Operative versus nonoperative treatment in children with painful rigid flatfoot and talocalcaneal coalition.

BACKGROUND: The management of painful rigid flatfoot (RFF) with talocalcaneal coalition (TCC) is controversial. We aimed to compare operative and nonoperative treatment in children with RFF and TCC. METHODS: We retrospectively reviewed medical records and radiographs of children with RFF and TTC treated between 2005 and 2015. The nonoperative treatment consisted of manipulation under anesthesia, cast immobilization and shoe insert after cast removal. The operative treatment consisted of combined TCC resection, graft interposition and subtalar arthroereisis. RESULTS: Thirty-four children (47 ft) in the nonoperative group and twenty-one children (34 ft) in the operative group were included. No differences were found between groups, concerning baseline characteristics. The mean age at treatment was 11.8 years (9-17): 11.6 (9-17) for the nonoperative group, 12.2 (10-15) for the operative group. The mean follow-up averaged 6.6 (3-12) years and was significantly longer in the nonoperative group (7.8 versus 4.7 years; p < 0.0005), since the operative procedure was increasingly practiced in the latest years. There were no complications in either groups, but 6 patients (7 ft) in the nonoperative group were unsatisfied and required surgery. At the latest follow-up, the AOFAS-AHS improved in both groups, although the operative group showed significantly better improvement. The operative group reported also significantly better FADI score, after adjustment for follow-up and baseline variables. CONCLUSION: The operative treatment showed better results compared to the nonoperative treatment. Symptomatic RFF with TCC in children can be effectively treated in one step with resection, graft interposition and subtalar arthroereisis. Further prospective randomized studies are needed to confirm our findings and to identify the best operative strategy in this condition.

Stress fracture of the fourth metatarsal in a relapsed clubfoot of a 5.5-year-old child.

Stress fractures are uncommon in skeletally immature patients and usually affect adolescents involved in competitive sports, whereas they are very rare in young children. Involvement of the fourth metatarsal is very infrequent and has been associated with metatarsus adductus deformities. The authors describe a stress fracture of the proximal fourth metatarsal occurred in a 5.5-year-old child with a relapsed clubfoot. Operative correction of the deformity and cast immobilization provided consolidation of the fracture. Stress fractures of lateral metatarsals may represent a possible source of pain in recurrent clubfeet, even in young children. In these cases, early correction of the deformity is required.