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

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  #1  
Old 9th November 2011, 05:00 PM
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Default Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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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?

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Old 9th November 2011, 06:43 PM
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Default Re: How young do you treat biomechanical issues?

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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
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.
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Old 10th November 2011, 02:58 AM
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Default Re: How young do you treat biomechanical issues?

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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.
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
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Old 10th November 2011, 06:59 AM
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Default Re: How young do you treat biomechanical issues?

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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
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.
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Old 10th November 2011, 08:16 AM
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Default 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.....

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Mark
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Old 10th November 2011, 09:16 AM
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Default Re: How young do you treat biomechanical issues?

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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
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.

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
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Old 10th November 2011, 09:57 AM
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Default 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
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Old 10th November 2011, 10:07 AM
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Default Re: How young do you treat biomechanical issues?

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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
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".
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Old 10th November 2011, 10:42 AM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

Surgical Treatment of Flexible Flatfoot in Children : A Four-Year Follow-up Study

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Conclusions


Extra-articular arthroereisis with use of a bioreabsorbable implant in the sinus tarsi was simple and effective in correcting functional flexible flatfoot. Surgery performed during growth provides an optimal and lasting correction of the deformity, restoring the talocalcaneal alignment with remodeling of the subtalar joint. This correction improves the biomechanics to prevent problems caused by persistent pronation of the foot. The bioreabsorbable implant proved to be virtually complication-free and did not need to be removed.
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Old 10th November 2011, 10:57 AM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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.

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Subtalar Arthroereisis for Pediatric Flexible Pes Planovalgus

Fifteen Years Experience with the Cone-shaped Implant


Paul Michel Koning, MD*,
Petra J.C. Heesterbeek, MSc† and
Enrico de Visser, MD, PhD*

+ Author Affiliations

*Department of Orthopaedics, St. Maartenskliniek, Nijmegen, the Netherlands.


†Department of Research, Development and Education, St. Maartenskliniek, Nijmegen, the Netherlands.

Corresponding author: Paul Michel Koning, MD, Department of Orthopaedics, St. Maartenskliniek, Hengstdal 3, Gelderland 6522 JV Nijmegen, the Netherlands. (E-mail: p.koning@maartenskliniek.nl)


Abstract

Flexible pes planovalgus is a common condition with flattening of the medial longitudinal arch accompanied by hindfoot valgus. Severe cases of pes planovalgus may need surgery, and a technique that has gained popularity over the past decades is subtalar arthroereisis. An endoorthotic implant of various shapes is inserted in the sinus tarsus, which limits the excessive eversion of the subtalar joint present in flexible pes planovalgus. None of these implants, however, allow for easy control of the extent of talocalcaneal and talonavicular correction. The primary aim of this study was to describe our technique with the custom-built cone-shaped implant. Our secondary aim was to evaluate patient satisfaction, clinical and radiologic results, and complications with a minimal follow-up of 5 years. Between January 1992 and June 2002, 40 patients (80 feet) underwent subtalar arthroereisis for flexible pes planovalgus. After temporary sinus tarsi tenderness (12 feet), implant dislocation (two feet) was the most common complication. Questionnaires from 27 patients (54 feet) were analyzed and 44 feet were also clinically and radiographically evaluated. Thirteen patients were lost to follow-up. Mean (± SD) follow-up was 12.6 years (range, 5.9–16.1). Eighty-one percent of the patients were satisfied with the result. Clinically, normal alignment was present in 14 feet, and mild deformities remained in 26 feet. Radiographically, the average foot angle measurements were normal. We conclude that subtalar arthroereisis is a simple, minimally invasive operative option with satisfactory subjective and clinical results after mid- to long-term follow-up. (J Am Podiatr Med Assoc 99(5): 447–453, 2009)
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Old 10th November 2011, 11:54 AM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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?

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Old 10th November 2011, 12:19 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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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
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
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Old 10th November 2011, 02:49 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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?

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Mark
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Old 10th November 2011, 05:36 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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.
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Old 10th November 2011, 06:55 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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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
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!
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Old 10th November 2011, 07:20 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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!

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Old 10th November 2011, 09:26 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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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
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.
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Old 11th November 2011, 03:48 AM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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.

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Old 17th November 2011, 03:47 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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
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Old 4th December 2012, 02:19 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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.
Quote:
Chronic pain and gait disturbance are possible complications of subtalar arthroereisis. Despite literature indicating a considerably high rate of such complications, subtalar arthroereisis continues to be commonly performed for children with pes planus. The goals of this study are to identify common presenting features and an approach to the treatment of foot pain after subtalar arthroereisis. This case report includes six feet in which subtalar implants were used to treat flatfoot deformities in children. After failing conservative management for chronic postoperative pain, all patients had their implants removed resulting in relief of pain. The expedited removal of subtalar implants in cases of chronic foot pain after arthroereisis is encouraged. The authors do not recommend the use of subtalar arthroereisis in pes planus given its potential complications and literature review indicating a paucity of cases with improved function and activity level as a result of the procedure.
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Old 25th December 2012, 02:46 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

Correcting Pediatric Flatfoot With Subtalar Arthroereisis and Gastrocnemius Recession: A Retrospective Study.
Jay RM, Din N.
Foot Ankle Spec. 2012 Dec 21
Quote:
Background. Flatfoot deformities are common in children and are treated using many conservative and surgical approaches. Subtalar extra-articular arthroereisis, in particular, limits talar motion, spares the subtalar joint, and prevents excessive subtalar joint pronation. Addressing the underlying equinus deformity with gastrocnemius recession is an important factor in optimizing outcomes in patients with flatfoot deformity.

Methods. This study included 20 children, 4 to 17 years old. The patients presented 34 cases of functional flexible flatfoot, and each was treated with gastrocnemius recession and a subtalar implant insertion of either a resorbable arthroereisis plug constructed of poly-L lactic acid or a threaded titanium alloy plug. Clinical evaluation was based on the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale as well as subjective assessments of pain, function, shoe wear, and overall preoperative and postoperative satisfaction.

Results. The average AOFAS Ankle-Hindfoot Scale reading improved by 21.3 points (standard deviation = 8.1; 95% confidence interval = 17.5-25.1), from an average preoperative reading of 67.7 points to an average postoperative reading of 89 points (P < .0001). Subjectively, patients experienced reduced pain and improved function, cosmesis, and shoe wear.

Conclusions. Treating equinus deformity with gastrocnemius recession significantly improved patient outcomes when treating flatfoot deformity. Reconstructive flatfoot surgery that combined subtalar arthroereisis with a resorbable arthroereisis plug and gastrocnemius recession resulted in favorable clinical outcomes and patient satisfaction. Symptom improvement and preservation of the subtalar joint were seen with these procedures, which are reasonable and useful options in treating children with symptomatic flexible flatfoot
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Old 26th March 2015, 09:33 PM
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Default Re: Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity

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
Quote:
Background. Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA.
Methods. Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate).
Results. A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of non-US respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are painful congenital flatfoot, posterior tibial tendon dysfunction, and flatfoot associated with accessory navicular.
Conclusion. Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants, commonly for pain. SA is still being performed in the United States and throughout the world.
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