Use of the arthroereisis screw with tendoscopic delivered platelet-rich plasma for early stage adult acquired flatfoot deformity

Clinical outcomes of subtalar arthroereisis for the treatment of stage 1 flexible progressive collapsing foot deformity

BACKGROUND

The use of subtalar arthroereisis as an adjunct to the surgical treatment of stage 1 flexible progressive collapsing foot deformity (PCFD) is controversial. The aim was to investigate the clinical outcomes and report the implant removal rate of subtalar arthroereisis as an adjunct for stage 1 PCFD.

METHODS

A retrospective study of 212 consecutive feet undergoing operative management of stage 1 PCFD with adjunctive subtalar arthroereisis between October 2010 and April 2018. The primary outcome was the Foot and Ankle Outcome Score (FAOS). Secondary outcomes included Foot and Ankle Disability Index (FADI), Euroqol-5D-5L Index and implant removal rate.

RESULTS

Post-operative clinical FAOS outcomes were collected for 153 feet (72.2%). At mean 2.5-year follow-up, the mean ± standard deviation FAOS for each domain was as follows; Pain: 81.5 ± 18.5, Symptoms: 79.5 ± 12.9, Activities of Daily Living: 82.5 ± 15.4 and Quality of Life: 64.2 ± 23.7. EQ-5D-5L Index was 0.884 ± 0.152. Pre-operative scores were available for 20 of these feet demonstrating a statistically significant improvement in all FAOS, FADI and EQ-5D-5L domains (p < 0.05). The implant removal rate for persistent sinus tarsi pain was 48.1% (n = 102).

CONCLUSION

Use of a subtalar arthroereisis implant as an adjunct to conventional procedures in stage 1 flexible PCFD can result in significant improvement in pain and function. Patients should be counselled as to the relatively frequent rate of subsequent implant removal.

LEVEL OF EVIDENCE

IV.

Outcomes Following the Use of Subtalar Arthroereisis in the Correction of Adult Acquired Flatfoot: A Systematic Review

BACKGROUND

Adult acquired flatfoot deformity (AAFD) is a condition affecting approximately 3% of the adult population. It can lead to severe morbidity, and therefore, prompt treatment is of the upmost importance in maintaining and restoring function. Recently, the use of subtalar arthroereisis has become more widespread in the treatment of AAFD. The purpose of this systematic review is to examine the clinical and radiological outcomes of AAFD when treated with subtalar arthroereisis.

METHODS

Studies involving the use of subtalar arthroereisis for the management of AAFD were reviewed, and appropriate studies selected based on inclusion and exclusion criteria. Studies were reviewed for both clinical and radiological outcomes following the use of subtalar arthroereisis as well as reported complications.

RESULTS

Nine studies met our inclusion criteria, with most of these involving stage II AAFD. A total of 190 subtalar arthroereisis procedures were performed with all studies demonstrating improvement in both clinical and radiological scores with a low rate of complications.

CONCLUSION

Subtalar arthroereisis may have benefits when used as an adjunct to treat stage II AAFD. However, more high-quality studies are needed to establish its best use.

LEVELS OF EVIDENCE

Level IV: Systematic review.

Subtalar Arthroereisis as an Adjunct Procedure Improves Forefoot Abduction in Stage IIb Adult-Acquired Flatfoot Deformity

BACKGROUND

Our aims were (a) to determine whether subtalar arthroereisis (STA) as adjunct procedure improved radiographic correction of stage IIb adult-acquired flexible flatfoot deformity (AAFD); (b) to assess the STA-related complication rate.

METHODS

A retrospective analysis of 22 feet (21 patients) diagnosed with stage IIb AAFD treated by medializing calcaneal osteotomy (MCO), flexor digitorum longus (FDL) transfer, spring ligament (SL) repair with or without Cotton osteotomy and with or without STA in a single institution was carried out. Seven measurements were recorded on pre- and postoperative (minimum 24 weeks) radiographs by 2 observers and repeated twice by 1 observer. Inter- and intraobserver reliabilities were assessed. The association of demographic (gender, side, age, body mass index) and surgical variables (Cotton, STA) with radiographic change was tested with univariate analysis followed by a multivariable regression model.

RESULTS

Excellent inter- and intraobserver reliabilities were demonstrated for all measurements (intraclass correlation coefficient range, 0.75-0.99). Gender, side, Cotton osteotomy, and STA were included in the multivariable analysis. Regression showed that STA was the only predictor of change in talonavicular coverage angle (TNCA) (R² = 0.31; P = .03) and in calcaneo-fifth metatarsal angle (CFMA) (R² = 0.40; P = .02) on dorsoplantar view. STA was associated to a greater change in TNCA by 10.1° and in CFMA by 5°. Four patients out of 12 STA complained of sinus tarsi pain after STA, and removal of the implant resolved symptoms in 3 of them.

CONCLUSION

In this series, STA as an adjunct procedure to MCO, FDL transfer, SL repair in the treatment of stage IIb AAFD led to improvement in correction of forefoot abduction. STA-related complication and removal rates were 33%.

LEVELS OF EVIDENCE

Level IV: Retrospective cohort study.

Is subtalar arthroereisis a good procedure in adult-acquired flatfoot? A systematic review of the literature

INTRODUCTION

The aim of the present systematic literature review was to determine results and complications in subtalar arthroereisis for stage-2 adult-acquired flatfoot.

METHOD

A search of the PubMed, Medline, CINAHL, Cochrane and Embase databases used MeSH terms "arthroereisis" AND "flatfoot" OR "adult-acquired flatfoot" OR "pes planovalgus" OR "pes planus". Two of the authors analyzed 125 articles. After reading titles and Abstracts, 105 articles were read in full text and their references were analyzed. Finally, 12 articles were selected and divided into 2 groups: isolated and associated arthroereisis.

RESULTS

Improvement in functional scores was greater in associated arthroereisis. Whether isolated or associated, arthroereisis achieved radiologic correction. However, the rate of complications was high, mainly concerning tarsal sinus pain.

CONCLUSION

Subtalar arthroereisis for stage-2 adult-acquired flatfoot is rarely performed in isolation. When it is associated to other procedures, good radiologic and clinical results can be expected.

LEVEL OF EVIDENCE

IV.

Flexible Progressive Collapsing Foot Deformity: Is There Any Role for Arthroereisis in the Adult Patient?

Over the last two decades there is a growing interest in the adult literature for subtalar joint arthroereisis. Parallel to this interest, there have been improvements in the design and biomechanics of the implant, although the main indication of subtalar joint arthroereisis in adults is not clear. Most studies show significant improvement in postoperative clinical scores and visual analog scores. Sinus tarsi pain, being the most common complication, is the main determinant of clinical satisfaction. This review focuses on the role and complications of subtalar joint arthroereisis in the adult population.

Role of Minimally Invasive Surgery in Adult Flatfoot Deformity

Adult acquired flatfoot deformity (AAFD) as a consequence of posterior tibial tendon dysfunction is commonly divided in flexible (stages I and II) and fixed (stages III and IV) deformities. The aim of this article is to summarize the evidence available for minimally invasive surgical techniques that can be used in the treatment of flexible AAFD, including tibialis posterior tendoscopy, subtalar arthroereisis, minimally invasive calcaneal osteotomy, and medial proximal gastrocnemius recession. A treatment algorithm and technical tips have also been provided.

Lateral column lengthening versus subtalar arthroereisis for paediatric flatfeet: a systematic review

PURPOSE

This systematic review aimed to compare radiographic correction, clinical outcomes, complications, and re-operations between lateral column lengthening (LCL) and arthroereisis (AR) for treating symptomatic flatfoot in children.

METHODS

We conducted a comprehensive search on MEDLINE, EMBASE, and Cochrane Library databases. Literature search, data extraction, and quality assessment were conducted by two independent reviewers. The outcomes analyzed included radiographic parameters, clinical scores, satisfaction, complications, and re-operations.

RESULTS

Twenty-one and 13 studies were included in the LCL and AR groups, respectively. The change in anteroposterior talo-first metatarsal angle was greater in the LCL (9.5° to 21.7°) than in the AR group (10.6° to 12.8°). The change in calcaneal pitch was greater in the LCL (2.1° to 26.53°) than in the AR group (- 1.3° to 3.23°). Improvements in the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score were greater in the LCL (27.7 to 39.1) than in the AR group (17 to 22). The percentage of satisfaction was similar between the LCL (68% to 89%) and AR (78.5% to 96.4%) groups. The complication rate was higher in the LCL (0% to 86.9%) than in the AR group (3.5% to 45%). The most common complications were calcaneocuboid subluxation and persistent pain in the LCL and AR groups, respectively. The re-operation rate was similar between the LCL (0% to 27.3%) and AR (0% to 36.4%) groups.

CONCLUSIONS

The LCL group has achieved more radiographic corrections and more improvements in the AOFAS score than the AR group. Complications were more common in the LCL group than in the AR group, and the re-operation rates were similar between the two groups.

The role of arthroereisis of the subtalar joint for flatfoot in children and adults

Subtalar arthroereisis has been reported as a minimally-invasive, effective and low-risk procedure in the treatment of flatfoot mainly in children but also in adults.It has been described as a standalone or adjunctive procedure, and is indicated in the treatment of flexible flatfoot, tibialis posterior tendon dysfunction, tarsal coalition and accessory navicular syndrome.Different devices for subtalar arthroereisis are currently used throughout the world associated with soft-tissue and bone procedures, depending on the surgeon rather than on standardised or validated protocols.Sinus tarsi pain is the most frequent complication, often requiring removal of the implant.To date, poor-quality evidence is available in the literature (Level IV and V), with only one comparative non-randomised study (Level II) not providing strong recommendations. Long-term outcome and complication rates (especially the onset of osteoarthritis) are still unclear. Cite this article: EFORT Open Rev 2017;2:438-446. DOI: 10.1302/2058-5241.2.170009.

[Degeneration of the posterior tibial tendon : Established and new concepts]

BACKGROUND

The most common cause of degeneration of the posterior tibial tendon is a congenital valgus deformity of the calcaneus. Other associated pathologies are forefoot supination, forefoot abduction and shortening of the gastrocnemius muscle.

DIAGNOSTICS

Loaded x‑rays of the foot in three planes as well as the hindfoot alignment view enable evaluation of the axis of the foot under static loading conditions. The posterior tibial tendon can be imaged with ultrasound and magnetic resonance imaging (MRI). The fatty degeneration of the posterior tibial muscle can be identified in MRI.

CONSERVATIVE THERAPY

Unloading of the posterior tibial tendon can be achieved by orthotics with medial support or braces.

SURGICAL THERAPY

The surgical therapy of the posterior tibial tendon alone has not been proven to be successful. The key element is the correction of the hindfoot valgus by medializing calcaneal osteotomy. Depending on the deformity, an additional lateral lengthening osteotomy of the calcaneus, as well as a dorsal open wedge osteotomy of the medial cuneiform bone (Cotton osteotomy) can additionally be indicated. The transposition of the tendon of the flexor digitorum longus muscle to the navicular bone is used to augment the posterior tibial tendon. Ruptures of the plantar calcaneonavicular ligament are sutured, in addition a sinus tarsi spacer can be implanted to protect medial soft tissues. A shortening of the gastrocnemius muscle is addressed by release of the aponeurosis. First results are published on use of biologically active substances, such as platelet rich plasma.

RESULTS

The correction of the hindfoot deformity as well as the subsequent treatment of the different components of the pathology lead to a significant improvement in foot function. Pre-existing degenerative alterations are limiting factors.