Recurrent TaloTarsal Joint Displacement...

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Michael E. Graham, DPM, FACFAS, FAENS, FAAFASMacomb, Michigan, USA

The Physicians Guide to

Recurrent TaloTarsal Joint Displacement (RTTJD)

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Contents:

Introduction..............................................................................2

Common Symptoms of RTTJD..................................................3

Clinical Signs of RTTJD.............................................................4

Radiographic Guidelines...........................................................5

Radiographic Confirmation of RTTJD........................................6

Talotarsal Joint Stabilization Options.........................................7

Type II EOTTS-HyProCure® Patient Selection Process...............8

EOTTS Patient Selection Based on Radiographic Review............9

Pre-EOTTS-HyProCure® Patient Considerations.....................10

EOTTS-HyProCure® Surgical Procedure...........................11–12

Post-EOTTS-HyProCure® Steps to Success...........................13

EOTTS-HyProCure® Troubleshooting Guide.............................14

HyProCure® Facts.....................................................................15

Introduction

The talotarsal joint (TTJ) is the “foundational” joint of the weightbearing body. The alignment & stability of the TTJ is crucial for efficient foot function. Talotarsal joint dislocation (TTJD) is the partial dislocation of the talus on the tarsal mechanism and represents a major deforming force to the structures within the foot and up the musculoskeletal chain.

Recurrent talotarsal joint displacement (RTTJD) is a dynamic deformity where the talus repeatedly dislocates on the tarsal mechanism during weightbearing activities. RTTJD is the leading underlying etiology to the majority of lower extremity musculoskeletal disorders. People won’t outgrow this pathologic deformity and there are no case studies presenting evidence that the TTJ will realign itself over time.

The stabilization of the TTJ while still allowing, as close as possible, a normal amount of range of motion (ROM), has to be a primary consideration in eliminating the underlying cause of chronic musculoskeletal deformities.

While there are patients who get relief from arch supports, there are others whose foot structure requires osseous reconstruction. However, between these two groups are a significant number of patients who find arch supports just aren’t enough and reconstructive surgery is simply too aggressive. These patients may be candidates for Extra-Osseous TaloTarsal Stabilization (EOTTS) with HyProCure®.RTTJD

Normal TTJ



Common Symptoms of RTTJD

Fact: Most patients with RTTJD will never experience pain directly within their sinus tarsi. Instead, the majority of patients will develop one or more of the following symptoms within their lifetime.

Functional SymptomsThe more active they are, the more they suffer. Growing pains and shin splints occur as a direct result of hindfoot instability/TTJD. The soft tissues within the leg are subject to excessive strain while walking. Weightbearing activities lead to increased strain on the tissues and subsequent soreness and pain.

Structural SymptomsThe recurrent partial dislocation of the talus on the tarsal mechanism leads to increased forces acting anteriorly on the midfoot and forefoot. Instantly, this increases the strain to the supporting soft tissues of the medial column in the foot. This also leads to a prolonged period of unlocking of the mid-foot joints during weightbearing and is directly responsible for a prolonged period of foot pronation, over-pronation or hyperpronation.

Therefore, RTTJD is the leading etiology to the development of:

Proximal Effects

RTTJD

Knee Joint

Hip Joint/Sciatica

Pelvic Tilt

Lower Back

Upper Back

Neck

Distal Effects

2a.3.

4.

1.

TTJ NSP TTJD = Increased IMA

Every year, in the USA

◆ 1,000,000 neck and back surgeries◆ 200,000 hip replacements◆ 1,500,000 arthroscopic & knee replacements◆ Annual cost of musculoskeletal disorders was

$849 billion in 2008 (direct and indirect).

Ask Yourself

1. How many of these people have an associated RTTJD deformity?

2. How many of them will continue to have pain or will need revision surgery?

The number of patients requiring treatment for these chronic diseases is on the rise, while the underlying etiology remains ignored or undertreated.

1. Posterior Tibial Tendon Dysfunction: due to navicular drop, plantarflexion of the sustentaculum tali.

2a. 1st Ray Disorders: metatarsus primus elevatus, metatarsus primus varus.

2b. 1st MPJ Disorders: hallux valgus, hallux limitus/rigidus.

3. Plantar Fasciopathy/Fasciitis: mechanical over-loading to the medial band of the plantar fascia.

4. Tarsal Tunnel Syndrome: increased pressures within the porta pedis and tarsal tunnel, elongation and strain to the posterior tibial nerve resulting in nerve disease.

2b.



Clinical Signs of RTTJD

Non-Weightbearing TTJ Exam

Weightbearing TTJ ExamFrontal: Medial talar displacement leads to a forefoot abduction and is associated with “too many toes” sign.

Medial: Loss of arch height may or may not be present with a TTJD deformity. The majority of patients with TTJD will have an associated navicular drop and therefore a lowering of the medial arch of their foot.

Posterior: Calcaneal valgus may or may not be present.

The clinical examination provides clues to a TTJD deformity, but only provides subjective findings. Standardized weightbearing radiographs are the only modality to provide objective data.

TTJ—NP Normal TTJ Pronation: Max 3 °– 5° Excessive TTJ Pronation: > 5°

AbnormalNormalAbnormalNormalAbnormalAbnormalNormalNormal

Abnormal = TTJDNormal = Aligned TTJAbnormal = TTJDNormal = Aligned TTJ

Moderate TTJDMild TTJDRSP TTJD—AbnormalRSP TTJ—Aligned/Normal



Radiographic Guidelines

Lateral X-ray

Sinus Tarsi: should be “open”; this indicates normal oblique transfer of forces posteriorly and anteriorly. Obliterated sinus tarsi reveals an abnormal shift of forces anteriorly.

Talar Declination Angle: < 23°, necessary for the transfer of forces anteriorly rather than plantarly. An angle greater than 23° reveals forces acting on the mid-foot rather than the forefoot and indicates a sagittal plane TTJD component.

Navicular Position: should only overlap the dorsal ¼ to ½ of the cuboid. Navicular drop leads to increased strain on the posterior tibial tendon and lowering of the medial column of the foot and arch.

Cyma Line: the head of the talus should only extend slightly beyond the anterior edge of the calcaneus. There are no specific measurements/standards due to variability from foot to foot, however a reduction of cyma indicates a decreased force acting on the spring ligament, plantar fascia, posterior tibial tendon, porta pedis, tarsal tunnel, 1st ray and 1st MPJ.

Calcaneal Inclination Angle: a lower than normal pitch angle leads to an anterior shift of forces onto the mid-foot. < 20° is considered lower than normal, 20°–30° is normal.

Talar—1st Metatarsal Angle: stability of the 1st ray is crucial for proper foot function (heel-lift). An abnormally elevated 1st ray will lead to forefoot valgus and could compromise the results of an EOTTS procedure if left ignored or untreated. < 4° is considered normal, > 4° is abnormal.

Rule Out Tarsal Coalition: don’t ignore the obvious “halo” sign. Compare RSP to NSP.

DP X-ray

Talar 2nd Metatarsal Angle: normal < 16°; > 16° indicates transverse plane TTJD component. Best hindfoot–forefoot comparison angle.

Cyma Line: the head of the talus should only extend slightly beyond the anterior edge of the calcaneus. There are no specific measurements/standards due to variability from foot to foot, however a reduction of cyma indicates a decreased force acting on the spring ligament, plantar fascia, posterior tibial tendon, porta pedis, tarsal tunnel, 1st ray and 1st MPJ.

Talonavicular Head Coverage: angle > 7° = talonavicular subluxation.

Other Considerations:

Rule out metatarsus adductus

1st Ray elevatus/instability (flexible/semi-flexible/rigid-fixed)

1st MPJ disease (valgus/limitus/rigidus)

Tarsal Coalition or “Halo” Sign

Sinus Tarsi

Talar Declination / Navicular Position

TTJ Normal/TD < 23° TTJD/TD > 23°

Cyma Line

TTJ Normal TTJD

Talonavicular Coverage

Talonavicular Dislocation

> 7°

Calcaneal Inclination Angle

< 20°> 20°

Talar 1st Metatarsal

> 4°< 4°

< 7°



Lateral Comparison Sinus Tarsi

Open = Aligned TTJObliterated = TTJD

Cyma Line Normal = Aligned TTJ Anteriorly Deviated = TTJD

Navicular Position Dorsal = Aligned TTJ Dropped = TTJD

Talar Declination Angle < 23° = Aligned TTJ > 23° = TTJD

DP ComparisonTalar 2nd Metatarsal Angle (T2MA)

< 16° = Aligned TTJ > 16° = TTJD

Cyma Line Normal = Aligned TTJ Abnormal = TTJD

Talonavicular Coverage < 7° = Aligned TTJ > 7° = TTJD

Ankle Comparison Rectus = NTTJ Valgus = TTJD

Neutral Stance Position

Radiographic Confirmation of RTTJD

Dynamic X-ray ComparisonWeightbearing radiographs only provide a static, snap-shot image of the osseous alignment of foot and ankle. The best way to document the reducibility/flexibility of the TTJ dislocation deformity is to take two sets of radiographs. The first set with the patient in relaxed stance position (RSP) and the second with the TTJ in neutral stance position (NSP).

Relaxed Stance Position



Talotarsal Joint Stabilization Options

ObservationThis is not a treatment. Excessive pathologic forces are acting on the structures within the foot and up the musculo-skeletal chain while weightbearing. Children do not out-grow this condition; It gets progressively worse as they age.

Arch Supports/Foot OrthosisArch supports can be useful for many foot pathologies. However, they are unable to realign and stabilize the TTJ. This form of treatment is sub-therapeutic and can lead to a false “sense of correction”. Many times insoles are used with other treatment options such as EOTTS to support secondary conditions such as a weakened medial column, instability of the 1st ray and limited 1st MPJ range of motion.

Inter/Intra-Osseous TaloTarsal StabilizationCertain foot structures can require more aggressive surgical correction, but the “cure” can be worse than the disease. There are many associated complications and risks, and a prolonged period of recovery to remove internal hardware.

Extra-Osseous TaloTarsal Stabilization Type I Arthroereisis Device

◆ Placed into the lateral half of the sinus tarsi◆ Arthroereisis—joint blocking/limiting devices◆ Anchored by lateral soft tissues◆ Limited scientific evidence◆ Removal rate 38% to 100% depending on device

Extra-Osseous TaloTarsal Stabilization Type II Device—HyProCure®

◆ Placed into the central portion sinus tarsi◆ Non Arthroereisis—non-joint blocking/limiting devices◆ Anchored by medial soft tissues◆ Established scientific evidence◆ Removal rate less than 7%

AdultPediatric Adolescent

35

36

38

41



Type II EOTTS-HyProCure® Patient Selection Process

Patient Criteria

1. Arch supports have not provided enough relief or correction, or are simply not a viable option.

2. The patient is three years or older*.

3. There are clinical signs, verified radiographically via dynamic weightbearing comparison radiographs of a partial, reducible/flexible TTJD deformity.

Considerations

Potential coexisting deformities have been ruled out or treatment planned such as:

◆ Weak or non-functioning spring ligament

◆ Weak or non-functioning medial band of the plantar fascia

◆ Weak or non-functioning posterior tibial tendon

◆ Equinus—functional/structural

◆ Non-reducible navicular drop

◆ 1st ray instability (excessively dorsiflexed 1st metatarsal flexible/rigid)

◆ 1st MPJ (hallux limitus/ridigus/valgus)

Deformities that must be taken into consideration:

◆ Functional/Structural equinus—tight gastrosoleus tendon complex

◆ Significant metatarsus primus varus/metatarsus adductus

◆ Grade IIB and greater posterior tibial tendon dysfunction

◆ Tarsal coalition (talocalcaneal)

◆ Cavo-varus calcaneus

Radiographic measurements**/EOTTS limitations:

◆ DP View: Talar 2nd metatarsal angle < 53° (average transverse plane correction 19°/maximum 37°)

◆ Lateral View: Talar declination angle < 42° (average sagittal plane correction 7°/maximum 19°)

◆ Calcaneal Inclination Angle: EOTTS will have a minimal effect to correct this angle

Contra-indications:

◆ Pediatric patient less than three years of age.

◆ Rigid, non-reducible deformity

Notes*This is not advocating/recommending that every patient with a TTJD at three years of age should undergo an EOTTS procedure. Rather, by three years of age, the chamber forming the sinus tarsi has ossified and is therefore capable of supporting this procedure.

**Radiographic Paper—J Foot Ankle Surg. 2011:50 (5);551–557.



EOTTS Patient Selection Based on Radiographic Review

Mild TTJDStand Alone Procedure

◆ T2MA: 16°–28°

◆ TDA: 21°–27°

◆ Normal CIA

◆ No Equinus

◆ Intact PF/PTT

◆ Stable 1st Ray

◆ Good 1st MPJ ROM

Severe TTJDRequires Additional Procedures

◆ T2MA: > 40°

◆ TDA: > 33°

◆ Lower to Negative CIA

◆ Severe Equinus < 15° PF

◆ PF Loss/Stage 2B PTTD

◆ Rigid 1st Ray Deformity

◆ Hallux Ridigus

Moderate TTJDMay Require Additional Procedures

◆ T2MA: 29°–40°

◆ TDA: 28°–33°

◆ Lower CIA

◆ Slight/Moderate Equinus

◆ Questionable PF/PTT

◆ Moderate 1st Ray Instability

◆ Good 1st MPJ ROM



Pre-EOTTS-HyProCure® Patient Considerations

Unilateral vs Bilateral ProceduresThere are advantages and disadvantages to performing bilateral EOTTS-HyProCure® in one surgical setting. Disadvantages include an increased risk that one of the stents will displace due to compensatory gait pattern, lack of “one-good-foot” to walk on, as well as potential for longer recovery. However, many surgeons successfully perform procedures on both feet at the same time; just ensure the patient understands the potential higher risks for bilateral procedures.

It’s recommended that patients have EOTTS on both feet, but at separate times so that the first corrected foot won’t cause pain and soreness due to the instability of the contra-lateral limb. The optimum time to perform the second EOTTS procedure is 3 to 4 weeks after the first.

Pediatric—What Happens Upon Osseous Maturity?Frequent questions arise about whether subtalar stents used in children will need to be replaced as the child grows.The answer takes into consideration that average size HyProCure® stents used in adults are 6 & 7. If you have placed a size 6 or 7 stent into a child’s foot, they already have the most common adult size, therefore it is possible, but unlikely, that the stent will need to be replaced once they reach osseous maturity.

Body-Mass Index—Weight Limitations/Implications

Weight of the patient does not play a factor in the decision making process. The weight of the body travels through the tibia onto the talus which is then displaced via the articular facets on the calcaneus and navicular. There is minimal force acting on the stent itself.

Activity Level Post-EOTTSThere are no limitations to activity level once the soft tissues have healed after the placement of HyProCure®.

Use of Short/Intermediate Acting SteroidIt’s extremely important to add 3/4 cc of a short/intermediate acting steroid to the pre-EOTTS local anesthesia block administered prior to making the incision. The leading cause for post-op pain is due to the inflammatory reaction caused by the surgical procedure. The introduction of the short/intermediate acting steroid reduces this reaction, significantly reducing post-op pain and speeding recovery. The use of a short/intermediate steroid is well established in foot/ankle surgery.

EOTTS Success Rates—Setting Patient ExpectationsThere are no implantable devices that have a 100% guarantee. While the removal rate for HyProCure® is significantly lower than any other sinus tarsi stent, there is still a chance that it simply may not work. This is usually due to anatomic variance within the sinus tarsi. A higher likelihood of failure is possible when the TTJD deformity is more severe, or combined with other secondary structural deformities. The EOTTS procedure is not a panacea and patient expectations must be kept realistic.

Patient Pre-Surgical Check List:Reviewed the Benefits & Risks Document

Signed the EOTTS No Guarantees Form

Signed the EOTTS Informed Consent Form

Received & Reviewed Post-op Hints/Follow-up Sheet



EOTTS-HyProCure® Surgical Procedure—Part I

12. Final TTJ ROM Testing11. Check Stent Placement

Incorrect Correct

13. Close Skin and Bandage

1. Landmarks 2. Local Anesthesia & Steroid 3. Incision 4. Superficial Dissection

5. Sinus Tarsi Decompression & Realignment of TTJD 6. Insert Wire Guide

10. Stent Placement9. Perform TTJ ROM Testing

Incorrect Correct

7. Insert Trial Sizer 8. Check Trial Sizer Placement



EOTTS-HyProCure® Surgical Procedure—Part II

Placement GuideThe surgeon must take into consideration that the sinus tarsi stent is held in situ via the soft tissue adherence and osseous canal. A slight shift from the intra-op non-weightbearing x-ray, when compared to the initial post-op weightbearing image, may occur. Intra-op to post-op stent shifting is the final seating of the stent. It will “seek-it’s-own level” upon weightbearing. The goal is that the lateral end of HyProCure® is medial to the lateral neck of the talus.

Showing Incorrect Placement

EOTTS-HyProCure® Before/After Radiographs

◆ The tip/threaded portion of HyProCure® is typically dorsoposterior.

◆ HyProCure® is angled anterior-distal-lateral to posterior-proximal-medial.

◆ Lateral portion of HyProCure® is medial to the lateral neck of the talus.

BeforeBefore AfterAfter

The stent is angled dorsoplantarly rather plantar dorsally.

Stent is angled posterior anteriorly rather than anterior posteriorly.

Stent is angled distally rather than proximally.

The tip is not inserted in the canalis tarsi.

While it’s important to understand that there will always be variable positions, a surgeon can follow these tips to achieve the best results for their patient:



Post-EOTTS-HyProCure®—Steps to Success

1. Make sure the patient is a good candidate for the EOTTS-HyProCure® procedure (has a flexible/reducible TTJD deformity verified radiographically with relaxed stance and neutral TTJ stance position).

2. Identify any secondary deformities and address them conservatively/surgically.

3. Make sure the patient will have both talotarsal joints stabilized and warn them their first HyProCured®

foot will continue to have soreness until the contra-lateral limb is stabilized.

4. Perform a pre-incision sinus tarsi injection of a mixture of 8cc of long-lasting anesthesia with epinephrine mixed with 3/4 cc of short/intermediate acting steroid. This significantly reduces post-op pain and speeds recovery. Failure to do so could lead to increased post-op pain and a chronic inflammatory reaction.

5. Sinus tarsi decompression—imperative to release the soft tissues within both the canalis and sinus portions of the sinus tarsi to allow talotarsal realignment and proper placement of the stent. Also, these cut ends will heal around the threads of the stent anchoring it within the sinus tarsi.

6. Verify placement of the trial sizers during the surgical procedure. Make sure that the lateral end of the stent is deeper/medial to the lateral neck of the talus.

7. Perform TTJ ROM testing by maximally pronating the lateral column of the foot by pressing on the necks of 4th & 5th metatarsals with the mid-foot locked.

8. The most common sizes, in both pediatric and adult patients, are 6 and 7, followed by 5 and 8. Sizes 9 and 10 are rarely used.

9. Verify HyProCure® placement via intra-op radiograph (DP image) to make sure the lateral end of HyProCure® is medial to the lateral neck of the talus. It is better to have a deeper placed stent and lose some correction, than to have an “over-stuffed” stent as it may contribute to post-op pain and stent displacement.

10. You may see a slight shift in the stent position post-operatively from the intra-op x-ray due to final seating once the patient becomes weightbearing.

11. Understand that every sinus tarsi has unique characteristics and every stent will have a different placement/alignment within the sinus tarsi.

12. Stents are not drilled or anchored into bone and are therefore prone to slight shifting during the soft tissue anchoring process. These stents often seek their own final placement where they will function the best. Even if the placement is less than ideal, it’s possible for the stent to still stabilize the talotarsal joint.

13. If the patient develops post-op soreness run through a check-list of possible solutions prior to simply removing the device. The most common cause of continued post-op soreness is worn-out or unsupportive shoes.



EOTTS-HyProCure® Troubleshooting Guide

Device DisplacementPossible Causes

◆ Failure to properly decompress the sinus tarsi/canalis tarsi

◆ Atrophy of the interosseous talocalcaneal ligament due to prolonged TTJD deformity

◆ Improper stent selection (too large, unable to place deep into the sinus tarsi)

◆ Improper stent placement (tip not inserted into canalis tarsi)

◆ Poor patient compliance—too active, too soon; inappropriate shoe gear; trauma

◆ Anatomic variance—defect in osseous chamber of the sinus tarsi

Solution

If there is loss of correction or pain directly related to the displaced device (rather than expected post-op soreness pain), revision is required.

1. Remove the stent.

2. Re-insert the curved Stevens tenotomy scissors and decompress sinus tarsi structures.

3. Retrial size. You may want to use a smaller size in order to place the stent deeper into the sinus tarsi.

4. The patient should be immobilized and instructed on the importance of proper shoe wear.

Note: It is preferred to have better stent position over optimal stabilization of TTJ ROM. Some correction is better than no correction.

Acute Post-EOTTS Pain 3-Month Post-op Period

Possible Causes

◆ Failure to use pre-incision combination of short-/intermediate-acting steroid with local anesthesia sinus tarsi block

◆ Ineffective post-op oral anti-inflammatory medication

◆ Single vs. bilateral limb EOTTS correction (uni-EOTTS limb will be subject to excessive forces until the contra-lateral limb is HyProCured®. Patient should be warned about this pre-op)

◆ Shoe gear related issues—compensatory over-supination of the TTJ

Solution

X-ray to make sure stent is in good position and there isn’t loss of correction. Injection series (up to 3) of short/intermediate steroid with local anesthesia. Check shoes to make sure they aren’t worn out or contributing to the source of pain.

Post-EOTTS Pain > 6 Months Post-op Period

Possible Causes

◆ Unilateral correction

◆ Patient has become more active than previous period

◆ Faulty shoe gear—wearing worn-out shoes/over-supinating

◆ Stent displacement—must x-ray to rule out displacement

Solution

If there is loss of correction, recommend surgical repositioning/removal. The stent size may need to be downsized if the patient is not able to tolerate the new alignment.



HyProCure® Facts

Scientifically Proven to: ◆ Stabilize and realign the TTJ (J Am Podiart Med Assoc. 2011:101(5);390–399.)

◆ Decrease anterior forces acting on the medial column of the foot (J Am Podiart Med Assoc. 2011:101(5);390–399.)

◆ Decrease strain on the medial band of the plantar fascia by 33% (J Foot Ankle Surg. 2011:50(6) 682–686.)

◆ Decrease strain on the posterior tibial tendon by 51% (J Foot Ankle Surg. 2011:50(6);676–681.)

◆ Decrease pressures within the porta pedis and tarsal tunnel (J Foot Ankle Surg. 2011:50(1); 44–49.)

◆ Decrease strain/elongation of the posterior tibial nerve (J Foot Ankle Surg. 2011:5(6); 672–675.)

◆ Normalize sagittal plane TTJ dislocation deformity (J Foot Ankle Surg. 2011:50 (5);551–557.)

◆ Normalize transverse plane TTJ dislocation deformity (J Foot Ankle Surg. 2011:50 (5);551–557.)

◆ Normalize plantar foot forces (J Foot Ankle Surg.2013: 52(4); 432–443.)

◆ Removal rate < 7% after five years (J Foot Ankle Surg. 2012:51(1);23–29.)

◆ Shown to increase quality of life (J Foot Ankle Surg. 2013:52(2);195–202. J Foot Ankle Surg. 2012:51(1);23–29.)

◆ Positive functional out-come scores (J Foot Ankle Surg. 2013:52(2);195–202. J Foot Ankle Surg. 2012:51(1);23–29.)

Quick Facts◆ 10 years of clinical use

◆ FDA cleared since 2004

◆ CE mark in 2006

◆ Commonly used in both pediatric & adult patients

◆ Global acceptance by foot surgeons in more than 44 countries

◆ Has the lowest published removal rate of any subtalar implant

◆ Has the greatest evidence base of any subtalar implant

Benefits◆ Instant correction

◆ Immediate weightbearing (guarded, dependent upon other ancillary surgical procedures)

◆ Internal solution to an internal deformity

◆ Permanent, yet reversible solution

◆ Option for pediatric & adult patients

◆ Eliminates/reduces the underlying etiology/force to the most common foot/ankle/musculoskeletal pathologies

Risks/Complications◆ No associated fractures or disease

◆ No non- or delayed unions

◆ Short-lived and self-resolving (post-device removal)

◆ Benefits far outweigh potential risks or complications

HyProCure® is the proven solution you and your patients have been waiting for.


www.HyProCureDoctors.com16HYPPG2014

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Recurrent TaloTarsal Joint Displacement...

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