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Podiatric Surgery II > 1) STJ Arthroresis > Flashcards

1) STJ Arthroresis Flashcards

1
Q

Arthroresis

A
  • From Greek root ereisis “propping up”
  • Props up supporting talus
  • “operation limiting motion in a joint”
  • Without complete arthrodesis
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2
Q

STJ arthroresis used for treatment of

A
  • Flexible flatfoot (no DJD, no Tarsal coalition)
  • Expanded indications for adults with or without PTTD
  • Equinus must be addressed
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3
Q

Motion-blocking implants

A
  • Placed in sinus tarsi
  • Restrict excessive STJ pronation while preserving supination
  • Originally designed for pediatric flexible flatfoot
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4
Q

Anatomy of the sinus tarsi

A
  • Wider portion directed anteriorly and laterally
  • Medial portion narrows to a transverse cylindrical space (tarsal canal/canali tarsi)
    which terminates posterior to the sustentaculum tali of the calcaneus
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5
Q

Sinus tarsi contents

A
  • Ligaments (5)
  • Adipose connective tissue
  • Branches of the peroneal and posterior tibial arteries which anastomose in the sinus
  • Cutaneous dorsolateral nerve (a branch of the superficial peroneal nerve), and proprioceptive nerve endings
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6
Q

5 ligaments of the sinus tarsi

A
  • Interosseous talocalcaneal ligament(ITCL) aka interosseous ligament
  • Cervical ligament(aka Fick ligament, oblique talocalcaneal ligament, or lateral talocalcaneal ligament)
  • Medial root of the inferior extensor retinaculum
  • Intermediate root of the inferior extensor retinaculum (aka intermediary root)
  • Lateral root of the inferior extensor retinaculum
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7
Q

Interosseous talocalcaneal ligament(ITCL) aka interosseous ligament

A
  • Most medial ligament in tarsal canal

- Functions to stabilize the STJ

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8
Q

Cervical ligament(aka Fick ligament, oblique talocalcaneal ligament, or lateral talocalcaneal ligament)

A
  • Located anterior and lateral to the interosseous ligament
  • Attaches to inferolateral talar neck and dorsal neck of the calcaneus
  • Limits inversion, and also stabilizes the subtalar joint
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9
Q

Medial root of the inferior extensor retinaculum

A
  • Located posterior and medial to the cervical ligament
  • Attaching to the calcaneus at the floor of the medial sinus
  • Often merging with the calcaneal attachment of the interosseous ligament
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10
Q

Intermediate root of the inferior extensor retinaculum aka intermediary root

A
  • Attaches to the calcaneus just posterior to the cervical ligament, coursing anteriorly and superiorly over the medial margin of the extensor digitorum longus tendon
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11
Q

Lateral root of the inferior extensor retinaculum

A
  • Loops around the lateral margin of the EDB tendon, merging with the intermediate root to form a sling-like structure over the tendon
  • The lateral fibers course posteriorly and laterally, attaching to the lateral cortex of the calcaneus or blending with the deep fascia
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12
Q

STJ Mechanics

A
  • During pronation, the lateral process of the talus rotates forward as the talus plantarflexes and adductus
  • Further pronation is blocked as lateral process contacts floor of sinus tarsi
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13
Q

Chambers was first to note that by elevating the floor of sinus tarsi

A
  • Excessive pronation could be prevented
  • Accomplished with autogenous bone graft placed under leading edge of the posterior facet of the calcaneus
  • Served as basis for many different STJ arthroereisis procedures
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14
Q

STJ biomechanics

A
  • Triplanar joint with varied axis throughout ROM
  • Generally axis courses posterior, plantar, lateral to anterior, dorsal, medial
  • Average STJ maintains equal amounts of transverse and frontal plane motion
  • Ankle joint generally has majority of sagittal plane motion
  • Average STJ ROM 30 degrees from “neutral” (20 degrees of inversion, 10 degrees of eversion)
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15
Q

STJ CKC pronation

A
  • Visualized as calcaneal eversion and/or talar tibial inversion, talar plantarflexion and adduction
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16
Q

When executed correctly STJ arthroereisis, restricts

A
  • Excessive CKC pronation
  • Resetting maximally pronated position, less calcaneal eversion and foot abduction
    Stabilizes foot for proper propulsion
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17
Q

Planal dominance

A
  • The more that a joint axis deviates from one of the cardinal body planes, the more the motion will occur in that body plane
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18
Q

STJ axis of rotation

A
  • Plantar posterior-lateral –> Dorsal anterior-medial
  • 42T, 16S
  • Transverse & frontal plane motion
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19
Q

Low STJ axis

A
  • If the axis falls in the transverse and sagittal planes, the motion will occur in the frontal plane
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20
Q

High STJ axis

A
  • If the axis falls in the frontal (vertical) and sagittal planes, the motion will occur in the transverse plane
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21
Q

When the high STJ axis is oriented twice as close to the vertical plane than the horizontal,

A
  • Twice as much motion will occur in the transverse plane as the frontal plane
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22
Q

When the STJ axis is Low oriented twice as close to the transverse plane than the vertical,

A
  • Twice as much motion will occur in the frontal as the transverse
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23
Q

When the axis is oriented equidistant between the two,

A
  • You get equal motion in the transverse and frontal planes (ideal/average at 42)
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24
Q

High STJ axis summary

A
  • Axis parallel to Sagittal = Transverse motion dominant (ABD/ADD)
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25
Q

Low STJ axis summary

A

Axis parallel to Transverse = Frontal motion dominant (INV/EVE)

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26
Q

Frontal STJ axis summary

A
  • Axis parallel to Frontal = Sagittal motion dominant (DORSI/PLANTAR)
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27
Q

STJ arthroresis indications

A
  • Flexible planovalgus deformity (pediatrics and adults)
  • Accessory navicular
  • Resected tarsal coalition
  • Stage II PTTD
  • Absence of pain does not preclude surgical intervention
  • Indications still being refined!
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28
Q

STJ arthroresis cautions

A
  • Obese patients
  • Significant Gastroc/Soleus/ankle equinus
  • Excessively medial deviated STJ axis
  • Results in implant being subjected to extremely high impact forces within sinus tarsi leading to Chronic Sinus Tarsalgia or pathologic boney changes
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29
Q

Transverse plane deformity clinical clues

A
  • “Too many toes” sign
  • Medial bulge
  • Uncovering of talar head
  • Axis parallel to Sagittal = Transverse motion dominant (ABD/ADD)
30
Q

Frontal plane deformity clinical clues

A
  • Lateral fold of foot
  • High degree of calcaneal eversion
    > 15 degrees
  • Axis parallel to Transverse = Frontal motion dominant (INV/EVE)
31
Q

Sagittal plane deformity clinical clues

A
  • Midfoot sag
  • Medial column compromised
  • Talar declination does not line up with first metatarsal shaft
  • Axis parallel to Frontal = Sagittal motion dominant (DORSI/PLANTAR)
32
Q

Radiographic analysis of STJ

A
  • Normal hindfoot alignment
  • Talus sits on top of calcaneus
  • Sinus tarsi in “open position”
  • Unbroken cyma line
33
Q

Radiographic abnormal hindfoot alignment

A
  • Talus not sitting on calcaneus
  • Collapse of sinus tarsi
  • Anterior cyma line break
34
Q

Transverse plane dominance radiographic analysis

A
  • Talocalcaneal angle (Kites Angle) > 30°
  • Cuboid abduction angle
  • Wedge shaped navicular
  • Talonavicular coverage > 7°
35
Q

Sagittal plane dominance radiographic analysis

A
  • Talar declination angle > 21°
  • Talo – 1st met (Meary’s) angle > 15-30°mod
    > 30° severe
  • Talocalcaneal angle on lateral view > 25°
  • Calcaneal Inclination angle < 15°
  • Midfoot sagging, Naviculocuneiform breach
36
Q

Frontal plance dominance radiographic evaluation

A
  • Rearfoot eversion
  • 1st met declination angle
  • Height of sustentaculum tali
37
Q

Special radiographic views

A
  • Charger View

- Harris & Beath

38
Q

Charger view

A
  • Stress dorsiflexion lateral view

- Osseous block of AJ

39
Q

Harris & Beath view

A
  • R/O talocalcaneal coalition of posterior and middle facets
40
Q

Sagittal plane procedures

A
  • Kidner
  • FDL transfer
  • Lowman
  • Young
  • MAS
  • Cotton
41
Q

Frontal plane procedures

A
  • Calcaneal slide
  • Reverse Dwyer
  • Silver
  • Arthroresis
42
Q

Transverse plane procedures

A
  • Evans

- Medial based osteotomy

43
Q

Kidner (sagittal)

A
  • Removal of accessory navicular

- Transposition of posterior tibial tendon to reduce slack

44
Q

FDL transfer (sagittal)

A
  • Sacrifice FDL distally to transfer to navicular or along the P tendon
  • Attach distal stump to FHL
45
Q

Lowman (sagittal)

A
  • TAL
  • TN wedge arthrodesis
  • TA under navicular and suture spring ligament
  • Desmoplasty of the spring ligament on self
46
Q

Young (sagittal)

A
  • TAL
  • TA transposed with navicular creating new plantar ligament
  • Advancement of spring ligament on self
47
Q

MAS (sagittal)

A
  • Young plus PT tendon advancement
  • Tightening of spring ligament
  • FDL tendon transfer
48
Q

Cotton (sagittal)

A
  • Opening wedge medial cuneiform
  • Cut parallel to N-C joint
  • Keep plantar cortex intact
  • Reduction of elevatus
  • Stabilize medial cuneiform
49
Q

Calcaneal slide (frontal)

A
  • Medial translocation of posterior fragment of calcaneus
  • Corrects frontal plane deformity
  • Alters pull of gastroc-soleus muscle group
50
Q

Reverse Dwyer (frontal)

A
  • Lateral closing wedge located between posterior STJ facet and the Achilles attachment
51
Q

Silver (frontal)

A
  • Opening wedge bone graph on lateral calcaneus

- Posterior calcaneus is translated plantarly and medially

52
Q

Arthroresis (frontal)

A
  • Usually performed with implant that limits STJ eversion
53
Q

Evans (transverse)

A
  • Lateral column lengthening procedure
  • Opening wedge approximately 1.5 cm from calcaneocuboid joint with insert of bone graft or block plate
  • Triplanar correction (primarily transverse) with realignment of midtarsal joint and reduction of calcaneal inversion
  • Improvement of arch height and stabilization
54
Q

Medial based osteotomy (transverse)

A
  • Medial base wedge to allow for shortening of the medial column and reduction of the abduction deformity
55
Q

STJ arthroresis milestones

A
  • Chambers (1946)
  • Grice (1952)
  • Haraldsson (1962)
  • Subotnick (1974)
56
Q

Posterior facet osteotomy (Chambers 1946)

A
  • Correction of flexible flat feet in adolescents
57
Q

Extra-articular STJ arthrodesis (Grice 1952)

A
  • Extra-articular arthrodedid of suprastragular joint for correction of paralytic flat feet in children
58
Q

Bone wedge arthroresis (Haraldsson 1962)

A
  • Operative treatment of pes planovalgus staticus in juveniles
59
Q

Custom carved plug (Subotnic 1974)

A
  • STJ lateral extra-articular arthroresis
60
Q

Axis-altering implant (Smith 1976)

A
  • Ultra high molecular weight polyethylene (HMPE)
  • Platform and Stem
  • In sinus tarsi
  • Posterior facet arthroplasty to seat the implant
  • Different sizes
  • Elevating the subtalar joint axis reduces hindfoot eversion
61
Q

Vogler biomechanical classification (1987)

A
  • A = self-locking
  • B = axis-altering
  • C = impact-blocking
62
Q

Self-locking (not axis-altering) implants

A
  • Any material inserted into lateral sinus tarsi, restricting eversion of STJ
  • Implant prevents contact of the lateral talar process with floor of sinus tarsi, restricting pronation
  • Valenti – “grandfather” of threaded cylinder implants , 1976
  • MBA, Maxwell-Brancheau - 1997
  • HyproCure, Graham, 2004
  • Futura Conical (Wright Medical)
63
Q

Axis-altering implants

A
  • These implants elevate the floor of the sinus tarsi, altering the low STJ axis reducing frontal plane eversion
  • Implant stem is placed in vertical orientation in the floor of calcaneus
  • Pronation is limited by preventing excessive plantarflexion of the talus as it rides on implant
  • Primarily used with FRONTAL plane deformities
  • Does not work well with high STJ Axis
64
Q

Impact-blocking implants

A
  • Without changing STJ axis, these implants block the lateral process of the talus from advancing beyond the posterior facet
  • STA-Peg implants
65
Q

Surgical pearls STJ Axis parallel to Transverse (Low STJ axis) = Frontal plane dominant motion

A
  • Koutsogiannis
  • Dwyer
  • Silver
  • Arthroereisis*
66
Q

Surgical pearls STJ Axis parallel to Sagittal (High STJ axis) = Transverse plane dominant motion

A
  • Kidner

- Evans*

67
Q

Surgical pearls STJ Axis parallel to Frontal = Sagittal plane dominant motion

A
  • Young
  • Cotton
  • Lapidus
68
Q

Koutsogioannis calcaneal osteotomy

A
  • Medial displacement osteotomy (~1cm)
  • Through and through
  • Parallel to & behind peroneal tendons
  • Posterior calcaneus shifts medially
  • Restore heel beneath ankle
69
Q

Reverse Dwyer calceneal osteotomy

A
  • Medial closing wedge

- Varus producing

70
Q

Silver calcaneal osteotomy

A
  • Lateral opening wedge with graft
  • Directly posterior to posterior facet
  • Varus producing
71
Q

Evans calcaneal osteotomy

A
  • Extra-articular correction
  • Lengthens lateral column
  • Realign midtarsal joints
  • 1.5 cm proximal to calcaneocuboid joint
  • Insertion of bone graft anteriorly

Podiatric Surgery II (6 decks)

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