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

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


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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


    *****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
     
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