arthroereisis lecture
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Subtalar ArthroereisisHistory and Application
The Non-Weightbearing to Weightbearing Normal Foot
Normal arch
Open sinus tarsi
The Non-Weightbearing to Weightbearing FlatfootFlexible flatfoot
Closing sinus tarsi
Juvenile Talipes Valgus
Nine Year old healthy youth, except for a long history of painful feet. Is not active in any form of
athletics. A little better with custom orthotics
Obliterated sinus tarsi
Adult Talipes Valgus
66 year old female with rheumatoid arthritis and foot pain for years. Stage 2 PTTD. On Enbrel and prednisone.
Obliterated sinus tarsi
Surgical correction of flatfootARTHRODESIS
(Eliminates joint motion)
ARTHROEREISIS(Restricts excessive
joint motion)
SOFT-TISSUEPROCEDURES
OSTEOTOMIES(Preserves joint motion)
Subtalar Arthroereisis• From the Greek root ereidein (to press a
thing against)• the term ereisis means ‘a propping up’ and
the term arthroereisis itself means “an operation to limit motion of a joint in cases of excessive mobility from unknown weakness”
Churchill’s Illustrated Medical Dictionary. New York, Williams and Wilkins, 1989
Milestones in the Development of Subtalar Arthroereisis
1974Subotnick
1946Chambers
1970LeLievre
1962Haraldsson
1952Grice
Posterior Facet Osteotomy Chambers, 1946
Chambers, EF: An operation for the correction for flexible flat feet in adolescents. West J. SGO. 54:77-86, 1946. From the Jefferson
Medical College, Philadelphia.
Extra-Articular Subtalar Arthrodesis Grice, 1952
Grice, DS: An extra-articular arthrodesis of the subastragalar joint for correction of paralytic flat feet in children. JBJS. 34A:927-940, 1952. From the Massachusetts Infantile Paralysis Clinics, Children’s Hospital, Boston.
Bone Wedge “Arthrorhisis” Haraldsson, 1962
Haraldsson, S: Operative treatment of pes planovalgus staticus juvenilis. Act Orthop. Scand. 32: 492-498, 1962. From the Orthopaedic Clinic, Lund,
Sweden.
Staple arthroereisis LeLievre, 1970
LeLievre, J: Current concepts and correction of the valgus foot. CORR. 70:43-55, 1970. From Paris, France.
Custom-carved plug Subotnick, 1974
Subotnick, S: The subtalar joint lateral extra-articular arthroereisis. JAPA. 67:157-171, 1977. From the California
College of Podiatric Medicine, San Francisco.
Evolution of subtalar arthroereisis
4 Pathways
Posterior facet osteotomy Chambers, 1946
Bone wedge “arthrorhisis”Haraldsson, 1962
Staple arthroereisisLeLievre, 1970Open sinus tarsi model
3
Only 1 axis-altering device
• One piece• Ultra high molecular weight polyethylene
(HMPE)• Platform & stem• In sinus tarsi• Stem in calcaneus to fixate the implant• Posterior facet arthroplasty to seat the implant• Different sizes
STA-pegSmith, 1976
Implants: Posterior Facet Osteotomy Pathway
Axis-altering deviceSmith, 1976
Posterior facet osteotomyChambers, 1946
Elevating the subtalar joint axis reduces hindfoot eversion.
Implants: Open Sinus Tarsi Pathway
Implant-blocking device(Vogler, 1987)Open sinus tarsi
Blocking the anterior translation of the lateral talar processreduces hindfoot eversion.
Implant-Blocking Devices• HMPE• Platform & stem• In sinus tarsi• Stem in calcaneus to fixate
the implant• Different sizes
• Silastic• Cap & stem• In sinus tarsi• Stem in calcaneus to fixate
the implant• Different sizes
STA-peg Smith, 1976
Sgarlato “mushroom”Sgarlato, 1983
Implants: Bone Wedge “Arthrorhisis” Pathway
Self-locking wedge(Vogler, 1987)
Bone wedge “arthrorhisis”Haraldsson, 1962
Prevents contact between the lateral talar process with the floor of the sinus tarsi reducing hindfoot eversion.
Self-Locking Wedge: The 70’S
• HMPE• Threaded cylinder• In sinus tarsi• Different sizes
• Silastic• Carved block• In sinus tarsi• Adjustable
Custom-carved plug Subotnick 1974
Valenti “threaded” implantValenti 1976
Viladot “cuplike” implantViladot 1977
• Silastic• Umbrella & stem• In sinus canalis & sinus tarsi • Different sizes
Self-Locking Wedge: The Expandables
• PE & titanium• Expanding cylinder &
internal screw• In sinus tarsi
• Teflon & stainless steel• Expanding cylinder &
internal screw• In sinus tarsi
Flatfoot expanding implantGiannini 1985
KalixViladot 2003
Flatfoot expanding implantGiannini 2001
• PLLA (absorbable)• Expanding cylinder
& internal screw• In sinus tarsi
• Titanium• Threaded
cylinder/cone/cylinder & cannulated
• In sinus canalis & sinus tarsi
• Cut interosseous ligament• Different sizes
• Titanium• Threaded cylinder,
slotted and cannulated• In sinus tarsi• Different sizes MBA
Maxwell/Brancheau 1997
HyProCureGraham 2004
“Grandfather”Valenti implant
Self-Locking Wedge
The MBA clonesCompany DESIGN MATERIAL FEATURE(S)
CSI(Futura)
Threaded cone Titanium Anatomic design, dimples
Talar-fit(Osteomed)
Threaded cone Titanium alloy
Anatomic design
bioBlock(KMI/Integra)
Threaded cylinder PLLA Absorbable
ProStop(Arthrex)
Threaded cone Titanium Anatomic design
TOV(Vilex)
Threaded cone Titanium alloy
Anatomic design
Classifying Implants
First-generation implants • 1970’s and 1980’s• At least eleven designs• Evolved from…
– Haraldsson procedure– Chambers procedure– Open sinus tarsi model
Second-generation implants
• After 1997 (MBA)• At least 12 designs• More advanced designs
Fit
Fixation
Environmentmodification
Location
Shape
Material
Vogler’sbiomechanicalclassification
Numberof components
Classificationof implants
Biomechanical classification (Vogler,1987)
• Self-locking wedge (SLW)• Axis-altering device (AAP)• Impact-blocking device (IBD)
Adapted from: Maxwell, JR; Cerniglia, MW: Subtalar joint arthroereisis. In AS Banks; MS Downey; DE Martin; SJ Miller, ed., McGlamry’s ComprehensiveTextbook of Foot and Ankle Surgery, 3rd edition, Philadelphis, Lippincott Williams & Wilkins, 2001, p. 904. Reprinted with permission.
SLW AAP IBD
MaterialNonabsorbable• Silastic
• Polyethylene (PE)
• Titanium
• Hybrid (metal & PE)
Absorbable• Poly-L-lactic acid (PLLA)
Classification of implantsLocation• Sinus tarsi
Sinus tarsi Sinus canalis
• Sinus canalis
Definitions
• The sinus tarsi is NOT a joint• No articular surfaces present• Only soft tissue
Anatomy of the Sinus Tarsi
• Shape of the sinus versus canalis tarsi
• Axis is Distal plantarlateral to Proximal dorsomedial
Aims of Arthroerisis
• Restrict excessive range of motion at the subtalar joint
• Allow 3-5º of range of motion • Preserve functionality of the subtalar
joint
Lundeen RO: The Smith STA-peg operation for hypermobile pes planovalgus in
children. J Am Podiatr Med Assoc. 75(4):177-83, 1985
Indications
• >3 years of age • Flexible foot type• Pathologic foot without
active symptomotology?
Food and Drug Administration: Indications for use for K042030, device
name: HyProCure®
subtalar implant system. Rockville, MD. Sep 16th, 2004
Contraindications• Rigid foot type• Femoral
anteversion/antetorsion• Tibial torsion• Destructive
osteoarthritis changes causing symptoms
Hutchinson, J: Contributions to Orthopaedic Surgery, New York, Rand, Avery and Co, 1880. P. 93
Patient Examination
• Weightbearing and non-weightbearing films of foot to compare position
• 3 radiographic signs:– Calcaneal valgus– Obliteration of the sinus tarsi– Important in the cavus foot
Needleman RL: A operative approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot
Ankle Int. 27(1):9-18, 2006
Chadha, H; Pomeroy, G; Manoli, A: Technique tip: radiologic signs of unilateral pes planus. Foot Ankle Int. 18:603-604, 1997
Patient Examination• Fluoroscopy far
superior for this examination
• Real-time view of motion at the sinus tarsi
Results
• Adults with ‘acquired’ deformities– Adjunctive procedures done: double calcaneal
osteotomies, Cotton, tendo-Achilles lengthening or Gastrocnemius recession
– Arthroereisis done to limit subtalar joint range of motion
– Average of 8-12+ weeks to weight bearing with associated morbidity
Schon LC: Subtalar Arthroereisis: A New Exploration of an Old Concept. Foot Ankle Clin N Am. 12 329-339, 2007
Soomekh DJ, Baravarian B: Pediatric and Adult Flatfoot Reconstruction: Subtalar Arthroereisis versus Realignment
Osteotomy Operative Options. Clin Podiatr Med Surg. 23 695-708, 2006
Results• Adults with flatfoot alone
– Cylindrical and Conical devices solely have high removal rates
– Wine glass shape (HyProCure®) used as sole modality has low removal rate (<3%)*
• No tendo-Achilles lengthening or Gastroc recession done
Soomekh DJ, Baravarian B: Pediatric and Adult Flatfoot Reconstruction: Subtalar Arthroereisis versus Realignment
Osteotomy Operative Options. Clin Podiatr Med Surg. 23 695- 708, 2006
* Unpublished data based upon a study of 284 patients over a two year follow-up time
Removal Rates
• Pediatrics– 0% [Giannini]1
– 5% [Nelson et al]2
– 33% [Sangeozan]3
– 60% [Manoli]41Giannini S, Kenneth A. Johnson Memorial Lecture: Operative treatment of the flatfoot: why and how. Foot Ankle Int. 19(1):52-8, 19982Nelson SC, Haycock DM, Little ER. Flexible Flatfoot Treatment with Arthroerisis: Radiographic Improvement and Child Health Survey Analysis. P. 1493Sangeorzan BJ, Mosca V, Hansen ST Jr: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle. 14(3):136-41, 19934Needleman RL: A operative approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot Ankle Int. 27(1):9-18, 2006
Removal Rates
• Adults– Needleman
• 39% (28 feet with 11 removals)
– Schon• 30-40% (depending upon implant, having used
MBA (KMI), Futura (Nexa), ProStop (Arthrex)
Retention of Correction
• Reported by Schon as high• Theory that once soft tissue healed, the implant was
no longer needed• Possibly due to adjunctive procedures and not
residual to the arthroereisis procedure itself?
Schon LC: Subtalar Arthroereisis: A New Exploration of an Old Concept. Foot Ankle Clin N Am. 12 329-339, 2007
Complications• Cyst formation1
• Silastic breakdown synovitis2
• Overcorrection/undercorrection• Device migration (backing out)
– Dependent upon ingrowth of soft tissue
• Lateral foot and ankle soft tissue strain– New, rectus position of the foot/ankle
1Rockett AK, Mangum G, Mendicino SS: Bilateral intraosseous cystic formation in the talus: a complication of subtalar arthroereisis.
J. Foot Ankle Surg. 37:421-425, 19962Sammarco G, Tabatowski K: Silicone Lymphadenopathy
Associated with Failed Prosthesis of the Hallux: A Case Report and Literature Review
2Worsing RA, Engber WD, Lange TA: Reactive synovitis from particulate silastic. J Bone Joint Surg Am. 64: 581-585, 1982
Complications
• Infection• Psychogenic reactions• Wearing of the material in non-metallic
implants• Unremitting and unresolving pain
Conclusions
• Acts as an “internal orthotic”1
• Reversible procedure• Can be step one in a multi-step surgical approach,
with adjunctive procedures done later on• Can be combined with adjunctive osteotomies,
plications, lengthenings
1Zaret, DI; Myerson, MS: Arthroereisis of the subtalar joint. Foot Ankle Clinics N. Am. 8:605-617, 2003
Conclusions• Using the correct device in the correct
patient• Proven in Pediatric cases• Proven in Adult cases
– Especially as part of posterior tibialis tear or dysfunction
Thank You
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