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Biomechanics of Hyprocure Arthroesis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Robertisaacs, Jan 4, 2010.

  1. 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.:drinks
     
  2. drk

    drk Member

    Hi Mike,

    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.

    Best wishes, Andrew.
     
  3. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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.
     
  4. drsha

    drsha Banned

    Re: Biomechanics of Hyprocure Arthroereisis

    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.

    Dennis
     
  5. MERF thats what you are going 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
     

    Attached Files:

  6. drsha

    drsha Banned

    Re: Biomechanics of Hyprocure Arthroereisis

    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
     
  7. drdebrule

    drdebrule Active Member

    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.
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi DrDebrule

    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
     
    Last edited: Jan 9, 2013
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    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.
     
  10. efuller

    efuller MVP

    Raises an interesting question. What is the average improvement post intervention? For any intervention.
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
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    Computed tomography review of tarsal canal anatomy with reference to the fitting of sinus tarsi implants in the tarsal canal.
    Bali N, Theivendran K, Prem H.
    J Foot Ankle Surg. 2013 Nov-Dec;52(6):714-6.
     
  12. Paul Bowles

    Paul Bowles Well-Known Member

    ..and this is the kicker.....the common sense answer and approach. We all have patients who fail conservative therapy and need to progressive to more aggressive management options.

    On review in our clinical practice we have had a fair few in the last 3 yrs progress to hyprocure and I can say without reservation it has made a marked improvement in their quality of life - one which footwear changes, physiotherapy, orthoses, manipulation etc... were not making. We have had one patient have it removed, not because of pain or issues but because he said when he walked he couldn't get used to the "position" he felt in - so much so he wanted it removed, no issues in doing that and he went back to trial conservative care again.

    If the peg fits.....use it.
     
  13. reckles

    reckles Member

    The issues I have had with implantation and hyprocure in particular stem from what I perceive to be a one peg fits all approach which strikes me as commerce more than medicine. A solution to "pronation"or "talar instability"- whatever that is- should be pathology specific, in other words, directed to the cause of the problem and I think we would all agree the hind foot is not always the culprit. Hyprocure in particular does not advocate the addition of procedures to correct, or even the assessment for, proximal or distal factors that may in fact be driving the abnormal position. These would include equinus, tibial rotational deformity, FF varus or first ray mobility issues.

    and so you know I am speaking from both sides of this argument.. my daughter DOES have an MBA device - at least in one foot- got it (with TAL) at age 16 as a result of CFO failure and quality of life issues. Couldn't get the other foot done in time before she went off to Uni in New Zealand.. maybe one day.

    it was an interesting dilemma doing this for her as she does have ITT and indeed the device unmasked some of it. She tends to stand, relaxed, in a very supinated position still, as she doesn't like the feel of the device at end rom, but she has little pain in the foot. She went into A&E recently in Auckland after an ankle sprain, had radiographs and sparked all kinds of interest... WTF is that?!?!?!?
     
  14. Paul Bowles

    Paul Bowles Well-Known Member

    I definitely don't disagree.... :)
     
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  16. Amazing how many of these are being removed and then referral coming in for bracing and or orthotics lately
     
  17. Dieter Fellner

    Dieter Fellner Well-Known Member

    Mike,

    Not my experience, here in NYC. What exactly is being removed?
    And is this from the same provider.
    Is this a specific implant - or any and all across the range.
    So many variables to consider.
     
  18. Not sure on details but 1 Dr put them in multiple are removing.

    Not hundreds mind 3 in 2 weeks enough that I noticed
     
  19. Dieter Fellner

    Dieter Fellner Well-Known Member

    Unlike some other posters here, in my humble opinion not all devices are made to function equally. In addition there is a learning curve associated with the evaluation of the patient, method of implantation and post-operative care.

    I believe one should exercise caution and resist the urge to condemn too readily and too broadly.
     
    Last edited: Jul 2, 2019
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