Nathan Hensley MS IV 7-18-2011

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

Excessive STJ pronation

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

Talus adducts on the foot, while the leg internally rotates

The talus controls the motion occurring in the midfoot, which ultimately controls how the forefoot functions

The foot functions in opposite motions to that of the talus

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

Conditions that result in excessive STJ Pronation

Ankle equinus, metatarsus adductus, internal tibial

torsion and forefoot varus

Conditions associated with excessive amounts of pronation

Bunions, hammertoes, PTTD, Plantar fasciitis, TTS, DJD,

Morton's neuroma

Flexible flatfoot in children is one of the most common disorders encountered

Incidence is unknown based largely on poor agreement

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

Soft tissue Procedures Arthroereisis

Restricts excessive joint motion

Definition: ereidein to press against

An operation to limit motion of a joint in cases of excessive mobility from unknown weakness

1946, Chambers

Posterior Facet Osteotomy

Flexible flatfeet in adolescents

1952, Grice

Extra-articular Subtalar arthrodesis

Correction of paralytic flat feet in children

1962, Haraldsson

Bone Wedge Arthrorhisis

Pes planovalgus staticus juveniles

1970, LeLievre

Staple Arthroereisis
CORR. 70:43-55

1974, Subotnick

Custom-Carved plug
171, 1977.

The Subtalar joint lateral extra-articular arthroereisis. JAPA. 67:157-

Bone

Absorbed, not reliable, not strong enough

Not strong enough, fragments with shards

Silicone

Polyethylene Polylactate

Not strong enough, fragments

Absorbs, temporary, eventually lose correction

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

Clinical and Radiographic Criteria Transverse Plane dominant

Abduction of forefoot and midfoot on rearfoot Abnormal TN congruency, with increased cuboid abduction angle and Talo-calcaneal angle

Frontal Plane Dominant

Excessive valgus position of heel in weight-bearing Stacking of metatarsals on lateral view, with decreased arch height

Midtarsal Joint Locking mechanism

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

Posterior facet osteotomy pathway

Elevation of the STJ axis reduces overall hindfoot eversion Later replaced with the axis altering device designed by Smith in 1976

Open Sinus Tarsi Pathway

Design is used to prevent anterior translation of the lateral talar process, which reduces overall hindfoot eversion 1987, Vogler: designed the implant-blocking device

Bone Wedge Arthrorhisis pathway

Bone Wedge Arthrorhisis, 1962 Haraldsson

Prevents contact between lateral talar process and the floor of the

sinus tarsi, thus limiting hindfoot eversion

Self-locking Wedge (MBA)

Implanted material is inserted into the sinus tarsi to separate the

talus and calcaneus STJ pronation anterior migration of talus is blocked

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

Custom-carved plug (Subotnick, 1974)

Silastic Carved block, adjustable Polyethylene Threaded cylinder

Valenti threaded implant (Valenti 1976) Viladot cuplike implant (Viladot 1977)
Silastic, umbrella and stem design Placed in the sinus canalis and sinus tarsi

Self-locking wedge: expandables Flatfoot exapanding implant , Giannini 1985

Stainless steel Expanding cylinder with internal screw, placed in the sinus tarsi

Flatfoot expanding implant, Giannini 2001 Kalix Viladot, 2003

sinus tarsi

Polyethylene and titanium Expanding cylinder with internal screw designed, placed in the

MBA (Maxwell/Brancheau 1997)

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

HyProCure (Graham 2004)

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)

Reported a case series looking at 78 children, suffering from Neuromuscular

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)

Performed a prospective study on 37 children receiving MBA implants as an

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

Fitzgibbons et. al.

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

Overcorrection Under correction Reactive synoviitis Detritic synovitis

Silicone implants

Subluxation/extrusion of implant Fragmentation of implant Inaccurate positioning of device DJD

Rigid flatfoot

Vertical talus, tarsal coalition

Rectus heel position Torsional and frontal plane leg/thigh abnormalities Neuromuscular disease

Equinus
Tendo-Achilles Lengthening Gastrocnemius recession

Faulty MTJ locking mechanism

Evans calcaneal osteotomy

(lengthens the lateral column) Improves transverse plane abnormalities

Posterior Tibial Dysfunction

Kidner Tendon Advancement/Repair Medial column soft tissue procedures

(Youngs teno-suspension)

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

Pediatric Flatfoot conditions

Rationale

Isolated Procedure

Recalcitrant, symptomatic flexible flatfoot deformity Posterior Tibial Repair, Gastrocnemius or Tendo-Achilles lengthening, Medial calcaneal osteotomy, Tarsal coalition excision

Adjunctive Surgical Component

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