MBA replacement

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I have a patient whom I did bilateral Medial Arch / MBA implants on several years ago. Her right foot has recently become symptomatic in the sinus tarsi area and an X-ray shows the MBA has dislodged.
I plan on replacing this.
My question is; does anyone have experience in replacing a STJ implant after this much time?
Any pearls?
Thanks
Steve

 

Steve:

I don't use MBA or other implants in the subtalar joint. Foot orthoses work remarkably well for most cases of symptoms caused by excessive STJ pronation moments.

The orthopedic surgeon I worked with for 16 years (and I just did surgery on) had a favorite saying when I spoke to him about any of my surgical complications: "You cut and you'll cry."

 

Hi Kevin:

I wasn't really asking for advice relative to whether or not to use STJ implants, but if someone had experience replacing one that has been in place for several years. If orthotics had helped any of these patients then they wouldn't have STJ implants.

What I do not know is if there are any changes within the Sinus Tarsi that may occur over several years with the MBA that might affect the reinsertion of the new one.

Thanks

Steve

 

I have been known to give advice on this website even though none has been asked for.

The first question that comes to mind, Steve, is what you call "orthotics". (That would be like me saying to you, the patient "failed bunion surgery" and you then asking me what specific bunion procedure and what specific modification of that bunion procedure did you use on the patient.)

In other words, what specific type of orthoses, including modifications, are you using for these patients that aren't being helped by orthoses that "have STJ implants"? I don't see many podiatrists here in Sacramento using these implants, even though I know that in certain parts of the country they must be popular.

The problem I have with this scenario of hearing that the doctor determined that the patient needed a STJ implant because the patient failed orthoses and now the patient has a failed STJ implant is that this patient now has a great potential to develop chronic sinus tarsitis due to a failed subtalar implant. And this potential chronic sinus tarsitis may have otherwise been successfully treated with foot orthoses, if the correct anti-pronation foot orthoses had been used for the patient.

If I was seeing this patient in my office because they were seeking a second opinion, I would have asked them what type of foot orthoses were used before surgery and asked to see the orthoses to inspect if they were of sufficient quality to justify the surgical podiatrist saying "the patient failed orthotics". I am very tired of many members of the podiatric surgical community making mediocre foot orthoses for patients and then saying their patients "failed orthotics" so that they can happily proceed on to surgery. I'm not saying that this is what you did, Steve, but is what I have seen time and again over my last 22 years of practice. It is frustrating for me when I see a patient with chronic pain from a surgical failure/complication that I know I could have made asymptomatic with a specifically modified set of foot orthoses. All I can think in this scenario is that I just wish I had seen the patient before the overly-anxious surgeon had treated the patient.

 

"that I know I could have made asymptomatic with a specifically modified set of foot orthoses. All I can think in this scenario is that I just wish I had seen the patient before the overly-anxious surgeon had treated the patient."

Well Kevin, of course ALL patients apparently can be made asymptomatic with orthotics, "your" orthotcs. I'm so very sorry that others do not (in your mind) practice Podiatric Medicine at the same level as you do. It must be difficult being you, having to see and treat all our mistakes.

I do not like the tone of your post. I do not appreciate the connotation that I somehow dispense substandard orthotics or that I am cut happy.
I was asking a very specific question on this site. If you’d like to discuss surgery vs conservative treatments then I suggest starting a new thread.

Steve

 

Regarding the term "cut happy", Steve. It may be time to take a step back and look at the avatar you now have on your postings to Podiatry Arena. There are many surgeons on Podiatry Arena, but only one that has a photo of himself in a surgical mask and operating room attire.

 

Wow: You are the judgemental one!
You know VERY VERY - VERY little about me. Please, get over the attitude and move on.
I really don't want to get into a "personality" debate, I'm a little old for this.
Try keeping this professional. IF you have nothing to contribute to the actual question I posted then please try another thread.
Thanks
Steve

 

Steve,
I've placed several MBA and MBA-type implants over the past several years. I so far have not had difficulties with the one's I have placed. Perhaps I'm lucky. I have had to remove a few. Though there is no real evidence to support their use or the advantages of a conical vs. standard, for example, I try to find differences in the devices that might make one better suited for a particular patient. My point, as I'm rambling and fairly nervous that someone will cut me down, is determine why the implant failed. Did it shift, was it outgrown, etc.

For me, when faced with the same question you originally posted, the answer was replace an MBA with a Hyprocure implant. I don't necessarily agree with their marketing and "specialized master surgeon training", nor do I have any financial interest in any manufacturer of orthotics, implants, or widgets, but the device is different enough to maintain the alignment of the foot and sits further into the tarsal canalis as to not aggravate potential damage from the MBA.

Hope this helps,
Matthew

 

1FootDoc:
Thank you for your response, and no need for a disclaimer with me!
If you're new here, don't worry about some of the posts that tend to lean towards the non objective/personal attack - just ego issues I'm sure.

As far as the MBA: This particular adult patient is quite heavy and has severe flexible pes planus. She works on her feet for 12 hour shifts and pivots constantly.

I have done the replacement procedure since I posted my question and all went well. She had the original implant in for 5 or 6 years and was doing very well until it slipped.

I replaced it with a slightly larger size MBA design and so far so good.

Thanks for the info.

Steve

 

Matthew:

Welcome to Podiatry Arena. You will find that this is a very informative podiatric website, probably the best on the internet currently. Podiatry Arena is diverse and its members are from many countries. Even though most of the contributors and members of the site are podiatrists, there are many other members from other medical specialties that follow along, and sometimes contribute. However, you will find that the vast majority of the podiatrists that are members of this site are primarily non-surgical podiatrists, doing little to any osseous surgery. Therefore, it is good to have another experienced podiatric surgeon contributing to the site since your expertise will be a valuable contribution to the overall academic worth of this website.

In regards to the subtalar arthroeresis procedure, I have seen its popularity come and go depending on the region of the country and depending on who you talk to during my 22+ years of practice. During my Biomechanics Fellowship back in '84-'85, Dr. Tom Sgarlato talked to me about doing these procedures in the 1970s with silastic blocks and them wittling them into the correct shape intraoperatively to sew them into the sinus tarsi.....my, how things have changed in the last 30 years!

Subtalar arthroeresis implants all basically function to prevent the subtalar joint (STJ) from reaching its end range of pronation by preventing the lateral process of the talus from contacting the floor of the sinus tarsi of the calcaneus. By effectively reducing the last few degrees of pronation range of motion or "resetting the maximally pronated position of the STJ", not only is the foot posture in the maximally pronated position changed, but also the STJ axis spatial location will be positioned in a less medially deviated and more laterally translated position relative to the plantar foot after the arthroeresis procedure. This shift in STJ axis spatial location will occur due to the talar head now being less adducted after the arthroeresis procedure than it was before the procedure. Theoretically, this change in foot posture may be quite significant, but, to my knowledge, no studies have been done on how much the osseous segments of the foot do change with the subtalar arthroeresis procedure.

Welcome again to Podiatry Arena, Matthew, and I'm looking forward to more of your contributions.

 

I have undertaken severla of these and found the results to be excellent (with a few problems - as there are with almost anything).

I have replaced an MBA implant that became dislodged after 2 years.

It was quite straightforward and the patient has been problem free for about 3 years now.

I must admit I had always been under the impression that if the implant had been in place for several years the fibrous plug that was left after the implant was removed would likely be strong enuough to approximate the effect of the implant. This woiuld mean that logically the first thing to try would be to remove the implant and see if the symptoms resolve (as they could be due to the malpositioned implant rather than the loss of the blocking effect of the implant.

Tom

 

"I had always been under the impression that if the implant had been in place for several years the fibrous plug that was left after the implant was removed would likely be strong enuough to approximate the effect of the implant. "

Hi Podsurg55:
Thanks for your insite.
As I may have mentioned, this patient is quite obese and, surprisingly, work on her feet for long hours. I tend to think this contributed to the movement of the implant.

Steve

 

Just stay out of the biomechanics board. It gets a bit weird in there.

Did you excise much scar tissue before you upsized?

 

Hi Nat:
No, I didn't excise any scar tissue. The old one felt "loose" to me, otherwise not much to it.
Steve

 

I generally put in the larger implant than what i had used before. Be sure to use intra-operative flouro and place the implant correctly. You should not need nor want to excise any scar tissue as you will need it to 'grab' the new implant.