Surgery: Flatfoot
Minimally invasive pediatric flatfoot surgery: endosinotarsal subtalar arthroereisis (endorthesis inside the sinus tarsi) and exosinotarsal arthroereisis (calcaneo-stop / C-stop), indications, recovery and specialist evaluation.
Minimally invasive surgery for severe flexible flatfoot
Learn about this condition →Surgical Techniques
Endosinotarsal subtalar arthroereisis (endorthesis inside the sinus tarsi)
Minimally invasive technique in which a small implant (endorthesis) is placed inside the sinus tarsi without bone anchoring in the calcaneus. It acts as a spacer limiting excessive hindfoot pronation and guides growth toward a physiological alignment.
Indication
Symptomatic flexible flatfoot in children aged 8-12 not responding to orthotics and physical therapy after at least 12-18 months of conservative treatment. Indicated for flexible, manually reducible hindfeet.
Recovery
No cast or brace. Wheelchair mobilization for 2-3 days with specific exercises. Progressive weight-bearing with crutches from day 3 to 15. Full weight without crutches from day 15 to 30. No weight-bearing sports for 2 months. The endorthesis may be removed after 2-3 years, once correction is consolidated, if it causes discomfort; otherwise it can be left in place.
Exosinotarsal subtalar arthroereisis – Calcaneo-stop (C-stop)
Minimally invasive technique in which a small screw is introduced from outside through the calcaneus until it protrudes into the sinus tarsi, where it acts as a mechanical «stop» against excessive valgus-pronation movement of the hindfoot. This is the so-called calcagno-stop or C-stop.
Indication
Symptomatic flexible flatfoot in the growing child (approximately 9-13 years) with hindfoot valgus not controlled by conservative treatment. Often preferred when a more stable mechanical block is needed compared to a sole endorthesis.
Recovery
No cast or brace. Same protocol as endosinotarsal endorthesis: progressive weight-bearing with crutches from day 3, full weight at 15 days, gradual return to sport. The screw may be removed after 2-3 years, once correction is consolidated, if it causes discomfort; if well tolerated it can be left in place.
Calcaneal Osteotomy (Evans, Cotton)
Procedure involving bone reshaping of the calcaneus to correct hindfoot alignment. May be necessary in more complex cases or adolescent age.
Indication
Severe rigid or semi-rigid flatfoot, failed arthroereisis, complex cases.
Recovery
Cast immobilization for 4-6 weeks. Progressive weight-bearing with brace. Physical therapy for 2-3 months.
Postoperative Overview
Postoperative course varies for each patient and depends on the surgical technique used. For arthroereisis: no cast or brace, early mobilization with specific exercises, progressive weight-bearing from day 3 and full weight from day 15. For bilateral cases, I operate both feet simultaneously. Following the personalized rehabilitation program is essential.
Endosinotarsal and exosinotarsal arthroereisis (calcaneo-stop): what's the difference?
Minimally invasive flatfoot surgery in children is generically called subtalar arthroereisis. Two main variants exist, depending on where the implant is placed and how it is anchored.
Endosinotarsal arthroereisis uses an endorthesis placed inside the sinus tarsi, without bone anchoring in the calcaneus. The implant acts as a spacer that limits excessive hindfoot pronation.
Exosinotarsal arthroereisis — better known as calcaneo-stop, calcagno-stop or C-stop — uses a small screw introduced from outside through the calcaneus that protrudes into the sinus tarsi, where it works as a mechanical «stop» against valgus-pronation movement.
The choice between endosinotarsal arthroereisis, calcaneo-stop / exosinotarsal arthroereisis or other techniques is not automatic and varies case by case. It depends on the child's age, foot flexibility, degree of hindfoot valgus, presence of pain, possible Achilles tendon contracture, radiographic findings and the surgeon's experience.
Therefore there is no single best technique for all children: the indication must always be personalized to the individual patient and foot.
Detailed Recovery Timeline
Note: The timeline below is a general baseline. The actual postoperative course varies depending on the specific surgical technique chosen (see procedures above).
Usually day-surgery or 1 night hospitalization. Discharge without cast or brace.
Days 1-3: Wheelchair mobilization with specific exercises taught to the patient. Days 3-15: Crutches with progressive weight-bearing. Dressing changes every 5-7 days.
Days 15-30: Full weight without crutches. Suture removal at 14 days. Normal walking resumed.
Months 1-2: Normal daily life. No weight-bearing sports for 2 months from surgery. Custom orthotics if indicated.
Return to Sport
Return to sport: 2 months for non-weight-bearing activities, 2-3 months for weight-bearing sports.
Follow-up Schedule
Follow-ups at 2 weeks, 6 weeks, 3 months, 6 months, then annual until implant removal (2-3 years).
Possible Complications
Possible: implant intolerance (rare, removed), under/overcorrection (rare), temporary stiffness.
Flatfoot: condition information page
Causes, diagnosis, conservative options and when surgery is considered.