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Subtalar Joint Arthroereisis in the Management of Pediatric Flexible Flatfoot: A Critical Review of the
Literature
Stuart A. Metcalfe, Frank L. Bowling and Neil D. Reeves
Foot Ankle Int 2011 32: 1127
DOI: 10.3113/FAI.2011.1127

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FOOT & ANKLE INTERNATIONAL
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2011.1127
Subtalar Joint Arthroereisis in the Management of Pediatric Flexible Flatfoot:
A Critical Review of the Literature
Stuart A. Metcalfe, BSc(Hons); Frank L. Bowling, PhD; Neil D. Reeves, PhD
ABSTRACT
Background: Pediatric flexible flatfoot is a common deformity
for which a small, but significant number undergo corrective
surgery. Arthroereisis is a technique for treating flexible flat-
foot by means of inserting a prosthesis into the sinus tarsi.
The procedure divides opinion in respect of both its effective-
ness and safety. Methods: A database search up until 2010 was
used to find articles regarding arthroereisis in pediatric patients.
We summarized the findings of this study. Results: Seventy-
six studies were identified. Eight of the nine radiographic
parameters reported show significant improvement following
arthroereisis reflecting both increased static arch height and
joint congruency. Calcaneal inclination angle demonstrated the
least change with only small increases following arthroereisis.
Arthroereisis remains associated with a number of complica-
tions including sinus tarsi pain, device extrusion, and under-
correction. Complication rates range between 4.8% and 18.6%
with unplanned removal rates between 7.1% and 19.3% across
all device types. Conclusion: Current evidence is limited to
consecutive case series or ad hoc case reports. Limited evidence
exists to suggest that devices may have a more complex mode
of action than simple motion blocking or axis altering effects.
The interplay between osseous alignment and dynamic stability
within the foot may contribute to the effectiveness of this proce-
dure. Although literature suggests patient satisfaction rates of
between 79% to 100%, qualitative outcome data based on
disease specific, validated outcome tools may improve current
evidence and permit comparison of future study data.
No benefits in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
Corresponding Author:
Stuart A. Metcalfe, BSc(Hons)
Manchester Metropolitan University
Institute for Biomedical Research into Human Movement and Health
John Dalton Building,
Oxford Road
Manchester, M1 5GD
United Kingdom
E-mail: footconsultant@gmail.com
For information on pricings and availability of reprints, email reprints@datatrace.com
or call 410-494-4994, x232.
1127
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Manchester, UK
Level of Evidence: II, Metanalysis
Key Words: Arthroereisis; Stent; Flexible Flatfoot
INTRODUCTION
From infancy, the lower limb and foot are known to
undergo morphological and functional adaptation in order
to meet the demands of the external environment. An initial
hyper-mobile unit with persistent low arch, the foot matures
achieving full adult form typically between 5 to 7 years.61,83
Ultimately, the healthy foot becomes a dynamically complex
structure able to cope with the demands of locomotion.
Failure to develop a normal medial arch is common in chil-
dren and adolescents, and historically has been considered a
pathological state.35 Traditional anthropometric measures of
the medial arch alone will capture all flat feet, yet fail to
differentiate between those in which there is internal joint
incongruence on weightbearing, i.e., the pathological flat-
foot and the flat but congruent foot. Uncertainty remains
regarding the short-, mid-, and long-term implications of
flat feet. Instability within the osseous and or soft tissue
restraining mechanisms of the foot will result in increased
workload of the antipronatory mechanisms (both in magni-
tude and temporally). Opinions remain polarized in respect of
the need to treat the pediatric flatfoot; some authors argue that
there is little if any need to intervene, claiming spontaneous
resolution and lack of morbidity.1,4 – 6 Others suggest that flat
feet are associated with functional aberration and increased
risk of injury.40,63 Further division exists with respect to
treatment, some advocating conservative measures whilst
others recommend “operative correction” of this enigmatic
condition.
Arthroereisis involves the placement of a “stent” or
“implant” within the sinus tarsi and represents the least inva-
sive operative intervention. While its technical simplicity
and rapid recovery may be seen as advantageous, some
authors claim this has led to inappropriate application.80 The
stent is believed to prevent abnormal rotations of the tarsus,
1128 METCALFE ET AL.
thus maintaining more normal anatomical relationships in
the dynamic setting. Alternative options necessitate more
extensive surgery, increasing operative risk and postoperative
recovery.23,42,54,74,94 Tarsal joint fusions and osteotomy also
have potential for non union and growth plate disturbance.
Though a well-established technique, there remains a paucity
of information surrounding the safety and effectiveness of
arthroereisis. As such there is a need to review the proce-
dure’s safety and effectiveness. Through a critical review of
over 40 years of arthroereisis literature, the authors examine
the operative and technological advancements pertaining to
this technique, summarizing key outcome data with respect to
arthroereisis as well as identifying areas for future research.
METHODS
A database search was conducted [Medline from 1966 to
2010; Cumulative Index to Nursing and Allied Health Liter-
ature (Cinahl) from 1982 to 2010; and Embase from 1982 to
2010] during the period of January 2010 to April 2010 using
the terms “arthroereisis,” “MBA,” “STA-peg,” “subtalar
implant,” and “pediatric flatfoot.” Abstracts were reviewed to
identify which articles were included and excluded according
to the criteria defined below. As there was a general absence
of well-controlled studies relating to arthroereisis, this review
included articles which met the following criteria:
1. The focus of the article was directly related to the
treatment of pediatric flexible flatfoot by means of
arthroereisis and /or relating to complication or biome-
chanical evaluation of arthroereisis,
2. The article was published in a peer-reviewed journal,
and
3. Published in the English language.
RESULTS
Seventy-six publications met the criteria for inclusion
in this review. Several factors prevent pooling of data
for the purpose of conducting any type of statistical test.
The literature on arthroereisis consists primarily of ad hoc
case reports and retrospective case series reports (Level
III and IV evidence). Methodological variations included
device type, inclusion criteria, surgical technique, application
of adjunctive procedures, and outcome measures. Some
series even report on adults and children within the same
study, or report on varied surgical techniques within the
same series.20,29,98 Few studies applied validated clinical
or patient reported outcome measures. Only one study
utilized a disease- and child-specific patient reported outcome
measure.54 This study, however, compared post-intervention
scores with aged matched controls rather than comparing
individual scores pre- and postoperatively.54 In reporting
on outcomes, the authors have not included ad hoc case
reports or case series involving children with underlying
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
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Foot & Ankle International/Vol. 32, No. 12/December 2011
neurological or connective tissue disease.25,79 This was
considered to have the potential to skew the complication
data with respect to the role of subtalar joint arthroereisis in
the treatment of pediatric flexible flatfoot. In summarizing
the available data within the present review, we considered
it appropriate, where possible, to distinguish outcomes and
complications by device type on the basis that variation
in surgical technique and or the nature of the device may
influence clinical outcomes. The devices were classified
as set out in Table 1. Where study numbers have been
insufficient to separate data by device type, data has been
pooled.
Radiological outcomes
Radiological measures have long been applied as markers
of success in the management of flatfoot deformity, though
their relationship to a patient’s perceived clinical status
remains to be proven. Lanham first reported on changes
in radiographic alignments following arthroereisis,45 after
which most authors have included some form of radiolog-
ical outcome measure.2,3,9,12,18,22,27,29,32,46,54,76 – 78,88,89,91,93
In reviewing the available published data, several limitations
become apparent. First, substantial variation exists in the
radiological parameters reported between studies. Second,
only a small number of studies declared their criteria and
measurement procedures for the reported charted values.
The importance of measurement reliability or the statistical
significance of the observed measures was not universally
reported.3,18,54 Additional confounding factors included vari-
ation in the timing of postoperative images, failure to disclose
actual values, and lack of complete data sets in the reported
case series.12,91 With these limitations in mind, the authors
have summarized the available data from 15 studies where
actual values for radiological values are declared together
with the cohort numbers.1,12,18,22,27,32,46,48,54,66,76−78,86,89
The n value for each radiological value summarized in
Table 2 will therefore vary due to the variation in reported
angles.
The results are consistent with a tendency, in static align-
ment, toward increased arch height and great congruency
within the tarsus and tarso-metatarsal alignments. No studies
within this review correlated changes in radiological align-
ments and patient reported outcome.
Table 1: Classification of Arthroereisis Devices
Device Type Named Example
Silicone non bespoke Swanson
Silicone bespke Viladot
Seated (within calcaneus) STA-peg Koning
Free floating bioresorbable Giannini
Free floating non resorbable MBA Kalix Hyprocure
Foot & Ankle International/Vol. 32, No. 12/December 2011 SUBTALAR JOINT ARTHROEREISIS 1129

Table 2: Radiological Charted Values (Degrees) Before and After Arthroereisis

Radiographic CI1,18,22,32, LT1st27,32, TD1,18,22,48,

12,32 22,66 22,66 46,48,78,87 46,54 54,77 – 78,87,90
Measure MCB TNJ LTCJ KITE22,54,66 CHt46 NHt90

Studies 2 2 2 8 4 9 3 1 1
Feet (n ) 115 108◦ 108 306 190 406 175 16 45
Preop Mean 145.5◦ 49.9◦ 40.45◦ 14.3◦ −16◦ 39.00◦ 28◦ 12 mm 16 mm
Postop Mean 132.5◦ 70.8◦ 33.65◦ 16.5◦ 0◦ 24.5◦ 20.0◦ 16 mm 24 mm
Change −13◦ +20.9◦ −6.8◦ +2.2◦ −16◦ −14.5◦ −8.0◦ +4 mm +8 mm

MCB, Moreau-Costa-Bartini; TNJCon, Talo navicular joint congruency; LTCJ, Lateral talo-calcaneal; CI, Calcaneal incliniation; LT1st, Lateral talo-first
metatarsal; TD, Talar declination; CHt, Cuboid height; NHt, Navicular height; N1, total number of feet in the one or more studies reporting on the
radiographic charted value.

Clinically related outcomes
Between 1970 and 2004, ten studies have provided overall
rating of clinical outcomes in a total of 756 feet aged between
36 and 240 months following subtalar arthroereisis using
a range of device types specifically for the treatment of
pediatric flexible flatfoot (Table 3).1,12,13,26,46,48,69,76,91
patients (16 feet), they demonstrated a mean improvement in
AOFAS scores of 19.4.46 While this outcome tool is not
validated specifically for use in the pediatric population,
statisitcally significant differences (p < 0.05) were seen in
postoperative scores (Figure 1).

Complications Associated with Arthroereisis

Patient Satisfaction
Six studies have included some element of patient satisfac-
tion though none utilized a validated foot specific outcome
tool for the pediatric population.1,22,42,46,86,89 Four studies
provide overall estimates of patient satisfaction, though none
declare whether these are based on subject view or those of
the parents of the pediatric subjects. Some variation exists in
the rating scales employed which is accounted for in Table 4
by inclusion of all categories described. In total, 118 patients
(212 feet) are included in estimates of overall patient satis-
faction using non-validated outcome measures.
To date, four studies have employed a validated foot
specific patient outcome tool, American Orthopaedic Foot
and Ankle rating scale (AOFAS).25,46,53,92 Only one study,
however, met the stated inclusion criteria. Involving eight
Review of the literature reveals eight main categories of
complication associated with arthroereisis devices. Table 5
summarizes theses complications where sufficient data was
available. In addition to the complications reported in
Table 3, several authors reported on transient symptoms,
including peroneal tendonitis, leg cramps, heel pain, and gait
abnormalities, which have been excluded.22,30,48,91 Analysis
of complications, in particular the application of regression
statistics to identify potentially important factors, has not
been possible due to the poor quality of data. A number
report overall percentage rates rather than raw data. To maxi-
mize the available data percentages, the total number of feet
are given in Table 5. For clarity, the studies included against
each data set are shown.

Table 3: Surgeon-Based Outcome Following Arthroereisis

Series¥ 176 292 31 413 548 687 726 812 946 1069
Device¥¥ S V SS V L ST GI GI K GI N/A
Cases (N1) 54 - 10 43 49 23 32 33 8 43
Feet (N2) 108 234 16 77 96 41 38 50 16 80
Excellent¥¥¥ 24.2 0 0 58.4 0 0 0 28 50 0 16.6
Good¥¥¥ 42.4 100 70 29.9 72.9 58.4 100 62 50 56.8 64.2
Fair¥¥¥ 27.4 0 20 11.7 19 36.6 0 4 0 30.3 14.9
Poor¥¥¥ 6 0 10 0 3 4.9 0 6 0 13 4.3

¥, Surgeon-based outcomes from ten studies (series 1 to 10) as cited. N1, number of cases in each study. N2, number of feet in each study.
¥¥ , Device types within each study (S, Silastic; V, Viladot; SS, Silastic sphere; L, Lundeen; ST, STA-peg; G, Giannini; K, Kalix).
¥¥¥ , Clinician-based assessment of the surgical result graded “excellent to poor.”

Copyright  2011 by the American Orthopaedic Foot & Ankle Society

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1130 METCALFE ET AL. Foot & Ankle International/Vol. 32, No. 12/December 2011

Table 4: Summary of Subjective Outcome Data

Reported Series 11 286 322 442 590 646

Device Type SS ST ST C GI K
Patients (N1) 10 23 21 27 29 8
Feet (N2) 16 41 40 54 45 16
Age range (months) NR 84– 240 48– 192 48–132 74.5– 186 96– 168
Mean age (months) NR NR 120 96 118 132
Mean followup (months) 54.5 32 36 144 36 31.4
% Would have operation again = “Yes” 90 85 85 63 NR NR
% Would have operation again = “No” 10 nr 0 18.5 NR NR
% Would have operation again = “Undecided” 0 nr 15 18.5 NR NR
SATISFACTION RESULTS
% Satisfied NR 90 NR 81.5 79 100%
% Reasonably satisfied NR NR NR 11.1 0 NR
% Moderately satisfied NR NR NR 7.4 0 NR
% Dissatisfied NR NR NR 0 21 NR

∗,SS, Silastic sphere; ST, STA-peg; C, Cone; G, Giannini; K, Kalix; NR, not reported. Six studies are represented in Table 4 reporting on subjective
outcomes with five device types.

the assumption being that with control of excessive foot

Fig. 1: Comparison of AOFAS scores following subtalar joint arthroereisis.
DISCUSSION
Functional impact, operative morbidity and longer term
sequelae following joint fusion(s) have most likely prompted
exploration of alternative approaches to the treatment
of flexible flatfoot. Arthroereisis is defined as the “limitation
of exogenous joint motion without complete arthrodesis.”55
Chambers described an operation to elevate the ante-
rior calcaneus, thus blocking abduction of the foot by
interfering with the forward and downward sliding of
the talus.15 Subsequently, modifications were reported, the
last being an opening wedge osteotomy of the sustentac-
ulum tali.70 Technicality and associated complications with
osseous techniques prompted exploration of
alternatives.8,11,14,15,28,31,34,47,70 Early pioneers of arthro-
ereisis sought to find a means by which patients might
achieve preservation of joint movement with control of
hypermobility.
Results of a free-floating Siliastic arthroereisis device
were first described in 1974.85 Subotnick highlighted the
need for any device to be mechanically stable for 2 years,
Copyright  2011 by the American Orthopaedic Foot & Ankle Society
pronation, bony and soft tissue adaptation would manifest as
correction of the arch. With a followup of only 12 months this
was not substantiated, though this concept underpins biore-
sorbable devices.25,27 Lanham et al. reported on a sample of
11 patients (22 feet) from a series of 51 patients (102 feet).
Using the stem of a Swanson implant they noted a reduction
in talar declination and talocalcaneal angles.35 Similar results
were reported by Volger using the same type of device fitted
into a drill hole so as to minimize the risk of extrusion.93
Adaptation of existing silicone toe implants paved the way
for a variety of purpose made devices.1,2,45,67,93 Addante et
al. reported on a single pediatric case of flexible flat feet using
a purpose made Silastic sphere (Sutter Biomedical Inc.).2
This technique involved a 7-cm incision with suturing of the
device into the spring ligament. Resolution of symptoms and
improvement in three radiological alignments was reported
at 3 years postoperatively. In a retrospective review, Smith
& Rappaport reported on outcomes following Silastic plug
arthroereisis in their series of 54 patients (108 feet) treated
for painful idiopathic flatfeet in children.76 All 20 patients
available for radiological review demonstrated improvement
in key radiographic alignments. Two required device removal
and one reported swelling suggestive of implant extrusion.
Selection of silicone most likely reflected availability,
and a belief that it was biocompatible with good loading
tolerance though no in vitro or in vivo testing was reported.
Viladot published the largest series of the time using a
purpose made “wine glass”-shaped Silastic implant.91 This
retrospective case series of 234 feet, in children 5 to 15 years
of age reported on a range of clinical, anthropometric and
radiological measures. Uniquely, the Viladot stent spanned

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 Table 5: Complications in Association with Arthroereisis

Device Type

Non Bespoke
Silicone Silicone Bioresorbable Seated Free Floating

Studies 244,76 51,9,12,92,94 127 722,30,42,48,77 – 78,86 1012,18,26,32,46,54,66,69,

90,99
Reported
Study Period NR 1970– 95 NR 1974– 2002 1989– 2007
Patients (n ) 65 69 21 204 278
Feet (n ) 130 351 42 394 500
Age (mean, mean = NR mean = 144m94 mean = NR mean = 102m22,30,42,48,78 mean = 132.3m12,18,32,
46,54,66,69,90,99
range)
range = NR range = range = 96– 180m27 range = range = 48– 204m12,18,
Foot & Ankle International/Vol. 32, No. 12/December 2011

26,32,46,54,66,69,90,99
60– 180m9,13,92,94 36– 240m22,30,42,48,77 – 78,86
Followup mean = 24m76 mean = 30.8m1,9,94 mean = 48m27 mean = 56.8m22,42,78,86 mean = 36.2m12,18,32,46,
54,66,69,90
(mean, range)
range = 4–48m44 range = 3–168m1,9,13,94 range = NR range = range = 2.5– 72m12,18,26,
32,54,66,69,90,99
12– 192m22,30,42,77 – 78,86
Complications N = 244 N = 431,9,12,92,94 N = 227 N = 6122,30,42,48,77 – 78,86 N = 7312,18,26,32,46,54,66,
69,90,99
(n )
44 1,9,12,92,94 27 22,30,42,48,77 – 78,86
% Overall 9.1% 18.6% 4.8% 19% 14.9%12,18,26,32,46,54,66,69,
90,99
Complications
Removal Rates mean = 19.3%76 mean = 8%1,9,12,92,94 mean = 0%27 mean = 7.1%22,30,48, mean = 7.9%12,18,26,32,
77 – 78,87 46,54,69,90,99
(grand

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means, range)
range = NR range = 0–36.4%1,9,12, range = 0%27 range = 1.9– 20%22,30,48, range = 0– 15.8%12,18,26,

Copyright  2011 by the American Orthopaedic Foot & Ankle Society

92,94 77 – 78,87 32,46,54,66,69,90,99
76 1,9,12,92,94 27
Extrusion mean = 9% mean = 0.5% mean = 4.8% mean = 0.8%22,30,48,77 – 78,87 mean = 2.7%12,18,26,32,
46,54,69,90,99
1,9,12,92,94 22,30,48,
range = NR range = 0–2.6% range = NR range = 0– 3.7% range = 2.5– 22%12,18,26,
77 – 78,87 32,46,54,69,90,99
1,9,12,92,94 27 22,30,48,77 – 78,87
Sinus Tarsi Pain mean = NR mean = 7.3% mean = 4.8% mean = 9.6% mean = 7.4%12,18,26,32,
46,54,66,69,90,99
1,9,12,92,94
range = NR range = 0–36% range = NR range = range = 0– 38%12,18,26,
32,46,54,66,69,90,99
SUBTALAR JOINT ARTHROEREISIS

1.1– 45.5%22,30,48,77 – 78,87

1131
 1132

Table 5: Continued

Device Type

Non Bespoke
METCALFE ET AL.

Silicone Silicone Bioresorbable Seated Free Floating

Synovitis mean = NR mean = NR mean = 0%27 mean = 0.3%22,30,48,77 – 78,87 mean = 0%12,18,26,32,
46,54,66,69,90

range = NR range = NR range = NR range = 0– 1.9% range = NR

22,30,48,77 – 78,87

Infection mean = 0%44,76 mean = 2.2%1,9,12,92,94 mean = 0%27 mean = 0.8%22,30,48,77 – 78,87 mean = 0%12,18,26,32,46,
54,66,69,90,99
(Superficial)
44,76 1,9,12,92,94 27 22,30,48,77 – 78,87
range = 0 range = 0–7.8% range = 0 range = 0 – 4.5 range = 012,18,26,32,46,
54,66,69,90,99
44,76 1,9,12,92,94 27 22,30,48,77 – 78,87
Infection (Deep) mean = 0% mean = 0.6% mean = 0% mean = 0.35% mean = 0%12,18,26,32,46,
54,66,69,90,99
44,76 1,9,12,92 27
range = 0 range = 0.2–6% range = 0 range = 0– 2.4% range = 012,18,26,32,46,54,
22,30,48,77 – 78,87 66,69,90,99
44,76 1,9,12,92,94 27 22,30,48,77 – 78,87
Under- mean = 0% mean = 0% mean = 0% mean = 10.5% mean = 15.4%12,18,26,32,
46,54,69,90,99
Correction
range = 044,76 range = 01,9,12,92,94 range = 027 range = 0– 34.1% range = 0– 93%12,18,26,
22,30,48,77 – 78,87 32,46,54,69,90,99
,76 1,9,12,92,94 27 22,30,48,77 – 78,87
Over-Correction mean = 1.5% mean = 0% mean = 0% mean = 0% mean = 0%
12,18,26,32,46,54,69,90,99

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1,9,12,92,94 27 22,30,48,77 – 78,87
range = NR range = 0 range = 0 range = 0 range = 0
12,18,26,32,46,54,69,90,99

Copyright  2011 by the American Orthopaedic Foot & Ankle Society

44,76 1,9,12,92,94 27 22,30,48,77 – 78,87
Peroneal Spasm mean = 0% mean = 0.1% mean = 0% mean = 0.6% mean = 0%
12,18,26,32,46,54,69,90,99
44,76 27
range = 0 range = 0–0.04 range = 0 range = 0– 0.25% range = 012,18,26,32,46,54,
1,9,12,92,94 22,30,48,77 – 78,87 69,90,99

The complications rates are not cumulative. For example, stent extrusion may have necessitated device removal, and therefore the reader is advised not to over-count the complications by adding
the columns. Not all studies reported on all parameters; therefore, relevant references for each data sets are shown. NR, Not reported.
Foot & Ankle International/Vol. 32, No. 12/December 2011
Foot & Ankle International/Vol. 32, No. 12/December 2011
the entire width of the sinus tarsi requiring extensive dissec-
tion for placement. The stem-shaped design was considered
to reduce the risks of extrusion, a complication of sili-
cone devices.1 – 2,45,76,85,93,96 Clinical improvement was seen
in all cases with normalization of the footprint using the
photopodogram in 56% and partial normalization in a further
43%.91 Carranza-Bencano et al. reported on a retrospective
series of 77 patients with 88% reporting either “excellent”
or “good” clinical outcomes.13 In stark contrast to many
authors, Black et al., in a retrospective case series of 15
patients (22 feet), reported a 36% removal rate due to device
intolerance and poor success as determined by anthropo-
metric, pressure, and radiographic analysis.1 – 2,13,45,67,76,85,91
Between 1974 and the 1990’s, several key papers report on
Silastic arthroereisis devices for the treatment of pediatric
flexible flatfoot. Whilst these reports lack a uniformity of
study design, evidence emerged to support the concept of
a non-biologic arthroereisis device paving the way for new
devices.1,13,19,29,45,67,76,85,91
First used in 1974 and reported in 1983, the STA-peg
represented the first purpose designed non silicone device.33
Fixed directly into the calcaneus, it was believed to alter
the axis of the subtalar joint preventing excessive anterior
shift of the talus thus correcting heel valgus and eliminating
excessive pronation.30,77 This first description retrospectively
reported on 27 patients (53 feet) between 3 and 17 years
of age. With a minimum followup of 3 (range, 3 to 9)
years, Smith’s paper represented the longest followup of
the time. Typical of previous papers, outcome measures
remained clinician based with significant improvements in
key anthropometric (heel valgus and arch appearance) being
reported in over 95% of patients. Complications included
pain and swelling in three patients which spontaneously
resolved in two; the third patient required synovectomy to
relieve symptoms. A fourth patient fractured the inferior
cortex of the calcaneum following a fall. Reduction of
mechanical integrity of the calcaneus and or alteration to
subtalar joint function, due to the STA-peg insertion may
or may not have played a role in this fracture. The device
found widespread popularity into the 1990’s with over 15
published papers reporting on STA-peg arthroereisis. A later
review of 11 patients (20 feet) aged 3 to 17 years applying
similar clinician based outcome measures, noted improved
appearance of the feet in ten of the 11 patients.77
Substantial age variation exists between studies, some
including children as young as 2 years.29,56,84 – 85 First, inter-
vention prior to foot maturation might imply unnecessary
treatment. Second, differentiation between natural resolution
and that owed to the intervention must be considered. Third,
skeletal immaturity complicates radiographic measurement
due to lack of osseous landmarks.
Lundeen modified the STA-peg device claiming improved
biomechanical function.48 Reporting on 49 patients (96 feet)
aged 3 to 19 (mean, 8) years and a mean followup of
46 (range, 19 to 76) months, this represented the largest
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SUBTALAR JOINT ARTHROEREISIS 1133
and most comprehensive case series of the day. Applying
clinician-based outcomes 78% of patients achieved a good
clinical outcome (reduced deformity and resolution of symp-
toms). Two patients were noted to have flattening of the
lateral talar process suggestive of implant bone contact
loading.48
Intraosseous cyst formation has been reported following
STA-peg arthroereisis.62 Computerized tomography and
subsequent intra operative inspection revealed erosion of the
calcaneum at the implant interface together with cyst forma-
tion within the talar neck. Micro motion, well known to
induce osteolysis, was considered to underpin the compli-
cations and thus non cemented fitting of STA-peg devices
may be implicated in migration of particulate debris resulting
in local osteolysis.41 In 2001, Forg et al. reported on 21
patients (40 feet) aged 4 to 16 years with a mean followup
of 3 years (range, 12 to 90 months).22 Six of seven subjec-
tive parameters improved with 85% of the cohort stating
they would “recommend” or “highly recommend” the proce-
dure. Complications included three patients, one developing
peroneal spasm following injury, the second with sinus tarsi
pain, and a third case requiring implant removal attributed
to excess bone cement.
Advance in arthroereisis design came with the introduction
of cannulated cementless systems requiring minimal opera-
tive assault. Purpose made implants with improved anatom-
ical configuration and ease of fitting saw a transition away
from both the silicone and cemented devices. In their paper
regarding the Valente procedure, Langford et al. showed that
Valente employed polyethylene implants of varying sizes
which could be matched intra operatively to the patients
clinical picture.43 Two cadaver studies have demonstrated
the relationship between device size and limitation of joint
motion supporting clinical observations.17,38 Limitations of
these studies include uniform loading and a failure to account
for muscle function during testing.71 – 72
Throughout the 1980’s to early 1990’s, numerous new
arthroereisis devices were reported. A retrospective review
of 32 patients aged 7 to 13 years using a two-component
device noted clinical improvement in all cases, though six
patients required device removal and no radiographic data
were included.26 Verheyden et al. provided a more detailed
analysis using the same device in patients aged 6 to 15 years
of age with painful flat feet.89 Of the 29 patients (45 feet), 14
underwent supplementary Kidner-type procedures. Results
of this retrospective case series highlight the importance
of including both clinician and patient evaluations. While
Giannini’s original report included only clinical outcomes,
Verheyden et al. employed a patient satisfaction question-
naire in addition to the clinical and radiographic outcome
measures. Eighty percent of their patients reported subjective
satisfaction with the operative outcome, 21% were dissat-
isfied. Using a single observer to minimize measurement
error, improvements in both navicular height and talar decli-
nation were reported. In contrast to Giannini’s technique,
1134 METCALFE ET AL.
Verheyden removed the contents of the sinus tarsi cutting
the interosseous ligament, which may have contributed to
the observed differences.
Developed in the mid-1980’s Maxwell et al. reported on
the MBA device in 1999.49 This device claimed several
design benefits over its predecessors. Titanium had by this
time, established a record of excellent biocompatibility.
Varying sized implants (6 to 12 mm) and temporary sizers,
permitted intraoperative sizing with identical devices. Deep
threads along the implant claimed to reduce implant extru-
sion. Three grooves cut into the device body were claimed to
offer “shock absorption,” though this has not been demon-
strated in vivo.16 By the late 1990’s, arthroereisis devices
shared many common features; cannulated application, intra
operative sizers, biocompatible materials and a range of
implant sizes. A further shift is seen with regard to age of
application, with fewer reports of application in infants in
today’s literature compared with the reports of the 1970’s and
1980’s. This more judicious approach allows natural skeletal
development and the opportunity of self-correction in young
children.
Of the four studies employing the AOFAS, only one study
met, in full, the inclusion criteria for this review.46 Giannini
et al. published the first retrospective case series using the
American Orthopaedic Foot & Ankle Scale (AOFAS) in
a pediatric population (mean, 14 years; range, 9 to 18
years).25 Twelve patients (14 feet) underwent correction
of flatfoot associated with tarsal coalition. Mean AOFAS
scores increased from 29 to 90 in keeping with subjective
outcome ratings. Though not validated for the use in the
pediatric population, other authors have adopted the AOFAS
in their case series. Needleman reporting on the MBA
device used to treat adult flexible flatfoot in 23 adults (n = 28
feet) demonstrated similar outcomes with mean scores of
52 preoperatively, rising to 87 postoperatively.53 Similar
improvements were reported in the single study to meet our
review criteria.46 A statistically significant (p < 0.005) mean
improvement in AOFAS scores was seen in the cohort of
eight patients (16 feet) at a mean followup of 31.4 months.
Inclusion of patient based outcome measures have become
more widely adopted since their application by Smith and
Rappaport in 1983.76 However, despite improved reliability
of validated disease and age-specific tools, only Nelson
employed a validated tool specific for pediatric populations.54
Although significant improvements in scores are reported, it
must be noted that baseline data was obtained from published
age matched norms and not from the treatment cohort. While
application of disease-specific patient outcome tools is to
be encouraged, it is essential that such tools are validated.
This is particularly important for the pediatric population
where complexity, language, and design may limit both
criterion validity, responsiveness, and longitudinal validity of
the scales.97 Incorporation of both objective and subjective
outcome data is essential. Intuitively, one might assume a
strong correlation though this may not be the reality.89 The
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Foot & Ankle International/Vol. 32, No. 12/December 2011
Oxford Child Foot Questionnaire represents one such tool
which could be universally applied in this setting.52 Adoption
of a disease specific and age validated tool would permit
pooling of future published data.
Arthroereisis reports often include data on radiographic
alignments, comparing pre and postoperative alignments.
Vanderwilde et al. published normative data for a range
of radiographic values in their study of 74 children aged
6 to 74 months, though no measures of repeatability were
included.87 Repeatability of X-ray measurement is subject to
both biological and technical error.10,33,59,64 In adults stan-
dardization has been shown to provide reproducible images.
Measurements taken from films is known to be subject to
significant intra and inter observer error.64 Additionally the
production of a two-dimensional image to represent the three-
dimensional foot has been shown to produce potential errors
when comparing X-ray with cadaver models.60 A further
consideration is the effect of skeletal development which
may impact on radiographic measurement. Future studies
may consider reporting short- and long-term radiographic
changes. Despite these limitations, there is a notable trend
to suggest arthroereisis leads to an improvement in many of
the key charted values54 though a number of authors have
failed to investigate for possible correlation between radio-
graphic alignment and subjective evaluation.7,88,92 Cadaver
studies have demonstrated reduced load to the plantar liga-
ments after simulated arthroereisis using a 6-mm wooden
dowel in a simulated flatfoot model.6 Restoration of talar
declination may conversely be associated with reduced load
to these restraining structures. Many authors have suggested
application of arthroereisis whilst there is substantial growth
potential within the foot to allow for adaptive recovery of soft
tissues. Coupled with the potential for secondary deformity,
in particular fixed forefoot inversion as a result of patholog-
ical stance phase heel eversion, one can begin to make a case
for a theoretical optimum age.
In July 2009, the UK’s National Institute of Clinical
Excellence (NICE) published interim guidance regarding
arthroereisis (Interventional procedure guidance 305),
concluding that there is currently insufficient evidence with
the respect to the safety and efficacy of this procedure. Within
their published summary of procedure safety they grouped
all devices, even those no longer in common usage. Compli-
cations of all devices are grouped, even those devices no
longer used. Improved transparency with regard to outcome
data will minimize misinformation provided to patients and
clinicians alike. Several specific areas are worthy of further
discussion.
Safety of arthroereisis
Critics of arthroereisis often cite complications without
due consideration of the risks of alternative interventions.
Complications must be contextualized to be of value in
the clinical decision making process. Silicone devices, once
in common use, have been superseded by titanium and
Foot & Ankle International/Vol. 32, No. 12/December 2011
polyethylene.1 – 2,9,67,76,91,93 Advances in instrumentation,
improved device biocompatibility and minimally invasive
techniques have mitigated some of the historical compli-
cations. Avoidance of polymethylmethacrylate overcomes
complications associated with thermal necrosis, inhibition
of antibacterial activity and cement-induced hepatitis.62
Whilst polyethylene and titanium are considered “biocom-
patible” by the operative community, no material is truly
“biocompatible.”37 In vitro testing provides insight into the
wear characteristics of materials and thus potential dura-
bility. However, differences may exist in vivo. Polyethy-
lene has been shown to undergo dynamic changes in vivo
associated with reduced mechanical performance. Production
of osteolytic mediators exposed to titanium wear particu-
lates have been reported.37 These cellular mechanisms may
underpin a number of the observed complications associ-
ated with arthroereisis including pain, edema, and bone
osteolysis. Modern devices are typically made of stain-
less steel, polyethylene, titanium, combined construction
or bioresorbable.21,27,49,65,92 Loading stresses may play an
important part in the pattern and degree of device wear. In
a cadaver-based model undergoing cyclical loading, Schon
reports contact loading of as little as 1.3 N at the bone device
interface though detailed methodology is not disclosed.68
Confirmation of loads between the tarsus and implant is
important for future device design and prediction of stress
related complications.
Tissue discoloration due to titanium deposition has been
reported around most types of implants.95 Behaviour of
materials, including biocompatibility, is influenced by its
specific application. Both arthroereisis material and design
will impact on mechanical performance. The MBA device
with sharp titanium flutes differs from the smoother profiles
of other device designs such as the Kalix and Hyprocure
(Figure 2).
The first purpose designed bioresorbable device was
reported in 2001.27 Others have adapted bioresorbable
devices (screws) as arthroereisis devices.65 Application of
absorbable screws cut down and lodged within the sinus
tarsi is reminiscent of historical techniques.44 In the single
published case series using a bioresorbable device (poly L-
lactic acid) involving 21 patients (42 feet), two patients
Fig. 2: Example of different arthroereisis devices.
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SUBTALAR JOINT ARTHROEREISIS 1135
(10%) required device removal because of implant degra-
dation related soft tissue swelling associated with pain.
While the biochemical aspects of the degradation process
are the same for all patients, not all patients develop pain
and swelling. Biological load related to implant size and
degradative capacity probably play a role, that is to say,
greater volume of material impose greater demands. Reduced
vascularity and tissue coverage may limit cellular capacity
for implant breakdown. Application of bioresorbable mate-
rials for arthroereisis requires confirmation that the device
is necessary for a limited time frame, consistent with the
characteristics of the materials employed.
Maintenance of correction following implant removal,
albeit with short-term followup, has been previously
reported.27,65,68 Arthroereisis has been claimed to reduce
stress to peri talar structures, promoting restoration of
function and recovery from attenuation. Using a three-
dimensional multi-segment cadaver model, Arangio assessed
joint moments in normal, simulated flat, and flatfoot with
arthroereisis. Insertion of a simulated arthroereisis device
(6-mm wooden dowel) decreased pronatory moment arms
within the medial column.6 The observed improvements
being similar to a similar simulation examining the impact
of medial calcaneal displacement osteotomy.68 The correc-
tive effect of 6-mm wooden dowel may be less than that of
actual arthroereisis device. A relationship between implant
size and increased corrective effect has been previously
demonstrated.17 Changes in the frontal plane position of the
subtalar joint alter the moment arm of the medial and lateral
heads of gastrocnemius, progression toward calcaneal ever-
sion in stance produces an increasingly pronatory pull by
gastrocnemius.
All of the modern-day arthroereisis devices adopt near-
identical techniques and thus infection rates should reflect
those of similar clean elective interventions. The impact
of sinus tarsi evacuation and inter osseous release require
further investigation to determine their contribution to
adverse outcomes. Literature reveals no consensus in regard
to cutting of the sinus tarsi ligaments. Some authors
consider it a critical component of the procedure.43,76 Subot-
nick describes releasing the inter osseous ligament in all
cases.84 – 85 Smith and Rappaport suggest release of the
1136 METCALFE ET AL. Foot & Ankle International/Vol. 32, No. 12/December 2011

ligament is associated with an observed supination of the
calcaneus.76 Tompkins et al. highlight the need to release
portions of both the cervical and interossseous ligaments to
gain adequate operative exposure to correctly fit the device.68
Nelson et al. advocated cutting of the interosseous liga-
ment in all 37 (67 feet) pediatric patients treated by MBA
arthroereisis.54 Others stipulate retention of this structure,
suggesting that evacuation of the sinus tarsi and cutting
of the interosseous ligament might underpin the differences
in outcomes.53 Zaret and Myerson suggest cutting of the
interosseous ligament is unnecessary, causing instability of
the subtalar joint.98 The significance of inter osseous release
with respect to arthroereisis success or failure remains to be
elucidated.
Reversibility
Arthroereisis has the potential for “reversibility.”43,92
Compared to alternative operative procedures, the operative
insult is small and recovery more speedy when performed
in isolation.98 Whilst there is no specific published data
examining outcomes of failed arthroereisis leading to device
removal, some encouraging insight is possible. Vedantam
et al. removed five STA-peg implants (3.5%) because of
persistent pain.88 Symptoms resolved in all cases following
removal. Using a bioabsorbable implant Giannini et al. report
on outcomes in 21 children. Two patients required removal
because of persistent pain with both cases resolving.24
Resolution of pain following removal of the implants with no
observed synovitis or bone damage was noted.88 By contrast
Rockett et al. removed two uncemented STA-peg devices at 2
years due to pain associated with erosive and cystic changes
achieving only partial resolution of symptoms.62 In 2000,
Siff and Granberry reported on a single case of avascular
necrosis in one foot 10 years following bilateral arthroereisis
using a polyethylene device.73 Biopsy confirmed avascular
necrosis and giant cell host response though device removal
resulted in significant improvement in symptoms. Metcalfe
reported on pain following MBA arthroereisis device due
to erosion of the talar neck and recurrence of the flatfoot.51
Symptoms resolved following device removal.
Where arthroereisis fails, the majority of patients recover
to their preoperative state following implant removal.
Surgeons and patients should be alerted to the need to inves-
tigate postoperative discomfort early to mitigate the risk of
more serious complications.51,62 Careful preoperative assess-
ment is essential prior to correction of pediatric flatfoot. Such
assessment is mandatory irrespective of intervention. Equinus
deformity requires careful evaluation as it acts as a deforming
force on the foot. Left unchecked it is probable that ankle
joint equinus promotes failure of flatfoot correction.5 Clinical
assessment may be subject to variation of assessor loading
(rate and peak) which may need to be adjusted to indi-
vidual patients body mass index.57 Future publications should
attempt to standardize assessment and criteria for this impor-
tant component of foot function. Overcorrection and forefoot
varus are reported by a number of authors, though few if any
explanations are offered. Smith and Westlin observed that in
the face of ankle valgus high rates of complications could
be expected and this should be included in the preoperative
work-up.75
CONCLUSION
Pediatric flexible flatfoot remains a poorly defined pathology
with little agreement regarding treatment.39,40,81,82 Arthroereisis
represents a minimally invasive procedure capable of correcting
flexible flatfoot through a combination of static, dynamic
and proprioceptive mechanisms. As a treatment option it
continues to polarize opinion. A focus on internal joint
congruency rather than simple anthropometric measures may
sharpen our understanding. There is a growing body of
evidence linking abnormalities in joint malalignment to the
development of osteoarthrosis.4,36,58,90 More recent obser-
vational studies have demonstrated a greater incidence of
osteoarthrosis in flat feet compared with controls.50 For
the foreseeable, arthroereisis remains a popular intervention
with foot and ankle surgeons. While the precise mecha-
nism by which arthroereisis improves foot alignment remains
to be elucidated, several studies have demonstrated signifi-
cant improvements in key radiographic parameters reflecting
both increased arch height and improved joint congruency
following arthroereisis. Progressive loss of both static and
dynamic stabilization of the foot with advancement of flat-
foot deformity may underpin, at least in part, suboptimal
outcomes. Arthroereisis is an established yet evolving tech-
nique for the management of pediatric flatfoot deformity.
As yet, future decision-making around intervention for flex-
ible flatfoot remains clinical rather than evidence-based,
with no arthroereisis device demonstrating superiority over
another and based entirely on patient selection. The technical
simplicity of arthroereisis does not imply lack of correc-
tive power, nor longevity of correction. Where complica-
tions do arise, removal of the implant appears to usually
leads to uncomplicated recovery without the irreversible
consequences sequelae seen with more aggressive interven-
tions. Application of disease specific validated outcome tools
together with standardization of reported data sets would may
improve upon current evidence and permit comparison of
study data.
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