SLR - April 2019 - Mariam Botros
Reference: Suh DH, Park JH, Lee SH, Kim HJ, Park YH, Jang WY, Baek JH, Sung HJ, Choi GW. Lateral column lengthening versus subtalar arthroereisis for pediatric flatfeet: a systematic review. Int Orthop. 2019 Jan 30.Scientific Literature Review
Reviewed By: Mariam Botros, DPM
Residency Program: Long Beach Memorial Medical Center, Long Beach, CA
Podiatric Relevance: Concerned parents often present to the foot and ankle surgeon for evaluation of their child’s flatfeet. Conservative treatment is usually well tolerated. However, there are children who have persistent symptoms and require surgical intervention. Lateral column lengthening (LCL) is an option for treating flexible flatfeet, but malposition, nonunion and loss of correction are just a few complications that can arise. Due to its minimally invasive technique and rapid postoperative course, the subtalar arthroereisis (AR) is popular. The lack of evidence-based comparative studies comparing LCL and AR prompted the authors to perform a systematic review comparing radiographic correction, clinical scores, patient satisfaction, complications and reoperations.
Methods: A literature search of MEDLINE, EMBASE and Cochrane library databases was performed. Utilizing a predefined data extraction form, two independent reviewers extracted the data. The Methodological Index for Nonrandomized Studies (MINORS) scale quantified the quality of the literature. The outcomes analyzed were radiographic parameters, clinical scores, satisfaction, complications and reoperations.
Results: Twenty-one LCL studies and thirteen AR studies were ultimately included in this systematic review. The anteroposterior talo-first metatarsal angle improved more in the LCL group (9.5°-->21.7°) than in the AR group (10.6°-->12.8°). The change in calcaneal pitch was greater in the LCL (2.1°-->26.53°) than in the AR group (-1.3°-->3.23°). The American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was greater in the LCL (27.7-->39.1) than in the AR group (17-->22). The percentage of satisfaction was similar between the LCL (68 percent-->89 percent) and AR (78.5 percent-->96.4 percent) groups. The most common complications encountered were calcaneocuboid subluxation in the LCL group and persistent pain in the AR groups. Complication rates were higher in the LCL group (0 percent-->86.9 percent) than in the AR group (3.5 percent-->45 percent). The reoperation rate was similar between the LCL (0 percent-->27.3 percent) and AR (0 percent-->36.4 percent) groups. Loss of correction, deep infection and hardware removal were all reasons requiring reoperation in the LCL group. Implant removal or exchange in the AR group due to migration, persistent pain, deep infection or overcorrection required reoperation.
Conclusions: The authors concluded that the LCL group had greater radiographic corrections and improvement in the AOFAS score compared to the AR group. The LCL group had more complications than in the AR group. Reoperation rates were similar between groups. Due to these findings, the authors prefer LCL in cases with severe forefoot abduction, and AR in preadolescent patients with moderate forefoot abduction as an isolated or complementary surgical procedure. The authors were unable to perform a meta-analysis in this systematic review given the heterogeneity of the studies. Higher-level studies directly comparing LCL and AR are needed and may allow for improved statistical comparison.