Grice Arthrodesis and Arthroereisis in the Surgical Management of Pediatric Flatfoot: Radiological Outcomes and Limitations

<b>Background:</b> Flexible flatfoot is a common pediatric condition. Surgical intervention is indicated for symptomatic cases unresponsive to conservative treatment. This study evaluates the outcomes of two established procedures, Grice extraarticular subtalar arthrodesis and subtalar arthroereisis, in children treated for symptomatic flatfoot. <b>Methods:</b> A retrospective analysis was conducted on 158 patients (286 feet) treated between 2013 and 2024. Among them, 34 underwent Grice arthrodesis and 124 underwent arthroereisis. Demographic and procedural data were collected, including age, sex, neurological impairment (cerebral palsy), laterality, and concurrent Achilles tendon lengthening. Radiographic parameters assessed pre- and postoperatively included Meary's, Pitch, and Kite's angles (frontal and sagittal view), uncovering of the talus, and Cyma line. Only patients with both pre- and postoperative measurements were included in paired analysis. Statistical tests included paired <i>t</i>-tests within groups and Welch's <i>t</i>-tests for between-group comparisons. <b>Results:</b> Grice patients were younger (mean age 9.0 ± 3.1 years) and included all cerebral palsy cases (18/34; 52.9%), while arthroereisis patients were older (10.8 ± 2.6 years) and typically neurologically normal. Achilles tendon lengthening was performed in 100% of Grice and 48% of arthroereisis cases. Both groups showed significant radiographic improvement across all measured parameters (all <i>p</i> < 0.05). Grice arthrodesis produced greater reductions in Meary's angle (right Δ = -19.8° ± 9.2 vs. -13.1° ± 7.5; <i>p</i> = 0.024), while arthroereisis yielded larger increases in Pitch angle (left Δ = +9.2° ± 7.2 vs. +5.5° ± 6.2; <i>p</i> = 0.055). Other angular improvements (Kite's, uncovering, and Cyma line) were statistically significant within both groups but not between groups. <b>Conclusions:</b> Symptomatic flat-valgus foot in children remains a relevant public health issue. Treatment should be individualized, while cases secondary to unrecognized or untreated congenital conditions often require surgery to restore normal foot biomechanics.