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Subtalar Arthroereisis
    History and Application
The Non-Weightbearing to
Weightbearing Normal Foot
     Normal arch




  Open sinus tarsi
The Non-Weightbearing to
 Weightbearing Flatfoot
   Flexible flatfoot




Closing sinus tarsi
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
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.
Surgical correction of flatfoot
                            OSTEOTOMIES
   ARTHRODESIS                                          SOFT-TISSUE
(Eliminates joint motion) (Preserves joint motion)      PROCEDURES




                                                     ARTHROEREISIS
                                                     (Restricts excessive
                                                        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
                     1962
  1946                                1974
                   Haraldsson
Chambers                            Subotnick




           1952                  1970
           Grice                LeLievre
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
                                              3
                                              4 Pathways




Bone wedge “arthrorhisis”   Posterior facet osteotomy                            Staple arthroereisis
                                                        Open sinus tarsi model
Haraldsson, 1962            Chambers, 1946                                       LeLievre, 1970
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
Implants: Posterior Facet
         Osteotomy Pathway
Posterior facet osteotomy                Axis-altering device
    Chambers, 1946                           Smith, 1976




   Elevating the subtalar joint axis reduces hindfoot eversion.
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.
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
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.
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
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
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
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)
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
Number
                     of components
                                         Vogler’s
           Fit                        biomechanical
                                       classification



                     Classification
                                                  Material
Fixation
                      of implants



      Environment
                                          Shape
      modification

                        Location
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.
Material
Nonabsorbable                        Absorbable
•   Silastic
                                     •   Poly-L-lactic acid (PLLA)

•   Polyethylene (PE)


•   Titanium


•   Hybrid (metal & PE)
Classification of implants
Location
                  • Sinus canalis
• Sinus tarsi




    Sinus tarsi       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     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
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, 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
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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Arthroereisis Lecture

  • 1. Subtalar Arthroereisis History and Application
  • 2. The Non-Weightbearing to Weightbearing Normal Foot Normal arch Open sinus tarsi
  • 3. The Non-Weightbearing to Weightbearing Flatfoot Flexible flatfoot Closing sinus tarsi
  • 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.
  • 6. Surgical correction of flatfoot OSTEOTOMIES ARTHRODESIS SOFT-TISSUE (Eliminates joint motion) (Preserves joint motion) PROCEDURES ARTHROEREISIS (Restricts excessive joint motion)
  • 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
  • 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. 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
  • 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)
  • 25. First-generation implants • 1970’s and 1980’s • At least eleven designs • Evolved from… – Haraldsson procedure – Chambers procedure – Open sinus tarsi model
  • 26. Second-generation implants • After 1997 (MBA) • At least 12 designs • More advanced designs
  • 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.
  • 29. Material Nonabsorbable Absorbable • Silastic • Poly-L-lactic acid (PLLA) • Polyethylene (PE) • Titanium • Hybrid (metal & PE)
  • 30. Classification of implants Location • Sinus canalis • Sinus tarsi Sinus tarsi Sinus canalis
  • 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
  • 37. Patient Examination • Fluoroscopy far superior for this examination • Real-time view of motion at the sinus tarsi
  • 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
  • 44. Complications • Infection • Psychogenic reactions • Wearing of the material in non-metallic implants • Unremitting and unresolving pain
  • 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