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. 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.
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. Milestones in the Development of
Subtalar Arthroereisis
1962
1946 1974
Haraldsson
Chambers Subotnick
1952 1970
Grice LeLievre
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. 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. 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. Staple arthroereisis
LeLievre, 1970
LeLievre, J: Current concepts and correction of the valgus foot.
CORR. 70:43-55, 1970. From Paris, France.
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. 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. 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
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. 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. 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. 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. 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. 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
25. First-generation implants
• 1970’s and 1980’s
• At least eleven designs
• Evolved from…
– Haraldsson procedure
– Chambers procedure
– Open sinus tarsi model
27. Number
of components
Vogler’s
Fit biomechanical
classification
Classification
Material
Fixation
of implants
Environment
Shape
modification
Location
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.
31. Definitions
• The sinus tarsi is NOT a joint
• No articular surfaces present
• Only soft tissue
32. Anatomy of the Sinus Tarsi
• Shape of the sinus
versus canalis tarsi
• Axis is Distal
plantarlateral to
Proximal dorsomedial
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. 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. 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. 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
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. 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. 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. 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. 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. 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
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. 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
