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Surgery for excessive STJ Supination

Discussion in 'Foot Surgery' started by mike weber, Jan 7, 2010.

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  1. Members do not see these Ads. Sign Up.
    Hi all surg types.

    1st of I´m not a cutter so this might be a simple question.

    There has been some bimechanical threads about stent to control Excessive Subtalar joint Pronation

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=42481

    and

    http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=42435

    I asked but it may have been missed. If there are specific techniques for Excessive STJ pronation is there a specific technique for excessive STJ supination ?

    If so how does it work ? What does it look like in X-ray if possible and what post op problems are seen with it if any ?

    Thanks for your help.
     
  2. bob

    bob Active Member

    Re: Surg for excessive STJ Supination

    No need to apologise for what at first may seem a relatively simple question. I think your post highlights a problem with an approach to treating patients. Throughout the surgical training systems and within most medical disciplines, practitioners seek to treat a specific pathology, so it is really difficult to propose a specific surgical answer to the anatomical and mechanical based problem you propose. I don't treat excessive supination or pronation personally, I treat pathologies that may well be connected to or contributed to by them.

    Take tibialis posterior tendon dysfunction as an example within the 'excessive pronation' group. A patient presents with pain at the posterior medial aspect of their ankle, with a progressive (but flexible) flatfoot. X-rays may confirm no obvious osseous pathology, but positionally it seems that they have classic signs of a flatfoot (insert dominant plane here). An MR scan shows longitudinal tears/ attenuation of the tibialis posterior tendon with tenosynovitis but not total rupture (yet!). My surgery will not be totally designed to address the excessive pronation that I'm seeing, it's designed predominantly to address the pathology (tib post tendon) and to achieve a more 'normal' (whatever that is) position of the surrounding anatomy that may contribute to maintaining, perpetuating or exacerbating the presenting pathology.

    Personally, I don't treat people with 'stents' to 'cure hyperpronation' either! I might use an arthroeresis as a part of my attempt to restore/reduce/prevent anatomic/mechanical positions of the rearfoot that contribute to presenting pathology as described above. Some of the problems and concerns highlighted in some of the other threads on here stem from the 'treating hyperpronation' approach, in my opinion of course.

    If you have a look at common presenting complaints/pathologies of patients who are noted to excessively supinate (such as lateral ankle ligament injuries) you might find some surgical answers, but I do not perform surgery to primarily reduce excessive STJ supination. You could also look to extremes such as talipes, etc.. for further information on surgery in the supinated foot, but I'm not sure if this is what you are looking for given your initial post.
     
  3. Re: Surg for excessive STJ Supination

    Michael:

    Here are a few surgeries that might be used if you wanted to cause increased STJ pronation moment on a foot:

    1. Medial plantar fascial release.
    2. Lateral displacement osteotomy of calcaneus.
    3. Reverse Evans calcaneal osteotomy (never been done before, to my knowledge!).
    4. Dorsiflexion osteotomy of 1st metatarsal.

    Now, your job, Michael, is to tell me specifically how each of these surgeries may increase STJ pronation moment during weightbearing activities.
     
  4. Re: Surg for excessive STJ Supination

    More homework Kevin. !!

    I need to look up what the clac osteotomies are before I can answer.

    but 1 and 4

    1.Medial release of Plantarfascia : In a lateral deviated axis the medial band of the Plantar fascia (PF) Will (usually) be medial to the subtalar joint axis and will cause an external supination subtalar joint moment when windlass is engaged. By lengthening the PF you will get a reduction in the windlass effect from the medial band of the PF, which will mean a increased external STJ pronation moment.

    4.Dorsiflexion osteotomy of 1st metatarsal: By dorsiflexing the 1st it will mean that the windlass of the 1st met will be engaged later in the gait cycle or maybe not at all, which will mean that the windlass will have increased external pronation moments.

    off to google for 2-3 see what I come up with.
     
  5. Re: Surg for excessive STJ Supination

    Thanks Bob and it´s the same when using orthtoics but over the last few days with the report of stents for excessive pronation I thought I would ask. Your post make much more sense to me. Thanks again.
     
  6. Admin2

    Admin2 Administrator Staff Member

  7. Re: Surg for excessive STJ Supination

    Ok found some stuff but the Lateral displacement osteotomy of calcaneus has got me thinking.

    Evans Osteotomy

    I found the above article for Evans.

    3. Reverse Evans calcaneal osteotomy (never been done before, to my knowledge!). - Evans is a procedure for Pes plano Valgus foot type putting the foot and STJ in a more Supinated position, therefore a reverse Evans would take the foot from a Pes Cavoid position and make the foot and Subtalar joint more pronated.

    2. Lateral displacement osteotomy of calcaneus - I found the below article which stated that with a lateral displacement osteotomy of calcaneus there will be a change in the COP, (but this where I got a bit caught) in a lateral direction. As far as my understanding of COP in a Pronated foot the COP would be more medial and in a Supinated foot the COP more lateral. The only thing I can think of is if the COP is more lateral the amount of GRF which in this case we hope is lateral to the STJ axis increases therefore a external STJ pronation moment will occur. But I´m not so sure about this one.

    How did I go ?
     

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