Technique of subtalar arthroeresis in the treatment of advanced stages of flatfoot

Flat feet are one of the most common complaints in the office of a pediatric orthopedist. The term “flatfoot” combines various diseases and anatomical features manifested by smoothing of the longitudinal and transverse arches of the foot.

There are several main classification systems for flat feet based on various characteristics.

Based on severity, there are 3 main degrees. The degree of flatfoot is assessed radiographically. Photographs in the direct and lateral planes are taken with a load.

The degree of transverse flatfoot is assessed by the first intermetatarsal angle and the angle of deviation of the big toe.

In this image, yellow lines form 1 intermetatarsal angle and orange lines form the angle of deviation of the thumb.

Why is flat feet dangerous?

Flat feet is a rather complex disease that poses a health hazard.
With this disorder, the arch of the sole decreases and the heel bones deviate outward. As a result, the arch becomes flat and the foot becomes wide. The limb becomes completely on the floor.

This disease causes chronic pain in the arch of the foot.

People with this diagnosis experience tiredness in their legs. This symptom occurs even with light loads.

Modern surgical interventions help to cope with flat feet or reduce its symptoms. To obtain the desired results, subtalar arthroeresis surgery can be performed.

Transverse flatfoot by degrees.

The degree of longitudinal flatfoot is assessed by the angle of the longitudinal arch of the foot and the height of the arch.

Indications

Flat feet in themselves are an indication for surgery. If there is slight pronation of the foot and there is no discomfort, conservative methods of therapy are used.

These include special gymnastics, the use of orthopedic shoes and special insoles.

Indications for performing subtalar arthroeresis are the following symptoms:

• pain and swelling of the foot;
• gait disturbance, severe clubfoot, feeling of weakness in the legs;
• difficulties with choosing shoes, rapid wear;
• severe decrease in quality of life;
• problems in the professional sphere;
• lack of effect from conservative therapy.

If you do not consult a doctor in time or refuse to undergo surgery, there is a risk of serious damage to the musculoskeletal system.
Some people lose the ability to move completely. In this case, the load moves from the legs to the spine. In such a situation, neurological complications often occur. Indications for surgery

Types of arthrodesis

• Intra-articular. During the operation, the joint capsule is opened and the damaged cartilage is removed. The bones are held in the correct position using metal fixtures.
• Extra-articular. The joint is fixed using a bone graft; resection of the cartilage is not required.
• Combined. Combines the action of intra-articular and extra-articular methods. The cartilage structures are completely cleared from the surface of the joint, an autograft is installed, which is secured with metal plates.
• Compression. The articulating surfaces are compressed by a special apparatus - conditions for fusion are created. Ilizarov and Grishin apparatuses are used. No graft is required.

Benefits of subtalar arthroeresis

Subtalar arthroeresis has certain advantages compared to other methods of treating flat feet:

• has high efficiency;
• practically does not cause infectious complications;
• allows you to get stable results;
• completely safe;
• does not require limb immobilization, so the patient can move independently;
• completely eliminates clubfoot;
• does not require the use of bone cement to fix the implant;
• has good patient reviews.

DMU: professional support in the treatment of flat feet in Germany

Flat feet is a disease that you can put up with for a long time. Curved fingers, sore feet and back seem like minor troubles compared to finding good specialists. DMU is a team of professionals in the field of medical tourism, ready not only to select the best foreign doctors for you, but also to accompany you from preparation to returning home.

• Our coordinator will select a clinic for you and set a date for your visit.
• Managers will help with visa processing and flight arrangements.
• An interpreter will accompany you throughout your stay in Germany.
• We will check the invoices issued by the clinic for compliance with the prices for treatment of flat feet in Germany, regulated at the legislative level. We guarantee you the firmness and acceptability of the price list of any German clinic.

DMU is a team that creates comfortable conditions for treatment abroad. Understanding the importance of patient peace of mind, we make every effort to ensure that organizational issues do not cause the slightest discomfort.

Operation

For surgery to be successful, you need to see a qualified doctor. The specialist will conduct a detailed diagnosis and, based on its results, prescribe surgery.

Preparation and necessary research

Before undergoing subtalar arthroeresis, it is necessary to undergo a detailed examination. It includes the following procedures:

1. Examination by an orthopedist. The doctor must study the patient’s complaints and medical history.
2. Radiography. It is carried out in several projections.
3. Plantography. During the procedure, it is possible to obtain a foot print, which helps to identify areas of maximum stress.
4. Computed and magnetic resonance imaging.

Technique

To perform the operation, the patient is placed on his back and the lower third of the thigh is compressed using a tourniquet. Then a longitudinal incision of approximately 2 cm is made. After which an endorthosis is placed between the talus and calcaneus.

Before this, the back of the foot is supinated using a special lever. This allows you to free up space in the area of ​​the subtalar sinus.

During the operation, a cylindrical implant is used. Its size is selected individually. The device can be made of titanium, a substance that dissolves under the influence of hydrolysis, or a metal containing high molecular weight polyethylene.

Before surgery, the tibialis tendon may be shortened and part of the Achilles tendon may be lengthened.

The manipulation takes approximately 40 minutes. Surgery is performed under general anesthesia. In this case, both feet can be operated on at the same time. The patient is discharged the next day. When performing subtalar arthroeresis, there is no need to apply a plaster cast.

In addition to the use of an implant, tendon plastic surgery can be performed. In such a situation, the operation is performed on only one leg. After completion of the procedure, a plaster splint is applied to the limb. The second leg can be operated on after a year.

Photos before and after surgery

Longitudinal flatfoot by degrees.

To be fair, it should be noted that this radiological classification is used only in Russia, which is mainly caused by the excitement around issues related to the military registration and enlistment office. In the rest of the world, these angles are taken into account, especially when planning surgical treatment, but do not form a separate classification, since the angles on radiographs and the severity of the clinical picture have little correlation.

Based on the time of occurrence, congenital (associated with developmental anomalies) and acquired forms of flatfoot are distinguished. Congenital causes include such rare and severe forms as congenital vertical talus and calcaneal valgus foot. More common (from 1 to 6% of the population) and less severe causes of congenital flatfoot include calcaneonavicular, calcaneal-talus and some other synostoses, accessory navicular bone. Abnormalities of these bones lead to improper load distribution in the gait cycle and overload of the remaining stabilizers of the foot. The picture of flat feet in this case appears by the age of 8-15, which is associated with ossification and the transition of relatively elastic synchondroses into synostoses.

Depending on which of the arches of the foot is more involved in the pathological process, longitudinal and transverse flat feet are distinguished. Longitudinal flatfoot is more associated with dysfunction of the calcaneonavicular, navicular-cuneiform ligaments, plantar ligaments and plantar fascia. Transverse flatfoot is associated with dysfunction of the adductor pollicis muscle and intermetatarsal ligaments. In most cases, longitudinal and transverse flatfoot are observed simultaneously.

According to the clinical picture, there are 2 main forms of flat feet - rigid and elastic. The elastic form appears only in a standing position, and disappears when rising on the toes or in a resting position. The rigid form remains at rest.

Currently considered a variant of the norm. It is characterized by a decrease in the height of the median longitudinal arch at rest; during loading, a valgus position of the heel bone and abduction in the midfoot are noted.

Extremely widespread (occurs in 20-25% of the population). It has a genetic nature and is observed in families. Often accompanied by hypermobility syndrome in other joints. In most cases, the severity of the deformity decreases with age.

Rehabilitation process

After arthroeresis, special insoles should be worn for the first three months. They are made according to individual parameters. For the first time after surgery, it is recommended to avoid active stress on the legs. The installed implant is temporary. After fixing the problem, it is removed. This is usually done after 1-1.5 years.

However, for children the period is often extended to 18 years - it is with the onset of adulthood that the formation of the musculoskeletal system is completed. If the device does not cause discomfort, it is left in the leg.

Arthrodesis of the ankle joint

Arthrodesis of the ankle joint in the vast majority of cases is carried out during the treatment of purulent osteoarthritis. Surgical intervention in this case involves the following:

• removal of the affected part;
• fixation of the talus and tibia together.

The advantage of this method is the elimination of pain, which gradually disappears after surgery. There is, however, a big disadvantage, which is that the area where the operation was performed will remain motionless due to the fixation of the bones. Another disadvantage is the possibility of a purulent process occurring again, this time only without involving the joint. You can exclude the possibility of its occurrence by carefully observing all the rules of asepsis during and after the operation.

Recommendations

The cost of the operation depends on the clinic and the qualifications of the doctor. Today the price of surgical intervention is 20-30 thousand rubles per limb. This amount does not include the cost of the implant.

If the operation is supplemented with tendon plastic surgery, you will have to pay an additional 11-58 thousand rubles. The specific amount depends on the complexity of the violation. The operation can be performed at 9-10 years of age. If necessary, it can be done at other ages.

Since subtalar arthroeresis is a minimally invasive surgical procedure, it has virtually no restrictions on its implementation. If you have severe somatic pathologies, you should consult a doctor. If acute viral infections develop, surgery should be postponed until recovery.

Subtalar arthroeresis is a minimally invasive technique that is highly effective and does not require complex and lengthy rehabilitation. Thanks to such an operation, it will be possible to cope with flat feet and avoid dangerous complications.

How to perform subtalar arthroeresis, see our video:

Arthrodesis

Arthrodesis is a surgical operation aimed at restoring the supporting ability of a limb affected by a particular disease or susceptible to injury. Among them it is customary to highlight the following:

• pathological dislocations;
• improperly healed fractures;
• complications of pathologies that lead to dysfunction of the limbs and pronounced pain (arthrosis, arthritis, etc.).

The arthrodesis operation involves complete immobilization of the joint by fusing adjacent bones. In this way, artificial bone ankylosis is created, in which the joint is fixed in the most favorable position.

• Initial consultation – 2,700
• Repeated consultation – 1,800

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Arthrodesis is performed if the following indications exist:

• Dislocations with displacement.
• Severe stage of arthrosis with decreased joint mobility.
• Incorrect healing of bones after a fracture.
• Deforming arthritis.
• Floppy joint syndrome.
• Inflammatory processes in the joint capsule.
• Clubfoot.

• Chronic diseases of the cardiovascular system.
• Age up to 12 years or over 60 years.
• Allergic reaction to local anesthesia and general anesthesia.
• Phlebeurysm.
• Joint diseases in the acute stage.
• Lesions of the joint capsule with a large accumulation of pus.
• Increased thrombus formation.

Arthrosis of the subtalar joint

Please see the relevant section of our website for information regarding what you may encounter after surgery.

You must understand that the following is only an approximate rehabilitation plan, while each patient’s recovery process is different. This information is intended to help you understand the essence of your condition, treatment and rehabilitation options. The time frames we have given are only a minimum, and when deciding in favor of surgical treatment, you should keep in mind that in your case the healing and rehabilitation process may take longer.

Early postoperative period

All operations for osteoarthritis of the subtalar joint are performed under general anesthesia.

Arthroscopic debridement of the subtalar joint - open debridement

After a subtalar joint arthroscopy, you will have a small waterproof tape on your foot covering the arthroscopic ports, over which a bandage will be placed. We recommend not removing this bandage until the next dressing change, which is performed 2 weeks after surgery. During the first 2 weeks, we do not recommend exposing the dressing to moisture. When taking a shower, it is recommended to use a special sealed bag.

The load on the foot depends on what interventions were performed during arthroscopy. Most patients are allowed to walk using crutches with their feet lightly touching the floor for the first 48 hours, and then use the foot as tolerated, with or without crutches. You will receive detailed instructions in this regard upon discharge from the clinic. Make sure someone can take you home. Movement in the ankle joint must begin as early as possible. The load on the foot can be increased as pain is relieved.

Subtalar Joint Arthrodesis Addendum

For the first two weeks after surgery, the foot and ankle will be immobilized in a posterior plaster cast. You will spend the first night after surgery in the clinic, and the next day we will repeat antibiotic prophylaxis.

Postoperative immobilization

Do not remove the splint until the next dressing change, which will take place 2 weeks after surgery.

You should not put any weight on your limb for approximately 6-8 weeks after surgery. Before you are discharged home, you will be advised by a physiotherapist, who will include: will tell you how to use crutches correctly.

In the first 2 weeks after surgery, try to elevate your foot and keep it in that position 95% of the time.

Elevated foot position

Most people certainly don't have a functional bed at home like the one in this photo. However, the same effect can be achieved on a regular bed or sofa by placing a pillow under your foot. You should not put your feet in an elevated position when you are sitting on a chair. And once again we advise you to stay at home for the first two weeks.

To minimize the risk of infection, keep your feet dry and cool. Avoid excess humidity and heat. When showering, wear a sealed bag over your foot.

In order to prevent venous thrombosis, regularly perform movements in the foot and ankle joint. Drink enough fluids. If you have risk factors for thrombosis, be sure to tell your doctor about this; if necessary, he can prescribe you anticoagulants.

Two weeks after surgery

You will be examined by your doctor and your dressing will be changed. You will be allowed to drive for a short time, but only if your left leg has been operated on and your car has an automatic transmission. If the right leg has been operated on, we recommend driving no earlier than 6-8 weeks after the operation.

After arthroscopy of the subtalar joint - open debridement

If the healing process is going well, by this time your swelling and bleeding will have largely disappeared, but some swelling may persist for up to 3-4 months after surgery. If the wounds have completely healed, then we will tell you how to properly massage the tissues in the intervention area. Measures aimed at reducing the sensitivity of the scar begin only after the wound has completely healed. For this purpose, you can use a massage cream (for example, E45), which should be rubbed into the scar area and around it. You can expose the surgical area to moisture and take a shower only after the wounds have completely healed.

At this stage we may refer you to the rehabilitation department. And this is the earliest time you can return to your job.

Subtalar Joint Arthrodesis Addendum

At this stage, if post-operative swelling has largely subsided, we will allow you to lower your foot down more often, but we recommend that you still keep it flat most of the time if possible. The ankle joint will be immobilized with a rigid bandage for another 4-6 weeks. Loading during this period is still prohibited. You can take short walks outside as long as your pain and swelling allow.

Six weeks after surgery

Sanitation arthroscopy of the subtalar joint - open debridement

Significant reduction in the severity of swelling and pain. You will be able to start wearing normal shoes (as swelling will allow), but we recommend wearing hard-soled shoes during this time. Over the next 3-6 months, you will undergo physical therapy classes, which will allow you to achieve the most optimal result of the surgical intervention.

Subtalar Joint Arthrodesis Addendum

If the healing process is going well, by this time your swelling and bleeding will have largely disappeared, but some swelling may persist for up to 4-6 months after surgery.

Depending on the results of the x-ray control, you will be advised to use an orthopedic boot that allows the possibility of weight bearing on the operated foot, or immobilization will continue and weight bearing will continue to be excluded.

If the results of X-ray control are satisfactory and postoperative wounds have completely healed, massage of the soft tissues in the surgical area and desensitization of the scar will be recommended. Measures aimed at reducing the sensitivity of the scar begin only after the wound has completely healed. For this purpose, you can use a massage cream (for example, E45), which should be rubbed into the scar area and around it. You can expose the surgical area to moisture and take a shower only after the wounds have completely healed.

Three months after surgery

Sanitation arthroscopy of the subtalar joint - open debridement

If you are satisfied with the result, then this is your last visit to the doctor.

Arthrodesis of the subtalar joint

Control radiography, which should show signs of consolidation. You will be able to start wearing normal shoes (as swelling will allow), but we recommend wearing hard-soled shoes during this time. Over the next 3-6 months, you will undergo physical therapy classes, which will allow you to achieve the most optimal result of the surgical intervention.

Arthrodesis of the knee joint

An operation such as arthrodesis of the knee joint is practiced only in extreme situations. Indications:

• severe deforming arthrosis, accompanied by severe pain;
• instability of the knee due to paralysis of the femoral muscles.

The rehabilitation period in this case depends on the individual characteristics of the body and is carried out in a hospital. Contraindications to the procedure include:

• age under 12 and over 60 years;
• the danger of the appearance and development of inflammatory processes in the area of ​​surgical intervention;
• the presence of fistulas of non-tuberculosis nature.

Possible consequences and complications

Serious complications can only be avoided by choosing an experienced specialist and by 100% following all the doctor’s recommendations after surgery. In rare cases, the following complications are observed:

• Bone graft rejection.
• Anemia due to large blood losses.
• Uneven fusion of joints.
• Injuries to nerve endings during surgery.
• Infection, accumulation of pus and intoxication.
• Thrombosis.

If you experience pain, bleeding, cramps, fever or numbness, immediately contact your doctor for diagnosis and elimination of complications.