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Flatfoot surgery in children: arthroereisis and calcaneo-stop

Surgery for symptomatic flatfoot: arthroereisis, calcaneo-stop, osteotomies, recovery by technique, risks and implant removal.

When surgery is considered

A low arch alone is not a reason for surgery. Painless flexible flatfoot generally does not require treatment. Surgery may be discussed when pain and activity limitations persist despite appropriate conservative care and assessment confirms that the deformity contributes to the symptoms.

Before choosing a technique, the clinician considers flexibility, remaining growth, the Achilles tendon and associated conditions. Age and appearance alone do not establish an indication for surgery.

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Surgical Techniques

Endosinotarsal arthroereisis and the sinus tarsi implant

Arthroereisis restricts certain excessive movements of the subtalar joint without fusing it. With the endosinotarsal technique, an implant is placed in the sinus tarsi, the space between the talus and calcaneus. It is an option for selected symptomatic flexible feet; it is not automatically indicated for every child with flatfoot.

When it is used

Flexible flatfoot with pain and activity limitations persisting despite appropriate conservative care. Age and appearance alone are not enough: flexibility, remaining growth, the Achilles tendon and associated conditions all matter.

Recovery

No cast or brace. Active and passive ankle mobilization from the first day. Weight-bearing is deliberately cautious in the first days, because the implant sits in the sinus tarsi without crossing bone; walking with two crutches for a short period, indicatively until the first check-ups, then free walking. Running and weight-bearing sports are reintroduced gradually, indicatively from the second month: these are orientative windows, personalised on the clinical picture and the technique. The endorthesis is not removed routinely: removal is considered once correction is consolidated, only in case of discomfort or intolerance.

Calcaneo-stop or exosinotarsal arthroereisis

Calcaneo-stop, also called calcagno-stop or exosinotarsal arthroereisis, uses a screw anchored in the calcaneus to limit excessive hindfoot movement. The choice between this procedure and a sinus tarsi implant depends on the deformity and surgical plan. A screw does not, by itself, determine permitted weight-bearing or the date of return to sport.

When it is used

Flexible flatfoot with pain and activity limitations persisting despite appropriate conservative care. Age and appearance alone are not enough: flexibility, remaining growth, the Achilles tendon and associated conditions all matter.

Recovery

No cast or brace. Active and passive mobilization from the first day. Assisted weight-bearing with two crutches is usually allowed soon after discharge, limiting distances in the first days; crutches are discontinued when the clinical picture allows, indicatively around two weeks. Running and weight-bearing sports are reintroduced gradually, indicatively from the second month, with personalised timing. The transcalcaneal screw is not removed routinely: removal is considered only in case of discomfort, intolerance or a specific indication.

Foot osteotomies: Evans and Cotton

The Evans osteotomy involves the calcaneus; the Cotton osteotomy involves the medial cuneiform, a different foot bone. They are not both calcaneal osteotomies. They may be combined in selected cases, with protection of the correction and assessment of bone healing.

When it is used

Osteotomies correct alignment by cutting and repositioning bone. They may be considered for selected symptomatic deformities, including flexible feet; a rigid foot requires investigation of its cause and does not automatically follow an arthroereisis pathway.

Recovery

Protecting the correction and assessing bone healing. The surgeon defines cast or brace use, weight-bearing and rehabilitation for the procedure performed.

Postoperative Overview

The postoperative course varies for each patient and depends on the surgical technique used. For arthroereisis: no cast or brace, early mobilization with specific exercises and progressive weight-bearing. In bilateral cases, whether to operate both feet in the same session or in two stages is decided case by case, together with the family. Following the personalised rehabilitation programme is essential. The course described below is an indicative pathway, personalised after surgery.

Recovery: walking, school and sport are different steps

Before discharge, clarify permitted weight-bearing, how to use crutches, whether a cast or brace is needed and which movements are allowed. Early movement described for some isolated arthroereisis procedures does not authorise unrestricted movement after additional tendon or bone surgery.

Returning to school depends on pain, travel and independence: stairs, the journey and opportunities to rest need to be planned with the family. Running and jumping require the surgeon's review and adequate recovery of walking, movement, strength and movement control. An indicative protocol timetable does not replace these steps.

Rehabilitation protocol by technique

Achilles tendon lengthening or surgery on an accessory navicular changes recovery: the instructions for isolated arthroereisis should not be transferred to these procedures. Osteotomies require protection of the correction and assessment of bone healing. The available pathways distinguish:

These sheets are tools to select and personalise at the appointment. They are not a single prescription for every operation.

Does the screw need to be removed?

There is no identical rule for every implant: some pathways involve planned removal, while others depend on symptoms and specific indications. Discuss this with the surgeon, together with follow-up during growth. Persistent postoperative pain needs reassessment; do not assume that the screw must be the cause.

Benefits, risks and limits of the evidence

Studies of arthroereisis report improvements, but differ in implants, patients and follow-up duration. Long-term evidence and high-quality comparisons remain limited. UK NICE guidance highlights this uncertainty and the need to discuss it during consent; it is not an Italian recommendation or proof that one technique is superior.

Possible problems include pain or implant intolerance, undercorrection or overcorrection, stiffness and wound complications. Further surgery may be needed. Individual risk depends on the procedure and the child's condition: a permanent correction without any possibility of complications cannot be promised.

To discuss an indication for surgery in Milan, see the Gaetano Pini and CTO locations. Bring existing investigations and information about previous treatment: the decision starts with the child's functional problem.

Author: Dr Daniele Priano, paediatric orthopaedic surgeon. General information: this content does not replace an individual medical assessment.

For parents

Flatfoot: condition information page

Causes, diagnosis, conservative options and when surgery is considered.