in all the radiographic parameters including hindfoot alignment. Conclusion: There is a radiographic improvement in a flexible pes planus deformity after an EOTTS procedure, including hindfoot alignment. Clinical significance: Hindfoot alignment can be corrected with EOTTS procedure with or without associated procedures.



Abhishek Jain, Michael E Graham

Extra-osseous Talotarsal Stabilization (EOTTS) Utilizing Type II Sinus Tarsi Stent: Indications, Technique, and Tips

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:5] [Pages No:61 - 65]

Keywords: Arthroereisis, Extraosseous talotarsal stabilization, Flatfoot, Recurrent talotarsal joint dislocation, Subtalar implants

   DOI: 10.5005/jp-journals-10040-1285  |  Open Access |  How to cite  | 


Introduction: One important reason for a flexible flatfoot is the incongruency or partial dislocation of one or more joints within the talotarsal mechanism. This dislocation or subluxation may exist as a recurrent/dynamic/reducible or rigid/static/nonreducible condition. The flexible talotarsal malalignment is termed recurrent talotarsal joint dislocation (RTTJD). Addressing this malalignment to correct the flatfoot using a minimally invasive technique is the call of the present time. Aim: To elucidate, in the simplest of manner, the surgical technique of extra-osseous talotarsal stabilization (EOTTS) using a type II sinus tarsi device for flatfoot patients. Technique: With a 1.5–2.0 cm incision over the dorsolateral aspect of the foot, a type II sinus tarsi device (HyProCure) is inserted into the sinus tarsi after appropriate sizing. Instant and on the table correction of the deformity is achieved. Skin closure can be done with an absorbable subcuticular suture. The entire procedure takes 15 minutes to complete. Discussion: In the past, many orthopedic surgeons have published their work on flatfoot correction using sinus tarsi implants. Appropriate patient selection and sinus tarsi stent design dictate the success of EOTTS. There have been other soft tissue and bony procedures that have their place when appropriately indicated. However, they result in extensive surgical dissection, big and cosmetically challenging scars, long recovery periods with plasters, and nonweight-bearing instruction. The list of possible and known complications of these more aggressive surgical procedures to correct flatfoot is what led to the development of a more conservative option when indicated. Compliance with custom-made orthotic supports, braces, and shoe inserts is relatively poor. Also, there is no proven clinical evidence that externally applied foot orthotics realigns the osseous structure and restores the normal biomechanics of the foot. With EOTTS, all the above problems are bypassed and the most important advantage is its reversibility. Conclusion: Extra-osseous talotarsal stabilization (EOTTS) has resulted in excellent improvement in foot biomechanics, alleviation of symptoms like pain and obvious cosmetic deformity, and restoration of normal foot radiological angles. The procedure is a boon for both surgeon and the patient. It allows the patient for a minimal hospital stay and expense, minimal cosmetic scar, immediate correction of deformity, and a very short rehabilitation period.



Karthick Rangasamy, Akash K Ghosh, Vivek P Ksheerasagar, Jai P Khatri, Nirmal R Gopinathan

Effectiveness of Lateral Column Lengthening in Symptomatic Flexible Flatfoot of the Pediatric and Adolescent Population: An Updated Systematic Review

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:10] [Pages No:66 - 75]

Keywords: Adolescent, Calcaneal osteotomy, Flatfoot, Lateral column lengthening, Pediatric, Pes planovalgus

   DOI: 10.5005/jp-journals-10040-1296  |  Open Access |  How to cite  | 


Background: Pes planovalgus is one of the most common pediatric foot deformities; one can manage it most conservatively. Surgery is only indicated for symptomatic flexible flatfoot with failed conservative treatment. In children, lateral column lengthening surgery is advantageous as it preserves the growth and development of the foot without fusing the joints. Research question: Is lateral column lengthening effective in managing pediatric and adolescent symptomatic idiopathic flexible flatfeet? Materials and methods: Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and Google Scholar] were searched for relevant articles reporting the outcomes of lateral column lengthening surgery in idiopathic flexible flatfeet of children with a minimum 1-year follow-up. Pre and postoperative radiological outcomes were recorded using talometatarsal angles, talonavicular coverage, calcaneal pitch, and talocalcaneal angle. The functional results were recorded as pre and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores. Rehabilitation protocol and complications were noted. Results: A total of 16 studies were included for the final review, with a total of 336 patients (468 feet) with a mean age of 11.65 years. An autologous tricortical iliac crest was the most commonly used graft during lateral column lengthening. There was a statistically significant improvement in the postoperative radiological parameters like anteroposterior (AP) talocalcaneal angle, AP talometatarsal angle, AP talonavicular angle, and in lateral views talocalcaneal angle, talometatarsal angle, and calcaneal pitch in comparison to preoperative values (p < 0.00001). The mean postoperative AOFAS scores had a standard mean difference of −5.24 [95% confidence interval (CI); −6.39, −4.09] from the mean preoperative AOFAS scores, and this difference is statistically significant (p < 0.00001). Complications like pain in the foot, infection, under-correction, graft displacement, and calcaneocuboid or talonavicular joint subluxation were noted. Conclusion: Lateral column lengthening surgery is promising with good midterm clinical and radiological outcomes with acceptable complications for treating symptomatic flexible flatfeet in pediatric and adolescent populations.



Siddhartha Sharma, Aditya Kaushal

Arthroereisis for Flatfoot: Current Status of Our Understanding

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:3] [Pages No:76 - 78]

Keywords: Arthroereisis, Flatfoot, Flexible flatfoot, Pediatric flatfoot

   DOI: 10.5005/jp-journals-10040-1159  |  Open Access |  How to cite  | 


Flatfoot deformity can be seen in children as well as adults. Symptomatic flatfoot deformity at any age should be considered for surgical correction. Among the available options, arthroereisis has been gaining popularity in recent times, both as an isolated and an adjunctive procedure. In this commentary, we aim to discuss the history, evolution, biomechanics, controversies, advantages, and disadvantages of this procedure.



Ankit Khurana, Gurvinder Singh, Jujhar Singh, Zachary Littlefield, Ashish D Shah

Evaluation of Technical Differences in Arthroscopic Lateral Ligament Stabilization for Chronic Ankle Instability: A Review

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:9] [Pages No:79 - 87]

Keywords: Arthroscopy, Broström, Chronic ankle instability, Lateral ligament repair

   DOI: 10.5005/jp-journals-10040-1287  |  Open Access |  How to cite  | 


Background: Chronic ankle instability is among one of the most common pathological conditions in physically active individuals. Modified Broström is considered the gold standard for chronic ankle instability, which has failed conservative management. The arthroscopic modified Broström repair appears to be a reasonable alternative to open stabilization. This review attempts to assimilate the available literature on the arthroscopic technique of chronic lateral ankle instability and tries to bring out the technical differences in operative technique Materials and methods: A systematic search using databases PubMed, Embase, and Scopus was performed using the keywords and Boolean operators [“chronic ankle instability” or “lateral ankle instability” or “anterior talofibular ligament (ATFL)”] and (“arthroscopy”) and (“Broström” or “Broström-Gould” or ‘surgery’). Out of the total of 299 studies evaluated, 21 were included in the final analysis. Technical data, including operative techniques, were extracted from all articles, and data were tabulated and analyzed by the authors. Results: While all methods described in the literature have shown good outcomes, arthroscopic techniques described in the literature are varied, and this variation stems from several factors, including a difference in training, local implant and equipment availability, perceived stability, and personal preference. Conclusion: This review attempts to assimilate the available literature on the arthroscopic technique of chronic lateral ankle instability and tries to bring out the technical differences in operative techniques that have been described in the literature for this procedure. More evidence in the form of level 1 studies have to be done to prove the superiority of one technique over the other and to judge which technique of the various technical options gives the best results in terms of function, complications, and reinjury rates.



Yasser Aljabi, Arpit B Patel, Pinak Ray

Quality and Reliability of Online Resources on Lisfranc Injuries

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:4] [Pages No:88 - 91]

Keywords: HONcode, Lisfranc injuries, Lisfranc injury, Online resources, Orthopaedics, Patient education

   DOI: 10.5005/jp-journals-10040-1219  |  Open Access |  How to cite  | 


Introduction: There is an abundance of information available online on Lisfranc injuries; however, the quality and reliability of available information remains to be unclear. To our knowledge, this is the first study that evaluates the quality of information available online on Lisfranc injuries. Methods: Seventy websites were identified for assessment using the term “Lisfranc injury.” Google, Yahoo! and Bing were the search engines employed. Websites were classified by type and assessed by means of DISCERN score, Journal of the Medical Association (JAMA) benchmark criteria and the presence or absence of HONcode certification. Results: Majority of resources were academic (n = 23) followed by commercial (n = 18). Mean DISCERN and JAMA score was 47.4 and 2.2, respectively. A total of 21 websites had a HONcode certification present. Websites that bore the HONcode were associated with higher mean DISCERN and JAMA scores (p = 0.01). Conclusion: The authors of this study conclude that it is challenging to predict with certainty which resources are of superior quality. Clinicians must educate patients on quality of information available in order to help them make informed decisions.



Martin Ålund

Subtalar Arthroereisis as a Surgical Option in the Reconstruction of Progressive Collapsing Foot Deformity: A Prospective 3-year Follow-up Study on Patient Satisfaction and Causes for Implant Removal in 40 Cases Treated with the HyProCure Implant

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:10] [Pages No:92 - 101]

Keywords: Adult Flatfoot, HyProCure, Progressive collapsing foot deformity, Subtalar arthroereisis

   DOI: 10.5005/jp-journals-10040-1301  |  Open Access |  How to cite  | 


Background and purpose: Subtalar arthroereisis in the surgical treatment of Progressive Collapsing Foot Deformity is associated with high implant removal rates. This study reports the mid-term incidence and causes for implant removal, patient-reported outcomes, and radiographical results. Patients and methods: Prospectively collected data from 40 cases in 37 patients were analyzed. Subtalar arthroereisis was performed with a HyProCure-I implant as a single procedure in 19 cases and as an adjuvant procedure in 21 cases. In all cases, a Self-reported Foot and Ankle Score (SEFAS) was completed preoperatively. At the final follow-up, SEFAS was available in 32 cases. Standard weightbearing lateral and anteroposterior (AP) radiographs were obtained preoperatively in all cases and at final follow-up in 29 cases. Results: The implant was removed in four single procedure cases and four combined procedure cases (20%). Causes for pain leading to implant removal are discussed. Patient satisfaction in the remaining 32 cases was similar in both groups. Mean SEFAS improvement was 14.5 points [95% confidence interval (CI), 10.6–18.5] in the single procedure group and 17.2 points (95% CI, 12.0–22.3) in the combined procedure group. Similar radiographical improvements were noted in the two groups. Interpretation: Subtalar arthroereisis with a HyProCure-I implant, performed as either a single or a combined procedure, may yield good subjective results and radiographical improvement with high patient satisfaction rates. The 20% mid-term implant removal rate is still relatively high, and careful patient selection is needed for either procedure.



Mehar Dhillon

Letter to the Editor: Staged Reconstruction of Post-traumatic Medial Malleolus Bone Defects Using Fibular Head Osteochondral Graft: A Report of Two Cases

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:1] [Pages No:102 - 102]

   DOI: 10.5005/jp-journals-10040-1294  |  Open Access |  How to cite  | 



Suneel Ramanujapuram, Apurve Parameswaran

Author Response: Staged Reconstruction of Post-traumatic Medial Malleolus Bone Defects Using Fibular Head Osteochondral Graft: A Report of Two Cases

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:1] [Pages No:103 - 103]

   DOI: 10.5005/jp-journals-10040-1295  |  Open Access |  How to cite  | 



Parth Bansal

Letter to the Editor: The Incidence of and Demographic Disparities among Fifth Metatarsal Fracture Nonunions

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:1] [Pages No:104 - 104]

   DOI: 10.5005/jp-journals-10040-1293  |  Open Access |  How to cite  | 



Alexandra Flaherty, Bardiya Akhbari, Hamid Ghaednia, Soheil Ashkani-Esfahani, Lorena Bejarano-Pineda

Author Response: The Incidence of and Demographic Disparities among Fifth Metatarsal Fracture Nonunions

[Year:2023] [Month:April-June] [Volume:10] [Number:2] [Pages:2] [Pages No:105 - 106]

   DOI: 10.5005/jp-journals-10040-1298  |  Open Access |  How to cite  | 


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