Analysis of Radiographic Outcomes Comparing Foot Orthosis to Extra-osseous Talotarsal Stabilization in the Treatment of Recurrent Talotarsal Joint Dislocation

Seth J. Steber, Łukasz Kołodziej


The partial dislocation of the talus on the tarsal mechanism has been recognized as the root cause of multiple foot and lower extremity pathologies. Many conservative and surgical treatments have been utilized to treat this pathologic condition. The purpose of this multi-centered prospective study was to compare weight-bearing radiographic correction achieved in patients with recurrent talotarsal joint dislocation (RTTJD) treated with foot orthoses to that achieved in the same patients through an extra-osseous talotarsal stabilization (EOTTS) procedure. Radiographic data was obtained with no intervention (barefoot), on the orthosis and post-EOTTS from 19 patients (30 feet). Change to the pathologic angles measured for the talar 2nd metatarsal (T2M) on the anteroposterior (AP) view and talar declination (TD) angle on the lateral view were analyzed. The reduction in the angles following the use of orthoses was insignificant in both the transverse and sagittal planes. Following the EOTTS procedure, there was a significant change towards accepted normal weight-bearing radiographic angles in the transverse and sagittal planes. In the transverse plane, the EOTTS procedure resulted in an average 58.92% reduction and in the sagittal plane, a 28.32% reduction compared to pre-operative barefoot measurements. By comparison, the change from barefoot measurements to orthosis was 3.20% and 2.20% respectively. The EOTTS procedure did not result in an increase in pathologic angles or cause any angles that were within the normal range pre-operatively to become pathologic. These results support the hypothesis that the EOTTS procedure is more effective in stabilizing RTTJD as compared to orthoses.


Ankle joint; Dislocation; Extra-osseous talotarsal stabilization; Hyperpronation; Tarsal bones

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Wolf P, Stacoff A, Luechinger R, Boesiger P, Stuessi E. Transmissions within the tarsal gearbox. J Am Podiatr Med Assoc. 2008; 98(1):45-50.

Donatelli RA. Normal biomechanics of the foot and ankle. J Orthop Sports PhysTher. 1985; 7(3):91-5.

Root M, Weed J, Orien W. Normal and Abnormal Function of the Foot. Los Angeles, CA: Clinical Biomechanics Corporation; 1977.

Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports PhysTher. 1987; 9(4):160-5.

Graham ME, Parikh R, Goel V, Mhatre D, Matyas A. Stabilization of joint forces of the subtalar complex via HyProCure sinus tarsi stent. J Am Podiatr Med Assoc. 2011; 101(5):390-9.

Lanham RH Jr. Indications and complications of arthroereisis in hypermobile flatfoot. J Am Podiatry Assoc. 1979; 69(3):178-85.

Brody DM. Techniques in the evaluation and treatment of the injured runner. OrthopClin North Am. 1982; 13(3):541-58.

Nguyen AD, Schultz S. Identifying relationships among lower extremity alignment characteristics. J Athl Train. 2009; 44(5):511-18.

Addante JB, Chin MW, Loomis JC, Burleigh W, Lucarelli JE. Subtalar joint arthroereisis with SILASTIC silicone sphere: a retrospective study. J Foot Surg. 1992; 31(1):47-51.

Lepow GM, Smith SD. A modified subtalararthroereisis implant for the correction of flexible flatfoot in children. The STA Peg procedure. ClinPodiatr Med Surg. 1989; 6(3):585-90.

Kirby KA. Subtalar joint axis location and rotational equilibrium theory of foot function. J Am Podiatr Med Assoc. 2001; 91(9):465-87.

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. ClinOrthopRelat Res. 1989(239):196-206.

DiGiovanni JE, Smith SD. Normal biomechanics of the adult rearfoot: a radiographic analysis. J Am Podiatry Assoc. 1976; 66(11):812-24.

Forg P, Feldman K, Flake E, Green DR. Flake-Austin modification of the STA-Peg arthroereisis: a retrospective study. J Am Podiatr Med Assoc. 2001; 91(8):394-405.

Graham ME, Chikka A. Validation of the talar–second metatarsal angle as a standard measurement for radiographic evaluation. J Am Podiatr Med Assoc. 2011; 101(6):475-83.

Thomas JL, Kunkel MW, Lopez R, Sparks D. Radiographic values of the adult foot in a standardized population. J Foot Ankle Surg. 2006; 45(1):3-12.

Gentili A, Masih S, Yao L, Seeger, LL. Pictorial review: foot axes and angles. Br J Radiol. 1996; 69(826):968-74.

Steel MJ, Johnson KA, DeWitz MA, Ilstrup DM. Radiographic measurements of the 526 normal adult foot. Foot Ankle. 1980; 1:151-5.

Stovitz SD, Coetzee JC. Hyperpronation and foot pain: steps towards pain-free feet. PhysSportsmed. 2004; 32(8):19-26.

Brancheau S, Maxwell J, Ritchey KL, Knudson W. The Valenti STJ Arthroereisis Implant: a ten-year retrospective study. In: Vickers NS, Ruch, JA, eds. Reconstructive Surgery of the Foot and Leg. Update 96. Tucker, GA: the Podiatry Institute: 1996:44-53.

Vogler HW. Arthroereisis Principles and Concepts. In: Clark T, ed. Yearbook of Podiatric Medicine and Surgery. Mount Kisco, NY: Future Press; 1981.

Gould N. Evaluation of hyperpronation and pes planus in adults. ClinOrthopRelat Res. 1983; (181):37-45.

Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation. Foot Ankle Int. 1995; 16(11):712-8.

Sangeorzan BJ, Mosca V, Hansen ST Jr. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot Ankle.1993; 14(3):136-41.

Mosca VS. Calcaneal lengthening for valgus deformity of the hind foot. J Bone Joint Surg Am. 1995; 77(4): 500-12

Sobel E, Levitz SJ, Caselli MA. Orthoses in the treatment of rearfoot problems. J Am Podiatr Med Assoc. 1999; 89(5):220-33.

Helfet AJ, Gruebel Lee D.M. Disorders of the foot. Philadelphia, PA: Lippincott; 1980.

Landorf, K. Tibialis posterior dysfunction. Early identification is the key to success. AustPodiatr. 1995; 29:9-14.

Eslami M, begon M, Hinse S, Popov P, Allard P. Effect of foot orthoses on magnitude and timing of rearfoot and tibial motions, ground reaction force and knee moment during running. J Sci Med Sport. 2009; 12(6):679-84.

Mueller M, Strube MJ, Allen B. Therapeutic footwear can reduce plantar pressures in patients with diabetes and iransmetatarsal amputation. Diabetes Care. 1997; 20(4):637-41.

Kitaoka HB, Crevoisier XM, Harbst K, Hansen D, Kotajarvi B, Kaufman K. The effect of custom-made braces for the ankle and hindfoot on ankle and foot kinematics and ground reaction forces. Arch Phys Med Rehabil. 2006; 87(1):130-5.

Janisse D, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am AcadOrthop Surg. 2008; 16(3):152-8.

Zammit GV, Payne CB. Relationship between positive clinical outcomes of foot orthotic treatment and changes in rearfoot kinematics. J Am Podiatr Med Assoc. 2007; 97(3):207-12.

Landorf K, Keenam AM. Efficacy of foot orthoses. What does the literature tell us? J Am Podiatr Med Assoc. 2000; 90(3):149-58.

Catanzariti AR, Mendicino RW, Saltrick KR, Orsini RC, Dombek MF, Lamm BM. Subtalar joint arthrodesis. J Am Podiatr Med Assoc. 2005; 95(1):34-41.

Zaw H, Calder JD. Operative management options for symptomatic flexible adult acquired flatfoot deformity: a review. Knee Surg Sports TraumatolArthrosc. 2010; 18(2):135-42.

Easley ME, A. Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000; 82(5):613-24.

Kitaoka HB, Patzer GL. Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus. ClinOrthopRelat Res. 1997; (345):187-94.

Vora AM, Tien TR, Parks BG, Schon LC. Correction of moderate and severe acquired flexible flatfoot with medializing calcaneal osteotomy and flexor digitorumlongus transfer. J Bone Joint Surg Am. 2006; 88(8):1726-34.

Maxwell JR, Carro A, Sun C. Use of the Maxwell-Brancheauarthroereisis implant for the correction of posterior tibial tendon dysfunction. ClinPodiatr Med Surg. 1999; 16(3):479-89.

Needleman RL. Current topic review: subtalararthroereisis for the correction of flexible flatfoot. Foot Ankle Int. 2005; 26(4):336-46.

Schon LC. Subtalararthroereisis: a new exploration of an old concept. Foot Ankle Clin. 2007; 12(2):329-39, vii.

Graham ME, Jawrani NT. Extraosseoustalotarsal stabilization devices: a new classification system. J Foot Ankle Surg. 2012; 51(5):613-9.

Needleman RL. A surgical approach for flexible flatfeet in adults including a subtalararthroereisis with the MBA sinus tarsi implant. Foot Ankle Int. 2006; 27(1):9-18.

Viladot R, Pons M, Alvarez F, Omaña J. Subtalararthroereisis for posterior tibial tendon dysfunction: a preliminary report. Foot Ankle Int. 2003; 24(8):600-6.

Gutierrez PR, Lara MH. Giannini prosthesis for flatfoot. Foot Ankle Int. 2005; 26(11):918-26.

Nelson SC, Haycock DM, Little ER. Flexible flatfoot treatment with arthroereisis: radiographic improvement and child health survey analysis. J Foot Ankle Surg. 2004; 43(3):144-55.

Chang TJ, Lee J. Subtalar joint arthroereisis in adult-acquired flatfoot and posterior tibial tendon dysfunction. ClinPodiatr Med Surg. 2007; 24(4):687-97, viii.

Richie DH Jr. Biomechanics and clinical analysis of the adult acquired flatfoot. ClinPodiatr Med Surg. 2007; 24(4):617-44, vii.

Christensen J, Campbell N, DiNucci K. Closed kinetic chain tarsal mechanics of subtalar joint arthroereisis. J Am Podiatr Med Assoc. 1996; 86(10):467-473.

Husain ZS, Fallat LM. Biomechanical analysis of Maxwell-Brancheauarthroereisis implants. J Foot Ankle Surg. 2002; 41(6):352-8.

Brancheau S, Walker KM, Northcutt DR. An analysis of outcomes after use of the Maxwell-Brancheauarthroereisis implant. J Foot Ankle Surg. 2012; 51(1):3-8.

Garras DN, Hansen PL, Miller AG, Raikin SM. Outcome of modified Kidner procedure with subtalararthroereisis for painful accessory navicular associated with planovalgus deformity. Foot Ankle Int. 2012. 33(11):934-9.

Graham ME, Jawrani NT, Chikka A. Extraosseoustalotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up. J Foot Ankle Surg. 2012; 51(1):23-9.

Graham ME, Jawrani NT, Chikka A. Radiographic evaluation of navicular position in the sagittal plane—correction following an extraosseoustalotarsal stabilization procedure. J Foot Ankle Surg. 2011; 50(5):551-7.

Graham ME, Jawrani NT. The effect of HyProCure® sinus tarsi stent on tarsal tunnel compartment pressures in hyperpronating feet. J Foot Ankle Surg. 2011; 50(1):44-9.

Graham ME, Jawrani NT, Chikka A, Rogers RJ. Surgical treatment of hyperpronation using an extraosseoustalotarsal stabilization device: radiographic outcomes in 70 adult patients. J Foot Ankle Surg. 2012; 51(5):548-55.

Mereday C, Dolan CM, Lusskin R. Evaluation of the University of California Biomechanics Laboratory shoe insert in "flexible" pes planus. ClinOrthopRelat Res. 1972; 82:45-58.

Bleck EE, Berzins UJ. Conservative management of pes valgus with plantar flexed talus, flexible. ClinOrthopRelat Res. 1977; 122:85-94.

Bordelon RL. Correction of hypermobile flatfoot in children by molded insert. Foot Ankle. 1980; 1(3):143-50.

Penneau K, Lutter LD, Winter RD. Pes planus: radiographic changes with foot orthoses and shoes. Foot Ankle. 1982; 2(5):299-303.

Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989; 71(6):800-10.

Cornwall MW, McPoil TG. Footwear and foot orthotic effectiveness research: a new approach. J Orthop Sports PhysTher. 1995; 21(6):337-44.

Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports PhysTher. 1995; 21(6):317-27.

Penneau K, Lutter LD, Winter RD. Pes planus: radiographic changes with foot orthoses and shoes. Foot Ankle. 1982; 2(5):299-303.

Landsman A, DeFronzo D, Anderson J, Roukis T. Scientific assessment of over-the-counter foot orthoses to determine their effects on pain, balance, and foot deformities. J Am Podiatr Med Assoc. 2009; 99 (3):206-15.

Bresnahan P, Chariton J, Vedpathak A. Extra-osseous talotarsal stabilization using HyProCure®: preliminary outcomes of a prospective clinical study. J Foot Ankle Surg. 2013; 52(2):195-202.



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