Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

Discussion in 'Pediatrics' started by Mark Russell, Nov 10, 2011.


  1. Members do not see these Ads. Sign Up.
    Hi Kevin

    I remember not that long ago a time when it was considered controversial to suggest any intervention in paediatric flatfoot, never mind whether it was symptomatic or not. How times have changed. These days, when I see a severely flat footed child we not only discuss orthotic management but also subtalor artheroesis. I suspect you do also. Two questions: Would you perform this procedure on an asymptomatic flat footed child? When you do implant a child - symptomatic or not - do you augment the management with post surgical devices and if so, what prescription variables do you consider?

    Kindest

    Mark


    *****thread broken of from How young do you treat biomechanical issues? ..... Mike ******
     
  2. Re: How young do you treat biomechanical issues?

    Mark:

    I would not recommend a subtalar arthroereisis procedure on an asymptomatic flat footed child. I believe this procedure should be reserved for children with symptomatic flatfeet that have not responded successfully to custom foot orthoses.

    By the way, the subtalar joint arthroereisis procedure is not a new procedure here in California. It has been done here by many surgeons for the past 30 years.
     
  3. Re: How young do you treat biomechanical issues?

    Hi Kevin

    That's an interesting response. I would have thought if there was an argument for intervention with orthotics (in asymptomatic paediatric pes planus) the same tenets could - and should - be applied, for subtalor implants. Certainly no orthotics I have seen or used in the last 30 years are capable of reconstructing or remodelling the child's flat foot to the same extent as the arthreoresis. The attached photographs are of the same patient before and after implant surgery. Obviously there are risk factors - as with any procedure - but I would have thought that implant, with or without orthotic augmentation - would be the treatment of choice in these patients.

    Why the reluctance?

    Mark
     

    Attached Files:

  4. Re: How young do you treat biomechanical issues?

    Mark:

    I have a hard time understanding why a surgeon would place an implant into a chld that could cause post op sequellae when the child has no complaints. If the orthosis doesn't work, then the patient can remove it from the shoe. The subtalar implant can be removed also, but there is greater potential for more serious complications such as infection and permanent painful scarring.

    By the way, Mark, I have only done subtalar arthroereisis on cadavers, not live patients. However, I have seen plenty of subtalar arthroereisis sequellae in my office from other surgeons. I'm sure every surgeon has their own threshold as to when and when not to do the procedure.
     
  5. Re: How young do you treat biomechanical issues?

    Ok - that's also interesting. I wonder if there has been any studies done on the postoperative compliations of this procedure. The sequellae/sequestra issue is something that has been cited before and a suggestion that it was end range bone-implant impaction that was a causitive factor. This was the reason I asked about augmenting the procedure with orthotics postoperatively as I suspect we could reduce the degree of impact at the implant site.

    Considering the remodelling potential of this procedure, I would have thought there would have been clear focus by the profession on addressing potential complications. Then again, that may have some negative implications for the orthotics industry.....

    Best wishes

    Mark
     
  6. Re: How young do you treat biomechanical issues?

    Mark:

    Here in Sacramento, the subtalar arthroereisis procedure is not used frequently by podiatric or orthopedic surgeons. And, no, it is not due to some diabolical plot of the "orthotics industry" trying to prevent these surgeries from occurring.:craig:

    I believe it is likely due to the fact that 1) the procedure is not new here in California [Steve Subotnick, DPM, was doing these here nearly 40 years ago (Subotnick SI: The subtalar joint lateral extra-articular arthroereisis: a preliminary report. JAPA, 64:701, 1974)], 2) we have all been taught in podiatry school about them for the past 30 years whereas in other countries these are viewed upon as newly developed procedures, and 3) we have seen plenty of failures and complications before. All in all, most of us are of the belief that if foot orthoses can work to improve the gait and function for the child, then it is a safer method by which to produce the desired therapeutic outcome. However, with that being said, I think the subtalar arthroereisis procedure clearly makes sense for the child with symptoms that is not relieved by foot orthoses.

    You may want to read this study, Mark.

    Extensive Implant Reaction in Failed Subtalar Joint Arthroereisis: Report of Two Cases
     
  7. Re: How young do you treat biomechanical issues?

    Thanks for that Kevin - and I apologise to other readers for taking this thread off on a tangent. But now that we're here.... I would think that the arthroeresis has enormous potential in the management of flat foot. Absolutely orthotics has their place - and these may also be useful in concurrent management in preventing postoperative complications - but they cannot offer the child anything like the restoration potential of an STA procedure.

    Let's say a child and his/her parents come to you and they are committed to having the procedure done with another surgeon. They wish to minimise any postoperative complications and ask your advice regarding orthotic prescription. What are your considerations?

    Mark
     
  8. Re: How young do you treat biomechanical issues?

    Maybe someone should first split off this thread to another one titled "Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformiy".
     
  9. Surgical Treatment of Flexible Flatfoot in Children : A Four-Year Follow-up Study

     
  10. Another study was done on 41 juvenile flatfeet that had STJ arthroereisis procedure for mean post-op follow-up time of 12.6 years showed 81% were satisfied and that normal alignment was present in 14/41 patients, mild malalignment present in 26/41 patients. Of note, in this study, the implant was only in place in the child's foot for about one year.

    Koning PM, Heesterbeek PJC, Visser ED: Subtalar arthroereisis for pediatric flexible pes planovalgus. JAPMA, 99(5):447-453, 2009.

     
  11. Okay two studies showing, what I see as overall satifactory conclusions with the procedure with minimal complications. The n=2 study seems to indicate a failure or complication with the polythene STA peg and is inconclusive as to whether excessive forces were contributory. My question remains; would concurrent orthotic management reduce the potential for some or all of these complications? If so, what prescription variables should be considered?

    Best wishes

    Markl
     
  12. Mark:

    I would recast patient for a new set of orthoses about 3 months after the procedure was performed and attempt to make an anti-pronation orthosis, but would likely use a minimal amount of medial heel skive or inverted balancing position, depending on the kinetics and kinematics of gait post-operatively.

    Subtalar joint arthroereisis - increases internal STJ supination moment

    Foot orthosis - increases external STJ supination moment
     
  13. Cheers Kevin, that's what I was after. I have five children post op all under 15 years, two with additional gastroc release. All doing very well. We fitted them post op with semi-custom devices and mobilised them within three weeks. All participating in sports. All asymptomatic, certainly with your criteria.

    This would be a fascinating and worthwhile study. If foot orthoses can be shown to reduce or eliminate the failure rate in paediatric subtalor implant surgery, then surely this should be the gold standard in every pes planus management? Do I detect a lack of enthusiasm for the potential of this procedure, Kevin?

    Best wishes

    Mark
     
  14. Sorry to stick my oar in here. But I'd like to raise a few points.

    I think it would be worth considering the different types of implant which are available. There is substantial variation between them and positive data for one might not necessarily extrapolate to another. My primary concern with the use of these implants is remodeling of the sinus tarsi due to the high adaptive plasticity in juvenile bone. This element might be expected to be very different between, for example, "a custom-built cone-shaped implant", a softer silicon peg or a screw type stent.

    Also, although we have mentioned orthoses, nobody has talked about the more aggressive orthoses options (smafos for EG) or theraputic footwear. Technically all orthoses of course, but its worth emphasising that things we put in shoes are not the "only game in town".

    For me, assuming we are talking about asymptomatic (winces) Pes planus, there is still a substantial debate as to when and whether we should be treating AT ALL, much less with surgery. The argument as to whether or not to treat should consider both the risks of intervening, and the risks of not. When we talk about surgery we obviously increase those risks. As such I do not feel that an acceptance of blanket treatment of asymptomatic flatfoot with orthoses de facto indicates the acceptability of blanket treatment with surgery.


    Finally, as I've said before, I have a real aversion to the term "pes planus". Thus, whatever our views on whether an implant should be the treatment of choice for this patient, I think we need to be wary of suggesting either the implant or orthoses should be the TX of choice for pes planus. Rather we should be discussing its suitability for specific subgroups.
     
  15. Mark:

    If you only knew how many requests that I turn down every month for projects that people want me to do with them or want me to do for them then maybe you would better understand what you call "a lack of enthusiasm". My plate is very full.

    However, I think this would be an excellent project for you to take on, Mark. How many research papers have you been involved in or published? There is no time like the present!;)
     
  16. Kevin

    You misunderstand what I write. I seemed to detect a lack of enthusiasm for the STA procedure is your posts on the subject over the years - if I am correct, I was simply curious why. Aforementioned risks aside. How could I suggest your enthusiasm for published research in anything?! Of course my own portfolio stands on its own!

    All the best
     
  17. Mark:

    I have rarely found a child that doesn't become asymptomatic with foot orthoses that are specially designed for their specific biomechanics. That is why I don't feel the need, in my practice, for surgical treatment of these feet. However, in the very infrequent cases where foot orthoses don't work, I refer the patient to someone who is more experienced than I am with these surgeries. Hope this answers your questions.
     
  18. Kevin & Robert

    Agreed that intervention in paediatric flatfoot will be practitioner dependent and will attract a large variation from observation to custom orthotics to surgery. I accept that good arguments can be made on all positions. However, for me, if I had a child with a severe flexible flat foot deformity, then I could be persuaded that surgical intervention by way of a STA implant would be the most efficious intervention inso far as it has good outcomes and tolerance, it is reversible, restorative and it offers the possibility of long-term correction without the need for years of orthotic management.

    Obviously there is a debate as to whether one should intervene in asymptomatic paediatric flat foot, but I happen to agree with Kevin in that intervention is desirable - and earlier the better.

    Best wishes
     
  19. Frederick George

    Frederick George Active Member

    Dear Mark

    That's it exactly. You know that a flat footed (pes planus, hypermobile) child will never run and play sport, never have good balance, and will have foot, ankle, knee problems eventually.

    And the rule for any surgeon is (or should be), would you do it on a member of your family?

    The new implants are completely different in design and principle than the old "door stoppers."

    And it's remarkable to change a child's life so dramatically.

    Cheers

    Frederick
     
  20. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Outcomes of subtalar arthroereisis for the planovalgus foot.
    Hazany S, Ly N, Hazany D, Bader S, Ostuka N.
    J Surg Orthop Adv. 2012 Fall;21(3):147-50.
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Correcting Pediatric Flatfoot With Subtalar Arthroereisis and Gastrocnemius Recession: A Retrospective Study.
    Jay RM, Din N.
    Foot Ankle Spec. 2012 Dec 21
     
  22. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    2013 Subtalar Arthroereisis Survey
    The Current Practice Patterns of Members of the AOFAS

    Neil S. Shah, Richard L. Needleman, Omaima Bokhari, David Buzas
    Foot Ankle Spec March 26, 2015
     
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Modified calcaneo-stop screw method for treatment of symptomatic pediatric flexible flatfoot deformity.
    Abubeih, Hossam M.A. MD; El-Adly, Wael MD; Kotb, Mohamed M. MD
    Current Orthopaedic Practice: July 23, 2015
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Symptomatic flexible flatfoot in adults: subtalar arthroereisis.
    Ozan F et al
    Ther Clin Risk Manag. 2015 Oct 16;11:1597-602. doi: 10.2147/TCRM.S90649. eCollection 2015.
     
  25. Craig Payne

    Craig Payne Moderator

    Articles:
    8
  26. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Subtalar Arthroereisis Implant Removal in Adults: A Prospective Study of 100 Patients.
    Saxena A et al
    J Foot Ankle Surg. 2016 Feb 10
     
  27. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    SUBTALAR ARTHROERESIS IN THE TREATMENT OF PLANOVALGUS FEET DEFORMITY: THE PROS AND CONS (THE REVIEW OF LITERATURE)
    Oleksandr Korolkov, Paviel Rakhman, Gennadiy Kikosh
    ORTHOPAEDICS, TRAUMATOLOGY AND PROSTHETICS; No 1 (2016)
     
  28. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Return to sport activities after subtalar arthroereisis for correction of pediatric flexible flatfoot.
    Martinelli, Nicolò; Bianchi, Alberto; Martinkevich, Polina; Sartorelli, Elena; Romeo, Giovanni; Bonifacini, Carlo; Malerba, Francesco
    Journal of Pediatric Orthopaedics B: March 3, 2017
     
  29. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Therapeutic Outcomes of Kalix II in Treating Juvenile Flexible Flatfoot.
    Cao L et al
    Orthop Surg. 2017 Feb;9(1):20-27. doi: 10.1111/os.12309.
     
  30. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The role of arthroereisis of the subtalar joint for flatfoot in children and adults
    Alessio Bernasconi, François Lintz, Francesco Sadile
    EFORT Open Rev 2017;2:438–446. DOI: 10.1302/2058-5241.2.170009 8 November 2017
     
  31. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Patient-perceived outcomes after subtalar arthroereisis with bioabsorbable implants for flexible flatfoot in growing age: a 4-year follow-up study
    Cesare Faldini et al
    European Journal of Orthopaedic Surgery & Traumatology 03 January 2018
     
  32. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Functional evaluation of bilateral subtalar arthroereisis for the correction of flexible flatfoot in children: 1-year follow-up
    Paolo Caravaggi et al
    Gait and Posture; Article in Press
     
  33. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effectiveness of subtalar arthroereisis with endorthesis for pediatric flexible flat foot: a retrospective cross-sectional study with final follow up at skeletal maturity
    CristianIndinoaJorge HugoVillafañebRiccardoD’AmbrosiacLuigiManziaCamillaMaccarioacPedroBerjanoaFederico G.Usuellia
    Foot and Ankle Surgery; 21 December 2018
     
  34. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Flexible Juvenile Flat Foot Surgical Correction: A Comparison Between Two Techniques After Ten Years’ Experience
    Antonio Memeo, MD, Fabio Verdoni, MD, Laura Rossi, MD, Elena Panuccio, MD, Leopoldo Pedretti, MD
    JFAS; Article in Press
     
  35. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Lateral column lengthening versus subtalar arthroereisis for paediatric flatfeet: a systematic review.
    Suh DH et al
    Int Orthop. 2019 Jan 30. doi: 10.1007/s00264-019-04303-3
     
  36. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Are there benefits of a 2D gait analysis in the evaluation of the subtalar extra-articular screw arthroereisis? Short-term investigation in children.
    Hagen L et al
    Clin Biomech (Bristol, Avon). 2019 Feb 27;63:73-78
     
  37. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Radiological outcome after treatment of juvenile flatfeet with subtalar arthroereisis:
    a matched pair analysis of 38 cases comparing neurogenic
    and non-neurogenic patients.

    Kubo H, Krauspe R, Hufeland M, Lipp C,
    Ruppert M, Westhoff B, Pilge H.
    J Child Orthop 2019;13. DO
     
  38. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Radiographic and Functional Results following Subtalar
    Arthroereisis in Pediatric Flexible Flatfoot

    David Ruiz-Picazo , Plácido Jiménez-Ortega, Francisco Doñate-Pérez,
    Natalia Gaspar-Aparicio, Victor Garc-a-Mart-n, José Ram-rez-Villaescusa,
    and Sergio Losa-Palacios
    Advances in Orthopedics
     
  39. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Body Weight Effects on Extra-Osseous Subtalar Arthroereisis
    Chiun-Hua Hsieh et al
    J. Clin. Med. 2019, 8(9)
     
  40. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Arthroereisis for Symptomatic Flexible Flatfoot Deformity in Young Children: Radiological Assessment and Short-Term Follow-Up.
    Megremis P, Megremis O
    J Foot AnkleSurg. 2019 Sep;58(5):904-915
     
Loading...

Share This Page