Clinical practice guideline for pediatric flexible flatfoot: conservative and surgical options

The purpose of this clinical practice guideline is to provide evidence-based recommendations for the treatment of pediatric flexible flatfoot, developed in accordance with the Appraisal of Guidelines for Research and Evaluation II framework and with evidence certainty assessed using the GRADE framework and the Oxford Centre for Evidence-Based Medicine levels of evidence system. A multidisciplinary guideline development group under the Limb Reconstruction Committee of the Orthopedics Branch of China International Exchange and Promotion Association for Medical and Health Care systematically searched and reviewed evidence from primary studies including randomized controlled trials, cohort studies, and comparative studies, supplemented by existing systematic reviews and expert society surveys, to evaluate the effectiveness of conservative and surgical interventions and to guide clinicians and families on the content of an optimal treatment pathway. The guideline targets children and teenagers with flexible flatfoot and addresses interventions available to orthopedic surgeons, podiatrists, rehabilitation physicians, and orthotists, including observation, rehabilitative exercises, foot orthoses, subtalar arthroereisis, calcaneal osteotomy, and criterion-based progression to surgery. Structured conservative management should be considered the mainstay of care for all symptomatic children, with a minimum 6-month trial before surgical referral. However, there is limited evidence on the optimal type, dose, and duration of conservative treatment, and what constitutes an adequate trial of nonoperative care remains undefined. Foot orthoses can be helpful for symptomatic relief when pain or functional limitation is present, and rehabilitative exercise programs may allow superior normalization rates compared to orthoses alone. Pain-free ambulation and return to unrestricted sport are key milestones for both conservative and surgical pathways. However, no validated progression or discharge criteria exist to guide the transition from one treatment phase to the next. While the certainty of evidence was low to very low for most components of the treatment pathway, all 15 recommendation statements were formulated through two rounds of Delphi consensus polling, with 13 achieving the predefined ≥75% agreement threshold. This guideline also highlights the need for standardized diagnostic definitions, multicenter registry data, and age-stratified surgical indications not systematically addressed in previously published literature.