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What I find interesting in this is the concept of preventative surgery for 'hyperpronation'.
I have one Italian patient here who had one of his asymptomatic flat feet corrected after getting opinions from several surgeons in his home country. They (the family) were hesitant about getting the procedure, and eventually had it done in one foot first (most of the surgeons wanted to do both at the same time).
Suffice to say he now does have symptoms in the sinus tarsi of the foot he had the procedure done on- or did do until I fitted him with orthoses to balance the forces around the STJA...
The visiting surgeon here felt that the implant had shifted and wanted it removed.
His feet did not appear to me to be anything more than classic hypermobile flat feet- ie nothing like tibialis posterior dysfunction or spring ligament rupture.
And Podiatrists can be criticised for implementing foot orthotic therapy on asymptomatic children...
__________________
Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Hi Mike:
Thanks for the link, it's a well written article.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
If I might comment on Arthroereisis in general, and specifically in regard to Hyprocure. The biomechanics of the procedure is one of my favorite lecture topics here at NYCPM as it seems to fulfill an innate fantasy I've had- that an internal device can replace, safely, what we do externally. The difficulty as I see it, is in the reasonable application of the device. While I may accept that the hyprocure design is a positive evolution over other devices on the market, I remain concerned that its use occurs without appropriate forethought about why the foot is "pronated", (if in fact that's what it is). Clearly, pathology with a multi-faceted etiology cannot have just one- fits all- solution. In my view, any arthroereisis device, when used in the presence of FF varus, intractable equinus, high tibial varum, Met adductus and any internal torsional deformity of the proximal limb, risks creating substantial post surgical deformity. What is troubling is that many of these procedures are performed simply on the basis of arch height and symptomatology and may ultimately pose problems the practitioner and patient have not predicted- for the lack of appropriate pre-operative assessment. I would appreciate any feedback from colleagues outside the US (where a relatively higher number of arthroereisis procedures are performed). Many thanks
In my view, any arthroereisis device, when used in the presence of FF varus, intractable equinus, high tibial varum, Met adductus and any internal torsional deformity of the proximal limb, risks creating substantial post surgical deformity.
Perhaps you've seen this thread where we see and discuss exactly what you describe.
Quote:
The biomechanics of the procedure is one of my favorite lecture topics here at NYCPM as it seems to fulfill an innate fantasy I've had- that an internal device can replace, safely, what we do externally
And here, truly, is the rub. As Mike described on that thread, the normal style is for the bulk of pronation moment to be generated externally (Gravity via GRF) and equilibrium acheived by supination moment internally (Sinus tarsi compression / deltoid ligament / Tibialis contraction / Plantar fascia / windlass function). Most of the problems we see are in or around these structures so our standard conservative response is to spare whichever of these structures is knackered by generating External supination moment to reduce the amount of internal supination moment required.
The arthroesis, as you say, generates a significant degree of supination moment by bringing the "meeting point" of the sinus tarsi in much sooner, sparing the other supination generating structures.
My concern, in the medium and long term, is that the supination moment is STILL being generated internally. Ok so its bone on bolt not bone on bone but the compressive force in the Sinus tarsi still has to meet the demands placed on it.
So I guess the eligability question is, does the limitation of medial axial deviation reduce the pronatory moment to the point where it will not jeapordise the sinus tarsi. In the foot types you describe the answer will be a resounding no, because the COP will travel more medially than the axis.
Kind Regards
Robert
PS, Might we know your name Reckles? Whilst not compulsary you will find you are better received if you share your secret identity.
Thanks, Robert, for your comment. And you are correct, I don't usually spend alot of time on this site other than as an observer of trends. I am Bob Eckles, Assoc Prof of Ortho at NYCPM and Dean for Clinical Ed here.
Reason for my recent query is we recently hosted the hyprocure program here and while, as I said in my earlier post, I feel it makes more sense than other devices which exert their influence, with perhaps more impact related sequellae, outside the sinus tarsi, I left the session quite uncomfortable given that the speakers, other than myself, did not, I feel, fully advise against its use in the circumstances I noted. The device was promoted as a near universal solution to "hyper pronation" which is again a term I am uncomfortable with.
Hyprocure does alot of business outside the US which is why I wanted to post here to see if clinicians in other countries were seeing problems that have not been apparent here.
It sounds to me as if your concerns are indeed mirrored across the globe.
Quote:
"hyper pronation" which is again a term I am uncomfortable with.
You and me both my friend.
By the by, when did the passe old "overpronation" get replaced by the funky new "hyperpronation"? I must have missed the memo. Means the same but sounds much more scientific.
To reiterate for the record, when hyperpronation gets old, I've already come up with uberpronation, megapronation, macropronation and superpronation so don't anyone think of passing those off as your own idea.
Thanks, Robert, for your comment. And you are correct, I don't usually spend alot of time on this site other than as an observer of trends. I am Bob Eckles, Assoc Prof of Ortho at NYCPM and Dean for Clinical Ed here.
And we are former classmates and running buddies from the CCPM Class of 1983. Good to have you contributing, Bob!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin! my best regards to you in the hot hot Sacramento valley!
I'll do my best to chime in here when I can- makes a nice break from the administrative tortures I encounter. Hope all is well.
Kevin! my best regards to you in the hot hot Sacramento valley!
I'll do my best to chime in here when I can- makes a nice break from the administrative tortures I encounter. Hope all is well.
Bob:
Wasn't a bad day today. It only got to about 84 degrees.
As far as the arthroereisis implants are concerned, here in the greater Sacramento area, not too many podaitrists use them. It seems to be fairly regional in its use without much interest here in doing these procedures.
It would be nice to have you comment when you have a chance since you have been around for a few years, like myself, and you may be also able to offer a good perspective on the East Coast style of podiatry to Podiatry Arena.
Good luck with all the administrative meetings.....glad it's you and not me.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Thank you very much for pointing me towards this Podiatry Today article. It proved quite useful. Hope you are enjoying life in the northern hemisphere.
Effect of subtalar arthroereisis on the tibiotalar contact characteristics in a cadaveric flatfoot model.
Martinelli N, Marinozzi A, Schulze M, Denaro V, Evers J, Bianchi A, Rosenbaum D. J Biomech. 2012 Jun 1;45(9):1745-8.
Quote:
Previous studies reported the effect of flatfoot deformity on tibiotalar joint contact characteristics. The lateral shift of the load which occurred in flatfeet may be responsible for degenerative changes in the ankle joint. The purpose was to assess the pattern of joint contact stress of the tibiotalar joint in intact, flat, and corrected specimens with subtalar arthroereisis. Seven fresh-frozen cadaver specimens were studied in the intact and flat-footed condition after transection of ligaments which support the medial arch. Ankle joint contact stress and plantar pressure patterns were determined from a capacitive pressure sensor inserted in the tibiotalar joint and a pressure distribution platform when the specimens were axially loaded in simulated mid-stance. Contact pressure was also assessed after subtalar arthroereisis with a 12mm Kalix implant for correction of the flatfoot deformity. A maximum contact pressure of 1414.2±319.2 kPa was recorded in the middle-medial region in intact specimens. Flatfoot caused a lateral shift in the pressure distribution (p<0.05). In the flat specimens, the maximum contact pressure of 1394.7 8±470.5kPa was in the anterior-central region. After subtalar arthroereisis with the Kalix implant for correction of the flatfoot deformity a maximum contact pressure of 1323.3±497.5kPa was observed in the middle-lateral region. In a cadaver model, subtalar arthroereisis with Kalix implant failed to restore a normal intraarticular ankle joint pressure pattern. Further interventions should be considered to restore a normal pressure pattern.
If I might comment on Arthroereisis in general, and specifically in regard to Hyprocure. The biomechanics of the procedure is one of my favorite lecture topics here at NYCPM as it seems to fulfill an innate fantasy I've had- that an internal device can replace, safely, what we do externally. The difficulty as I see it, is in the reasonable application of the device. While I may accept that the hyprocure design is a positive evolution over other devices on the market, I remain concerned that its use occurs without appropriate forethought about why the foot is "pronated", (if in fact that's what it is). Clearly, pathology with a multi-faceted etiology cannot have just one- fits all- solution. In my view, any arthroereisis device, when used in the presence of FF varus, intractable equinus, high tibial varum, Met adductus and any internal torsional deformity of the proximal limb, risks creating substantial post surgical deformity. What is troubling is that many of these procedures are performed simply on the basis of arch height and symptomatology and may ultimately pose problems the practitioner and patient have not predicted- for the lack of appropriate pre-operative assessment. I would appreciate any feedback from colleagues outside the US (where a relatively higher number of arthroereisis procedures are performed). Many thanks
It's 2013, are we ready to scientifiaccly discuss this topic from the position of Foot Centering or do you still wish to call my parents mutants and look for a button that eliminates me from The Arena?
This posting reflects, I believe, the education that I have gotten (and thanked you for) here on The Arena when it comes to tissue stress and orthotic reactive forces (ORF's) but it also contains discussion on structure and muscle engine reactive forces (MERF's) that you seem to feel offer little weight in clinical biomechancs.
Are we ready to be civil?
Dr. Eckles echoes the position I have taken for The Hyprocure ever since its inception.
It seems to be the most anatomically correct, easy to install or remove and it doesn't needlessly drive a pin on through to the lateral side of the foot when installing.
Biomechanically, when well selected, this is the single greatest advacne in implanting for the foot that has occurred in my lifetime.
I look at it as an internal orthotic for correcting the flexible rearfoot functional foot type (it is included in our educational brochures as a viable option for all patinet to understand that suffer from this RF pathology).
As with other RF oriented biomechanics (instead of Vault oriented ones), there is no ability of the device, on its own, to manage biomechanical pathology that exists on the distal side of The Vault.
Most of the feet that test Inverted in SERM and everted in SERM for the RF also test plantarflexed for PERM and dorsiflexed for SERM in the FF typing them as Flexible RF/Flexible FF.
It has always been the starting platform of Foot Centering to manage the forefoot of this foot type with some type of therapy that will increase the 1st rau plantarflectory stiffness and increase the leverage, power and phasic activity of Peroneus Longus as a goal, neither of which are accomplished with a Hyprocure alone.
I have my own Hyprocure Equipment and until I stopped doing "bone surgery" I installed them in office and surgicenter environments including a "PostopThotic" (Trademarked this one too) which supported the new RF Vault position that the Hyprocure supplied until Wolf's and Davis's Laws adapted to it in function. In addition the device also contained Distal Vault corrections that reduced the forefoot pathology. This reduced the impact that the flexible forefoot FFT has in that it produces a pronatory moent on the STJ Axiis in the Flexible Forefoot Types.
Finally, a program of muscle engine testing and training was introduced that primarily trains the Peroneus longus to provide an increase pantarflectory stiffness moment to the 1st ray whihc takes the flexible 1st ray and plantarflexes it in function improving it as a medial column stabilizer of the structure of the foot.
The Hyprocure (or a foot centering orthotic) changes the action of PL from a pronatror into a muscle that provides a pronatory moment that due to the supinatory moment of The Hyprocure (or a foot centering orthotic) fails to deform the RF or pervert the STJ Axis medially.
This means that peroneal inhibition, whcih is so common in specifically the Flexible RF-Flexible Forefoot FF would be reduced making PL a much more efficient and productive muscle engine allowing it to stabilize the truss-flexible tie beam architecture of the foot so as to stimulate Wolf's and Davis's Laws to remodel in a positiove direction, correcting the biomechanics or Optimally, improving the foot type of the patients foot.
In all the time I was installed HYprocures, I had to remove two, both of which revealed that the RF had morhed into a more Optimal Functional POsition without the implant in place.
Hyprocure + PostopThotic = The best result, as Dr. Eckles position agrees with.
I would suggest you give the above post a very good proof read it make little sense, while it is great to add physic terms it might help if they make some sense
Dr. Weber is quite correct. I was busy and surpassed the 2 hour edit time limit which I usually use to edit my posts one final time. I am surprised that as a therapist, he cannot master the thoughts or language of MERF's as I post since most therapists that I have worked with find it understandable enough to either accept or reject in parts as opposed to the total blank that Mike seems to conjure.
It's 2013, are we ready to scientifically discuss this topic from the position of Foot Centering in order to expand the debate or do you still wish to call my parents mutants and look for a button that eliminates me from The Arena?[/b]
Dr. Eckles echoes the position I have taken for The Hyprocure ever since its inception. Dr. Graham and I have ha d many biomechanical discussions over the last 5+ years.
The Hyprocure subtalar stent is the most anatomically correct, the easiest to install or remove and it doesn't needlessly drive a pin on through to the lateral side of the foot when installing.
Biomechanically, when well selected, this is the single greatest advance in implant surgery for the foot in my lifetime.
The surgical biomechanics of The Hyprocure relates to Vaulting and Foot Centering because it aims to correct the sagittal and transverse plane underlying biomechanical pathology of a specific functional rearfoot foot type, the flexible rearfoot FFT. It can be applied as a prophylactic tool or a preventive or performance enhancement implant in well selected cases rather than us wait for complaints, symptoms or injury when working biomechanically with patients just as the Foot Centering Orthotic can be utilized.
There are those who state that The Hyprocure should not be applied before a complaint as they argue similarly about Foot Centrings, They would rather gravity and underlying foot type natal pathology win the functional battle and fill ther pockets with money as they band-aid complaint after predictable complaint like dominoes.
I look at The Hyprocure as an internal foot centering device for correcting the single or double flext FFT but as Dr. Eckles points out, the device has limitations and should not be marketed or utilized as a panacea for "flat feet" as it has been perverted to by some surgeons.
As with other RF oriented biomechanics paradigms like Root and SALRE, that reduce the import of sagittal and forefoot pathology care when clinically applying their theories, there is no ability of subtalar stenting, on its own, to manage biomechanical pathology that exists on the middle and distal side of The Vault.
Most of the feet that test Inverted in SERM and everted in SERM for the RF also test plantarflexed for PERM and dorsiflexed for SERM in the FF typing them as Flexible RF/Flexible FF. That is a Wellness Biomechanics fact that Dr. Weber nmay not understand because he has refused to fairly investigate Foot Centering. My science is not confusing when examined, IMHO, he is confused.
It has always been the starting platform of Foot Centering to manage the forefoot of this foot type with some type of therapy that will increase the 1st ray plantarflectory stiffness and increase the leverage, power and phasic activity of Peroneus longus as a goal, neither of which are accomplished with a Hyprocure alone.
As to my personal experience with The Hyprocure (as compared possible to Mike's), I have my own Hyprocure Equipment and until I stopped doing "bone surgery" recent;y, I actively installed them in office and surgicenter environments. My deviation from the Graham protocol was that, as Dr. Eckles intimates, I included a "PostopThotic" into the dressings which supported the new RF Vault position that the Hyprocure created with its RF Supinstion moment until Wolf's and Davis's Laws adapted to it in function. This reduced reactive tissue stress in the subtalar canal from becoming symptomatic in many cases IMHO.
In addition the device also contained midfoot and distal Vault corrections that reduced forefoot mechanical pathology from impacting the results.
Biomechanically, the flexible forefoot FFT produces a pronatory moment on the STJ Axis in the Flexible Forefoot Types that deviates it medially, as compensation. The foot centring reduces that compensation.
Finally, unless a program of muscle engine testing and training is introduced as part of the protocol (correct me if I'm wrong, Mike) that primarily trains the Peroneus longus to provide an increased plantarflectory stiffness moment to the 1st ray that plantarflexes the ray to oppose GRF, the medial colum in these feet rarely become stable enough to perform without permanent bracing of some kind.
The Hyprocure+ Foot Centering + Muscle engine training = The COmplete Package clinically.
The Hyprocure impact on PL (or a foot centering orthotic for that matter) changes the action of PL from being a pronator into a muscle engine that provides a pronatory moment that doesn't change the RF structure. The Hyprocure, by providing a supinatory moment changes the RF PERM from everted to a more stable or rigid one. The Hyprocure fails to provide a plantarflectory stiffness moment into the 1st ray or reduce the FF supinatory effect of medially deviating the STJ Axis.
This means that peroneal inhibition, which is so common in specifically the Flexible RF-Flexible Forefoot FF would benot be impacted by inserting a subtalar stent preventing The Vault from stabilizing the truss-flexible tie beam architecture of the foot so as to stimulate Wolf's and Davis's Laws to remodel in a positive direction, correcting the biomechanics by morphing the foot into a more Optimal Functional Position when weightbearing.
In all the time I was installing Hyprocures, I had to remove two, both of which revealed that the RF had morphed into a more Optimal Functional Position without the implant in place (this has been confirmed by other surgeons when they remove a Hyprocure that has been in place 1-2 yrs or more).
Dennis
The Following User Says Thank You to drsha For This Useful Post:
The article at the top of the thread here is a little too happy ever after for my taste, but is great marketing. One could certainly flip things around and say that hyprocure implants need to be removed something like15-20% of the time. Long term studies are lacking and often arthroeresis is combined with other flatfoot reconstructive procedures. I still don't know if hyprocure is that much better than the other arthroereisis options out there. I am unaware of any randomized side by side comparison studies.
I agree with Kirby that there is a place for this surgical procedure, but the patient population I treat is mostly adults. They seem to do well with orthotics custom and pre-fabricated. Would I put this implant in my daughter or son if they were asymptomatic? No, I don't think so.
I have used the various STJ implants quite a bit: MBA usually but I've tried various other designs (you're correct, I haven't found much of a difference. Instrumentation is slightly different, etc... conical vs columnar, etc...)
I can't say as I've ever implanted one on an asymptomatic patient. Normally they are peds with pain or adults with PTTD. They work quite well if the criteria are met.
I've also had luck with the absorbable implants for adult PTTD that I feel may correct themselves once the post tib is corrected.
I usually don't have any problem knowing which peds need one and which ones don't.
Severe and symptomatic, fully reducible and good muscle strength do fine. The only problem arises when you have a contracted GS. I usually have them perform aggressive stretching for at least 8 weeks to see if we can gain some ankle dorsiflexion so a lengthening will not be needed.
With a very flexible pes planus and good ankle dorsiflexion the procedure is very easy and very quick healing. I can understand how some (read "surgeons" who are not busy enough performing necessary surgery) might find themselves performing these instead of a simple orthotic Rx.
If your son or daughter were symptomatic and as a result not active, not involved in activities, not even able to walk the dog and orthotics have not helped.......... I think you might rethink this. When done on the proper peds the procedure is VERY effective and very rewarding for all concerned, including the surgeon.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Last edited by drsarbes : 9th January 2013 at 03:43 PM.
Reason: sp
Extraosseous Talotarsal Stabilization Using HyProCure(®): Preliminary Clinical Outcomes of a Prospective Case Series.
Bresnahan PJ, Chariton JT, Vedpathak A. J Foot Ankle Surg. 2013 Jan 10.
Quote:
The present multicenter, prospective study evaluated the subjective outcomes in patients after extraosseous talotarsal stabilization using the HyProCure(®) stent as a standalone procedure for the treatment of recurrent and/or partial talotarsal joint dislocation (RTTD) in a population of pediatric and adult patients. RTTD has been cited as a possible etiology for a number of foot ailments and might contribute to the development of pathologic features localized more proximally in the weightbearing musculoskeletal chain. Correction of RTTD might, therefore, lead to the reduction of pathologic features associated with this deformity. A total of 46 feet in 35 patients were included in the present investigation. Subjective evaluation used the Maryland Foot Score assessment, which was obtained preoperatively and 1, 2, and 3 weeks, 1, 2, 3, and 6 months, and 1 year postoperatively. The mean overall scores improved from a preoperative value of 69.53 ± 19.56 to a postoperative value of 89.17 ± 14.41 at the 1-year follow-up. Foot pain decreased by 36.97%, foot functional activities improved by 14.39%, and foot appearance improved by 29.49%. The greatest magnitude of improvement occurred 4 weeks postoperatively, with gradual improvement continuing through to the 1-year follow-up. Implants were removed from 2 patients (2 feet, 4.35%). No unresolved complications were observed. The positive subjective outcomes resulting from the extraosseous talotarsal stabilization procedure suggest that the intervention employing the device we have described alleviates pain and improves foot function and appearance in patients with RTTD.
Extraosseous Talotarsal Stabilization Using HyProCure(®): Preliminary Clinical Outcomes of a Prospective Case Series.
Bresnahan PJ, Chariton JT, Vedpathak A. J Foot Ankle Surg. 2013 Jan 10.
Subjective evaluation used the Maryland Foot Score assessment, which was obtained preoperatively and 1, 2, and 3 weeks, 1, 2, 3, and 6 months, and 1 year postoperatively. The mean overall scores improved from a preoperative value of 69.53 ± 19.56 to a postoperative value of 89.17 ± 14.41 at the 1-year follow-up. Foot pain decreased by 36.97%, foot functional activities improved by 14.39%, and foot appearance improved by 29.49%. The greatest magnitude of improvement occurred 4 weeks postoperatively, with gradual improvement continuing through to the 1-year follow-up. Implants were removed from 2 patients (2 feet, 4.35%). No unresolved complications were observed.
Raises an interesting question. What is the average improvement post intervention? For any intervention.
Re: Biomechanics of Hyprocure Arthroesis
. Not seen you before around the board. 
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