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Contact phase
Foot is mobile adapter, secondary to rearfoot pronation Resupination occurs, to form a rigid lever for propulsion
Midstance
The sinus tarsi is maximally opened at the end of swing phase, when the foot is supinated During contact, the foot transitions to a pronated position, in which the talus adducts on the posterior facet articulation, with the lateral talar process possessing a majority of the motion available
Resupination does not occur during midstance, allowing the foot to remain pronated and hypermobile
Abnormal motion of the foot during weight bearing contact portions of stance Helps to absorb normal ground reactive forces
The talus controls the motion occurring in the midfoot, which ultimately controls how the forefoot functions
Pronation places the pedal bones in a state of loose bones allowing for adaptation to terrain Over pronation prevents the foot from transitioning to the stable supinated construct needed for propulsion, requiring secondary support structures such as ligaments and tendons to make up for the deficit
Morton's neuroma
on strict clinical and radiographic criteria defining a flatfoot Surgical consideration is done when flexible flatfoot is painful and doesnt not respond to conservative treatments
Arthrodesis
Eliminates joint motion
Osteotomy
Preserves joint motion
An operation to limit motion of a joint in cases of excessive mobility from unknown weakness
1946, Chambers
1952, Grice
1962, Haraldsson
1970, LeLievre
Staple Arthroereisis
CORR. 70:43-55
1974, Subotnick
Custom-Carved plug
171, 1977.
Bone
Silicone
Polyethylene Polylactate
Titanium
Material of choice, stronger than bone Least reactive material implanted into the body, does cause oxidization in the tissues Small micropores allow for partial tissue attachment
The effectiveness of arthroereisis is based on the ability of the MTJ to lock on the rearfoot, failure to do so will collapse the Mid-tarsal joint as weight is transferred to the forefoot
*Excessive transverse plane deformities often require an
additional osteotomy such as an Evans Open base wedge to help maintain correction and functionality
Axis Altering Device Implant Blocking Device (Direct Impact) Self-locking Wedge
STA-peg
1976, Smith
One piece High durability polyethylene Consists of a platform and stem Stem is placed in the calcaneus to fixate the implant, the
posterior facet arthroplasty seats the implant Helps to elevate a low STJ axis
Reduces amount of frontal plane motion (calcaneal eversion) Designed for frontal plane dominate flexible flatfoot
Provide impingement force against lateral talar process, limits valgus motion
Angulated STA-peg
1976, Smith
Polyproylene Platform with stem placed in the sinus tarsi, preventing
anterior translation
Sgarlato mushroom
1983, Sgarlato
Cap and stem Placed in the STJ, with the stem in the calcaneus, preventing
anterior translation
Valenti threaded implant (Valenti 1976) Viladot cuplike implant (Viladot 1977)
Silastic, umbrella and stem design Placed in the sinus canalis and sinus tarsi
Stainless steel Expanding cylinder with internal screw, placed in the sinus tarsi
Polyethylene and titanium Expanding cylinder with internal screw designed, placed in the
Titanium Threaded cylinder, with slotted cannulated construct Placed in the sinus tarsi Type I: Cylinder and cone designs
Device is placed into the lateral aspect of the sinus tarsi Laterally anchored
*MBA Resorb: composed of poly lactic acid, capable of being resorbed by the body
Titanium Threaded cylinder, with cannulated construct Placed in both the sinus tarsi and canalis tarsi
*cut out interosseous ligament
The threads do not engage the talar sinus, rather allowing for fibrous on-growth Type II: devices is placed into the central portion of the sinus
Medially anchored deep into the canalis portion of the sinus tarsi
Incision made parallel to RSTL over the sinus tarsi after thorough palpation Structures to be aware of
Intermediate Dorsal Cutaneous Nerve Sural Communicating branch
Post Op Management
WB BK cast/CAM walker for 3 weeks Followed by a normal shoe with brace for 2-3 weeks
Arthroereisis is seldom implemented as an isolated procedure. Due to the long-term compensation and adaptation of the foot and adjunctive structures for flatfoot function, other ancillary procedures are usually used for appropriate stabilization. Long-term results of arthroereisis in the adult flexible flatfoot patient have not been established. Some surgeons advise against the subtalar arthroereisis procedure because of the risks associated with implantation of a foreign material, the potential need for further surgery to remove the implant and the limited capacity of the implant to stabilize the medial column sag directly Proponents of this procedure (arthroereisis) argue that it is a minimally invasive technique that does not distort the normal anatomy of the foot. Others have expressed concern about placing a permanent foreign body into a mobile segment of a childs foot. The indication for this procedure remains controversial in the surgical community.
The primary indication for the subtalar MBA devise is as a spacer for stabilization of the subtalar joint. It is designed to block the anterior and inferior displacement of the talus, thus allowing normal subtalar joint motion, but blocking excessive pronation.
Vedantam (1998)
disease whom received a STA-peg Subtalar implant Although a majority of participants required additional balancing procedures, a satisfaction of nearly 97% was reported
Nelson (2004)
isolated procedure Over an 18+ month follow-up, improvements in anatomic measurements where fount, but limited data on improvement of symptoms or functional outcomes limited the study
Needleman, (2006)
Found significant improvements in pain and function in 78% of participants undergoing subtalar implant as a component of reconstructive foot and ankle surgery This study however was limited on the small sample size (23 patients) and the lack of adequate controls Retrospective study looking at 39 patients with an average age of 12 years of age undergoing MBA subtalar implant Radiographic evaluation demonstrated a significant improvement in Cuboid Abduction Angle, Talar declination angle and Talo-Calcaneal angle
Scharer (2010)
Koning et al.
Between 1992 and 2002, followed 40 patients (80 feet) who underwent cone-shaped endoorthotic implant The study concentrated on describing the technique of custombuilt implant insertion and evaluation of patient satisfaction 81% of patients were satisfied with the overall result, with complications ranging from sinus tarsi tenderness to implant dislocation in two cases Clinically, normal alignment was only achieved in 14 feet 12 years post implant, with minimal deformities present in the remaining subjections Radiographically, normal foot angle measurements were found in a majority of the test subjects Conclusion: simple, minimally invasive procedure with satisfactory subjective and clinical results
Dr. Fitzgibbons, MD performed a prospective study on 4 patients ages 11,13, 16 and 26. All patients underwent a tarsal tunnel release with placement of a subtalar arthroereisis screw 13 month follow up showed no radiographic evidence of screw migration No clinical or radiographic evidence of flatfoot deformity recurrence was found Despite positive outcomes, Dr Fitzgibbons believes arthroereisis implants in pediatrics and adults with asymptomatic flatfeet should not be done Although he suggests using this procedure as an adjunct to other rearfoot procedures is becoming quite popular
Silicone implants
Rigid flatfoot
Rectus heel position Torsional and frontal plane leg/thigh abnormalities Neuromuscular disease
Equinus
Tendo-Achilles Lengthening Gastrocnemius recession
Forefoot Supinatus/varus
Position Statement
STJ arthroereisis is considered investigational and not medically necessary for the following Adult Flatfoot conditions
Symptomatic flexible flatfoot Acquired flatfoot deformity secondary to PTTD
Flexible flatfoot Paralytic flatfoot Ligamentous Laxity Flatfoot deformity
Rationale
Isolated Procedure
Recalcitrant, symptomatic flexible flatfoot deformity Posterior Tibial Repair, Gastrocnemius or Tendo-Achilles lengthening, Medial calcaneal osteotomy, Tarsal coalition excision
Overall, questions still remain regarding the best clinical indications for the use of the implant
AAOS: American Academy of Orthopaedic Surgeons Treatment for Pediatric pes planus debated May 2011 Issue http://www.aaos.org/news/aaosnow/may11/clinical7.asp Anthem: Subtalar Arthroereisis http://www.anthem.com/ca/medicalpolicies/mp_pw_b094101.h tm Banks, Alan S. McGlamrys Comprehensive Textbook of Foot and Ankle Surgery Volume 1, 3rd Edition pages 853-854, 1237 Koning, Paul. Hessterbeek, Petra. Visser, Enrico. Subtalar Arthroereisis for Pediatric Flexible Pes Planovalgus: Fifteen years Experience with the Cone-shaped Implant Journal of the American Podiatric Medical Association, Volume 99 number 5, 447-453. 2009 Needleman RL. Current topic Review: Subtalar arthroereisis for the correction of flexible flatfoot. Foot Ankle Int. 2005; 26(4):336346 Nelson SC, Haycock DM, Little ER. Flexible flatoot treatment with arthroereisis; radiographic improvement and child health survey analysis. J Foot Ankle Surg 2004; 43 (3):144-155 Novack, Brian J. DPM Arthroereisis of the Subtalar Joint Spring Surgical Notes, Ohio College of Podiatric Medicine
Over-pronation Slideshare http://www.slideshare.net/megdpm/overpronation Rockett AK, Mangu G, Mendicino SS Bilateral intraosseous cystic formation in the talus: a complication of Subtalar arthroereisis Journal of Foot and Ankle Surgery 1998, Sep-Oct, 37 (5) 421-5 http://www.ncbi.nlm.nih.gov/pubmed/9798175 Scharer BM, Black BE, Sockrider N. Treatment of painful pediatric flatfoot with Maxwell-Brancheau subtalar arthroereisis implant a retrospective radiographic review. Foot Ankle Spec. 2010; 3(2) 6772 Scher, David. Bansal, Manjula. Handler-Matasar, Sheryl. Bohne, Walther. Greeen, Daniel Extensive Implant reaction in failed Subtalar joint arthroereisis: Report of Two cases NCBI, 2007 September, 3(2): 177-181 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504261 Subtalar Arthroereisis: History and Application Slideshare http://www.slideshare.net/LEDocDave/arthroereisis-lecture Treatment for Pediatric Pes Planus Debated AAOS: American Academy of Orthopaedic Surgeons http://www.aaos.org/news/aaosnow/may11/clinical7.asp Why HyProCure Slideshare http://www.slidshare.net/megdpm/why-hy-pro-cure