Arthroereisis Lecture


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  • My wife had a subtalar implant inserted into her ankle and Aetna is denying the claim because it is 'experimental'. So glad to have found this presentation during my Google search to pose the question to Aetna. 'How can this be experimental when it was done in 1946?'
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Arthroereisis Lecture

  1. 1. Subtalar Arthroereisis History and Application
  2. 2. The Non-Weightbearing to Weightbearing Normal Foot Normal arch Open sinus tarsi
  3. 3. The Non-Weightbearing to Weightbearing Flatfoot Flexible flatfoot Closing sinus tarsi
  4. 4. Juvenile Talipes Valgus Obliterated sinus tarsi 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
  5. 5. Adult Talipes Valgus Obliterated sinus tarsi 66 year old female with rheumatoid arthritis and foot pain for years. Stage 2 PTTD. On Enbrel and prednisone.
  6. 6. Surgical correction of flatfoot OSTEOTOMIES ARTHRODESIS SOFT-TISSUE (Eliminates joint motion) (Preserves joint motion) PROCEDURES ARTHROEREISIS (Restricts excessive joint motion)
  7. 7. 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
  8. 8. Milestones in the Development of Subtalar Arthroereisis 1962 1946 1974 Haraldsson Chambers Subotnick 1952 1970 Grice LeLievre
  9. 9. 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.
  10. 10. 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.
  11. 11. 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.
  12. 12. Staple arthroereisis LeLievre, 1970 LeLievre, J: Current concepts and correction of the valgus foot. CORR. 70:43-55, 1970. From Paris, France.
  13. 13. 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.
  14. 14. Evolution of subtalar arthroereisis 3 4 Pathways Bone wedge “arthrorhisis” Posterior facet osteotomy Staple arthroereisis Open sinus tarsi model Haraldsson, 1962 Chambers, 1946 LeLievre, 1970
  15. 15. Only 1 axis-altering device STA-peg Smith, 1976 • 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
  16. 16. Implants: Posterior Facet Osteotomy Pathway Posterior facet osteotomy Axis-altering device Chambers, 1946 Smith, 1976 Elevating the subtalar joint axis reduces hindfoot eversion.
  17. 17. Implants: Open Sinus Tarsi Pathway Implant-blocking device Open sinus tarsi (Vogler, 1987) Blocking the anterior translation of the lateral talar process reduces hindfoot eversion.
  18. 18. Implant-Blocking Devices • HMPE • Platform & stem • In sinus tarsi • Stem in calcaneus to fixate the implant • Different sizes STA-peg Smith, 1976 • Silastic • Cap & stem • In sinus tarsi • Stem in calcaneus to fixate the implant • Different sizes Sgarlato “mushroom” Sgarlato, 1983
  19. 19. Implants: Bone Wedge “Arthrorhisis” Pathway Bone wedge “arthrorhisis” Self-locking wedge Haraldsson, 1962 (Vogler, 1987) Prevents contact between the lateral talar process with the floor of the sinus tarsi reducing hindfoot eversion.
  20. 20. Self-Locking Wedge: The 70’S • Silastic • HMPE • Silastic • Threaded cylinder • Carved block • Umbrella & stem • In sinus tarsi • In sinus tarsi • In sinus canalis & sinus tarsi • Different sizes • Adjustable • Different sizes Valenti “threaded” implant Custom-carved plug Viladot “cuplike” implant Valenti 1976 Subotnick 1974 Viladot 1977
  21. 21. Self-Locking Wedge: The Expandables • Teflon & stainless steel • PE & titanium • Expanding cylinder & • PLLA (absorbable) • Expanding cylinder & internal screw internal screw • Expanding cylinder • In sinus tarsi • In sinus tarsi & internal screw • In sinus tarsi Flatfoot expanding implant Kalix Flatfoot expanding implant Giannini 1985 Viladot 2003 Giannini 2001
  22. 22. Self-Locking Wedge “Grandfather” Valenti implant • Titanium • Threaded cylinder, slotted and cannulated • In sinus tarsi • Different sizes MBA Maxwell/Brancheau 1997 • Titanium • Threaded cylinder/cone/cylinder & cannulated • In sinus canalis & sinus tarsi • Cut interosseous ligament • Different sizes HyProCure Graham 2004
  23. 23. The MBA clones Company DESIGN MATERIAL FEATURE(S) CSI Threaded cone Titanium Anatomic design, dimples (Futura) Talar-fit Threaded cone Titanium Anatomic design alloy (Osteomed) bioBlock Threaded cylinder PLLA Absorbable (KMI/Integra) ProStop Threaded cone Titanium Anatomic design (Arthrex) TOV Threaded cone Titanium Anatomic design alloy (Vilex)
  24. 24. Classifying Implants
  25. 25. First-generation implants • 1970’s and 1980’s • At least eleven designs • Evolved from… – Haraldsson procedure – Chambers procedure – Open sinus tarsi model
  26. 26. Second-generation implants • After 1997 (MBA) • At least 12 designs • More advanced designs
  27. 27. Number of components Vogler’s Fit biomechanical classification Classification Material Fixation of implants Environment Shape modification Location
  28. 28. Biomechanical classification (Vogler,1987) • Self-locking wedge (SLW) • Axis-altering device (AAP) • Impact-blocking device (IBD) SLW AAP IBD Adapted from: Maxwell, JR; Cerniglia, MW: Subtalar joint arthroereisis. In AS Banks; MS Downey; DE Martin; SJ Miller, ed., McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd edition, Philadelphis, Lippincott Williams & Wilkins, 2001, p. 904. Reprinted with permission.
  29. 29. Material Nonabsorbable Absorbable • Silastic • Poly-L-lactic acid (PLLA) • Polyethylene (PE) • Titanium • Hybrid (metal & PE)
  30. 30. Classification of implants Location • Sinus canalis • Sinus tarsi Sinus tarsi Sinus canalis
  31. 31. Definitions • The sinus tarsi is NOT a joint • No articular surfaces present • Only soft tissue
  32. 32. Anatomy of the Sinus Tarsi • Shape of the sinus versus canalis tarsi • Axis is Distal plantarlateral to Proximal dorsomedial
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. Patient Examination • Fluoroscopy far superior for this examination • Real-time view of motion at the sinus tarsi
  38. 38. 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
  39. 39. 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
  40. 40. Removal Rates • Pediatrics – 0% [Giannini]1 – 5% [Nelson et al]2 – 33% [Sangeozan]3 1Giannini S, Kenneth A. Johnson Memorial Lecture: – 60% [Manoli]4 Operative treatment of the flatfoot: why and how. Foot Ankle Int. 19(1):52-8, 1998 2Nelson SC, Haycock DM, Little ER. Flexible Flatfoot Treatment with Arthroerisis: Radiographic Improvement and Child Health Survey Analysis. P. 149 3Sangeorzan BJ, Mosca V, Hansen ST Jr: Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle. 14(3):136-41, 1993 4Needleman 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
  41. 41. Removal Rates • Adults – Needleman • 39% (28 feet with 11 removals) – Schon • 30-40% (depending upon implant, having used MBA (KMI), Futura (Nexa), ProStop (Arthrex)
  42. 42. 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
  43. 43. 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, 1996 2Sammarco 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
  44. 44. Complications • Infection • Psychogenic reactions • Wearing of the material in non-metallic implants • Unremitting and unresolving pain
  45. 45. 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
  46. 46. 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
  47. 47. Thank You