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Podiatric Surgery II > 1) STJ Arthroresis > Flashcards

1) STJ Arthroresis Flashcards

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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
Low STJ axis summary
Axis parallel to Transverse = Frontal motion dominant (INV/EVE)
26
Frontal STJ axis summary
- Axis parallel to Frontal = Sagittal motion dominant (DORSI/PLANTAR)
27
STJ arthroresis indications
- 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!
28
STJ arthroresis cautions
- 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
29
Transverse plane deformity clinical clues
- “Too many toes” sign - Medial bulge - Uncovering of talar head - Axis parallel to Sagittal = Transverse motion dominant (ABD/ADD)
30
Frontal plane deformity clinical clues
- Lateral fold of foot - High degree of calcaneal eversion > 15 degrees - Axis parallel to Transverse = Frontal motion dominant (INV/EVE)
31
Sagittal plane deformity clinical clues
- 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
Radiographic analysis of STJ
- Normal hindfoot alignment - Talus sits on top of calcaneus - Sinus tarsi in “open position” - Unbroken cyma line
33
Radiographic abnormal hindfoot alignment
- Talus not sitting on calcaneus - Collapse of sinus tarsi - Anterior cyma line break
34
Transverse plane dominance radiographic analysis
- Talocalcaneal angle (Kites Angle) > 30° - Cuboid abduction angle - Wedge shaped navicular - Talonavicular coverage > 7°
35
Sagittal plane dominance radiographic analysis
- 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
Frontal plance dominance radiographic evaluation
- Rearfoot eversion - 1st met declination angle - Height of sustentaculum tali
37
Special radiographic views
- Charger View | - Harris & Beath
38
Charger view
- Stress dorsiflexion lateral view | - Osseous block of AJ
39
Harris & Beath view
- R/O talocalcaneal coalition of posterior and middle facets
40
Sagittal plane procedures
- Kidner - FDL transfer - Lowman - Young - MAS - Cotton
41
Frontal plane procedures
- Calcaneal slide - Reverse Dwyer - Silver - Arthroresis
42
Transverse plane procedures
- Evans | - Medial based osteotomy
43
Kidner (sagittal)
- Removal of accessory navicular | - Transposition of posterior tibial tendon to reduce slack
44
FDL transfer (sagittal)
- Sacrifice FDL distally to transfer to navicular or along the P tendon - Attach distal stump to FHL
45
Lowman (sagittal)
- TAL - TN wedge arthrodesis - TA under navicular and suture spring ligament - Desmoplasty of the spring ligament on self
46
Young (sagittal)
- TAL - TA transposed with navicular creating new plantar ligament - Advancement of spring ligament on self
47
MAS (sagittal)
- Young plus PT tendon advancement - Tightening of spring ligament - FDL tendon transfer
48
Cotton (sagittal)
- Opening wedge medial cuneiform - Cut parallel to N-C joint - Keep plantar cortex intact - Reduction of elevatus - Stabilize medial cuneiform
49
**Calcaneal slide (frontal)**
- Medial translocation of posterior fragment of calcaneus - Corrects frontal plane deformity - Alters pull of gastroc-soleus muscle group
50
**Reverse Dwyer (frontal)**
- Lateral closing wedge located between posterior STJ facet and the Achilles attachment
51
**Silver (frontal)**
- Opening wedge bone graph on lateral calcaneus | - Posterior calcaneus is translated plantarly and medially
52
**Arthroresis (frontal)**
- Usually performed with implant that limits STJ eversion
53
**Evans (transverse)**
- 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
Medial based osteotomy (transverse)
- Medial base wedge to allow for shortening of the medial column and reduction of the abduction deformity
55
STJ arthroresis milestones
- Chambers (1946) - Grice (1952) - Haraldsson (1962) - Subotnick (1974)
56
Posterior facet osteotomy (Chambers 1946)
- Correction of flexible flat feet in adolescents
57
Extra-articular STJ arthrodesis (Grice 1952)
- Extra-articular arthrodedid of suprastragular joint for correction of paralytic flat feet in children
58
Bone wedge arthroresis (Haraldsson 1962)
- Operative treatment of pes planovalgus staticus in juveniles
59
Custom carved plug (Subotnic 1974)
- STJ lateral extra-articular arthroresis
60
Axis-altering implant (Smith 1976)
- 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
Vogler biomechanical classification (1987)
- A = self-locking - B = axis-altering - C = impact-blocking
62
Self-locking (not axis-altering) implants
- 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
Axis-altering implants
- 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
Impact-blocking implants
- Without changing STJ axis, these implants block the lateral process of the talus from advancing beyond the posterior facet - STA-Peg implants
65
Surgical pearls STJ Axis parallel to Transverse (Low STJ axis) = Frontal plane dominant motion
- Koutsogiannis - Dwyer - Silver - Arthroereisis*
66
Surgical pearls STJ Axis parallel to Sagittal (High STJ axis) = Transverse plane dominant motion
- Kidner | - Evans*
67
Surgical pearls STJ Axis parallel to Frontal = Sagittal plane dominant motion
- Young - Cotton - Lapidus
68
Koutsogioannis calcaneal osteotomy
- Medial displacement osteotomy (~1cm) - Through and through - Parallel to & behind peroneal tendons - Posterior calcaneus shifts medially - Restore heel beneath ankle
69
Reverse Dwyer calceneal osteotomy
- Medial closing wedge | - Varus producing
70
Silver calcaneal osteotomy
- Lateral opening wedge with graft - Directly posterior to posterior facet - Varus producing
71
Evans calcaneal osteotomy
- 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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