Economic Impact of Congenital/Acquired Talotarsal Joint Dislocation and the Role of Extraosseous Talotarsal Stabilization

Daniel Hake, Peter Bregman


Musculoskeletal disorders are the leading cause of disability worldwide and the cost to treat these disorders continues to rise every year. The pain associated with muscular disorders results in decreased activity for those affected. Failure to properly treat musculoskeletal disorders can lead to the onset or exacerbation of existing secondary health-related diseases associated with decreased activity including diabetes, obesity, hypertension, heart disease, and osteoarthritis, which are also associated with increased healthcare costs. The foot, as the foundation of the body, must be properly aligned and/or balanced for the entire skeletal kinetic chain to function properly. Congenital/acquired talotarsal joint dislocation (TTJD) leads to an imbalance and misalignment of joints along the entire kinetic chain, ultimately leading to musculoskeletal disorders, pain, and comorbidities associated with a sedentary lifestyle. Conservative treatment of TTJD with orthotics is often ineffective due to poor patient compliance, and does not address the underlying cause of the pain associated with TTJD. Women are also less likely to use orthotics due to incompatibility with certain shoe styles. Invasive reconstructive surgery for the treatment of TTJD is associated with a risk of complications and a long recovery time. In contrast, extraosseous talotarsal stabilization is a minimally invasive procedure with few complications, and Type II implants have a removal rate of < 6%. Extraosseous talotarsal stabilization could serve as an important link in eliminating the underlying etiology of many chronic musculoskeletal deformities and, in the process, allow patients to maintain normal levels of activity to help combat the development of secondary health-related diseases associated with a sedentary lifestyle.


Chronic pain; extraosseous talotarsal stabilization; foot pain; musculoskeletal disorders; orthopedic surgery; talotarsal joint dislocation

Full Text:



Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital Health Stat 2009;10:1-157.

DeFrances CJ, Lucas CA, Buie VC, et al. 2006 National Hospital Discharge Survey. Natl Health Stat Report 2008:1-20.

Hing E, Hall MJ, Xu J. National Hospital Ambulatory Medical Care Survey: 2006 outpatient department summary. Natl Health Stat Report 2008:1-31.

United States Bone and Joint Initiative. The burden of musculoskeletal diseases in the United States 2014. Available at: Accessed onMarch 17, 2015.

Smith E, Hoy DG, Cross M, et al. The global burden of other musculoskeletal disorders: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:1462-1469.

Hoy D, March L, Brooks P, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:968-974.

Storheim K, Zwart JA. Musculoskeletal disorders and the Global Burden of Disease study. Ann Rheum Dis 2014;73:949-950.

Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73:1323-1330.

Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-241.

Foster-Schubert KE, Alfano CM, Duggan CR, et al. Effect of diet and exercise, alone or combined, on weight and body composition in overweight-to-obese postmenopausal women. Obesity (Silver Spring) 2012;20:1628-1638.

Hogan P, Dall T, Nikolov P, et al. Economic costs of diabetes in the US in 2002. Diabetes Care 2003;26:917-932.

Balu S, Thomas J, 3rd. Incremental expenditure of treating hypertension in the United States. Am J Hypertens 2006;19:810-816.

Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 2011;123:933-944.

Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood) 2009;28:w822-831.

Donatelli RA. Normal biomechanics of the foot and ankle. J Orthop Sports Phys Ther 1985;7:91-95.

Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot. Los Angeles, CA: Clinical Biomechanics Corp; 1977.

Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Orthop Sports Phys Ther 1987;9:160-165.

Graham ME, Parikh R, Goel V, et al. Stabilization of joint forces of the subtalar complex via HyProCure sinus tarsi stent. J Am Podiatr Med Assoc 2011;101:390-399.

Brody DM. Techniques in the evaluation and treatment of the injured runner. Orthop Clin North Am 1982;13:541-558.

Kirby KA. Subtalar joint axis location and rotational equilibrium theory of foot function. J Am Podiatr Med Assoc 2001;91:465-487.

Levens AS, Inman VT, Blosser JA. Transverse rotation of the segments of the lower extremity in locomotion. J Bone Joint Surg Am 1948;30:859-872.

Nguyen AD, Shultz SJ. Identifying relationships among lower extremity alignment characteristics. J Athl Train 2009;44:511-518.

Buchbinder MR, Napora NJ, Biggs EW. The relationship of abnormal pronation to chondromalacia of the patella in distance runners. J Am Podiatry Assoc 1979;69:159-162.

Giannini S, Catani F, Ceccarelli F, et al. Kinematic and isokinetic evaluation of patients with flat foot. Ital J Orthop Traumatol 1992;18:241-251.

Gross KD, Felson DT, Niu J, et al. Association of flat feet with knee pain and cartilage damage in older adults. Arthritis Care Res (Hoboken) 2011;63:937-944.

Inman VT. The influence of the foot-ankle complex on the proximal skeletal structures. Artif Limbs 1969;13:59-65.

Khamis S, Yizhar Z. Effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture 2007;25:127-134.

Levinger P, Menz HB, Fotoohabadi MR, et al. Foot posture in people with medial compartment knee osteoarthritis. J Foot Ankle Res 2010;3:29.

Saito ET, Akashi PM, Sacco Ide C. Global body posture evaluation in patients with temporomandibular joint disorder. Clinics (Sao Paulo) 2009;64:35-39.

Snodgrass LE. A note on posture in relation to flat feet. J Bone Joint Surg Am 1933;15:787-788.

Brenning R. Growing pain. Acta Soc Med Ups 1960;65:185-201.

Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther 1999;29:756-760.

Graham ME, Jawrani NT, Goel VK. Effect of extra-osseous talotarsal stabilization on posterior tibial nerve strain in hyperpronating feet: a cadaveric evaluation. J Foot Ankle Surg 2011;50:672-675.

Graham ME, Jawrani NT, Goel VK. Evaluating plantar fascia strain in hyperpronating cadaveric feet following an extra-osseous talotarsal stabilization procedure. J Foot Ankle Surg 2011;50:682-686.

Lapidus PW. Spastic flat-foot. J Bone Joint Surg Am 1946;28:126-136.

Kirby KA. Biomechanics of the normal and abnormal foot. J Am Podiatr Med Assoc 2000;90:30-34.

Gentili A, Masih S, Yao L, et al. Pictorial review: foot axes and angles. Br J Radiol 1996;69:968-974.

Graham ME, Chikka A, Jones PC. Validation of the talar-second metatarsal angle as a standard measurement for radiographic evaluation. J Am Podiatr Med Assoc 2011;101:475-483.

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

Bleck EE, Berzins UJ. Conservative management of pes valgus with plantar flexed talus, flexible. Clin Orthop Relat Res 1977:85-94.

Bordelon RL. Correction of hypermobile flatfoot in children by molded insert. Foot Ankle 1980;1:143-150.

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

Landorf KB, Keenan AM. Efficacy of foot orthoses. What does the literature tell us? J Am Podiatr Med Assoc 2000;90:149-158.

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

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

Reina M, Lafuente G, Munuera PV. Effect of custom-made foot orthoses in female hallux valgus after one-year follow up. Prosthet Orthot Int 2013;37:113-119.

Wenger DR, Mauldin D, Speck G, et al. Corrective shoes and inserts as treatment for flexible flat foot in infants and children. J Bone Joint Surg Am 1989;71:800-810.

Zammit GV, Payne CB. Relationship between positive clinical outcomes of foot orthotic treatment and changes in rearfoot kinematics. J Am Podiatr Med Assoc 2007;97:207-212.

Chambers EF. An operation for the correction of flexible flat feet of adolescents. West J Surg Obstet Gynecol 1946;54:77-86.

Graham ME, Jawrani NT. Extraosseous talotarsal stabilization devices: a new classification system. J Foot Ankle Surg 2012;51:613-619.

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

Koning PM, Heesterbeek PJ, de Visser E. Subtalar arthroereisis for pediatric flexible pes planovalgus: fifteen years experience with the cone-shaped implant J Am Podiatr Med Assoc. 2009;99:447-453.

Graham ME, Jawrani NT, Chikka A. Extraosseous talotarsal stabilization using HyProCure(R) in adults: a 5-year retrospective follow-up. J Foot Ankle Surg 2012;51:23-29.

Graham ME, Jawrani NT, Chikka A, et al. Surgical treatment of hyperpronation using an extraosseous talotarsal stabilization device: radiographic outcomes in 70 adult patients. J Foot Ankle Surg 2012;51:548-555.

Summary: weighing the options--criteria for evaluating weight-management programs. Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. J Am Diet Assoc 1995;95:96-105.

Bali N, Theivendran K, Prem H. Computed tomography review of tarsal canal anatomy with reference to the fitting of sinus tarsi implants in the tarsal canal. J Foot Ankle Surg 2013;52:714-716.

Bresnahan PJ, Chariton JT, Vedpathak A. Extraosseous talotarsal stabilization using HyProCure(R): preliminary clinical outcomes of a prospective case series. J Foot Ankle Surg 2013;52:195-202.

Pi-Sunyer FX. A review of long-term studies evaluating the efficacy of weight loss in ameliorating disorders associated with obesity. Clin Ther 1996;18:1006-1035.

Graham ME, Jawrani NT, Goel VK. The effect of HyProCure((R)) sinus tarsi stent on tarsal tunnel compartment pressures in hyperpronating feet. J Foot Ankle Surg 2011;50:44-49.

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health. Obes Res 1998;6 Suppl 2:51S-209S.

Ebrahim S, Smith GD. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. J Public Health Med 1998;20:441-448.

Eriksson KM, Westborg CJ, Eliasson MC. A randomized trial of lifestyle intervention in primary healthcare for the modification of cardiovascular risk factors. Scand J Public Health 2006;34:453-461.

Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

Phelan S, Wadden TA, Berkowitz RI, et al. Impact of weight loss on the metabolic syndrome. Int J Obes (Lond) 2007;31:1442-1448.

Dananberg HJ, Guiliano M. Chronic low-back pain and its response to custom-made foot orthoses. J Am Podiatr Med Assoc 1999;89:109-117.

Kalen V, Brecher A. Relationship between adolescent bunions and flatfeet. Foot Ankle 1988;8:331-336.

Kosmahl EM, Kosmahl HE. Painful Plantar Heel, Plantar Fasciitis, and Calcaneal spur: Etiology and Treatment. J Orthop Sports Phys Ther 1987;9:17-24.

Kwong PK, Kay D, Voner RT, et al. Mechanics and pathomechanics of treatment. Clin Sports Med 1988;7:119-126.

Lutter LD. Pronation biomechanics in runners. Contemp Orthop 1980;2:579.

Mann R, Inman VT. Phasic Activity of Intrinsic Muscles of the Foot. J Bone Joint Surg Am 1964;46:469-481.

Scherer PR. Heel spur syndrome. Pathomechanics and nonsurgical treatment. Biomechanics Graduate Research Group for 1988. J Am Podiatr Med Assoc 1991;81:68-72.

Schroeder BM, American College of Foot and Ankle Surgeons. American College of Foot and Ankle Surgeons: Diagnosis and treatment of heel pain. Am Fam Physician 2002;65:1686, 1688.

Shama SS, Kominsky SJ, Lemont H. Prevalence of non-painful heel spur and its relation to postural foot position. J Am Podiatry Assoc 1983;73:122-123.

Stovitz SD, Coetzee JC. Hyperpronation and foot pain: steps toward pain-free feet. Phys Sportsmed 2004;32:19-26.

Waller JF. Physiology of the foot and the biomechanics of the flexible flat foot. ONA J 1978;5:101-103.

Warren BL. Anatomical factors associated with predicting plantar fasciitis in long-distance runners. Med Sci Sports Exerc 1984;16:60-63.

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop Relat Res 1989:196-206.

Camasta CA. Hallux limitus and hallux rigidus. Clinical examination, radiographic findings, and natural history. Clin Podiatr Med Surg 1996;13:423-448.

Addante JB, Chin MW, Loomis JC, et al. Subtalar joint arthroereisis with SILASTIC silicone sphere: a retrospective study. J Foot Surg 1992;31:47-51.

Lepow GM, Smith SD. A modified subtalar arthroereisis implant for the correction of flexible flatfoot in children. The STA Peg procedure. Clin Podiatr Med Surg 1989;6:585-590.

Katz JN, Wright J, Wright EA, et al. Failures of total hip replacement: a population-based perspective. Orthop J Harvard Med Sch 9:101-106.

Graham ME, Jawrani NT, Goel VK. Effect of extra-osseous talotarsal stabilization on posterior tibial tendon strain in hyperpronating feet. J Foot Ankle Surg 2011;50:676-681.

Steber S, Kołodziej Ł. Analysis of radiographic outcomes comparing foot orthosis to extra-osseous talotarsal stabilization in the treatment of recurrent talotarsal joint dislocation. J Minim Invasive Orthop 2015;2:e8.

Fitzgerald RH, Vedpathak A. Plantar pressure distribution in a hyperpronated foot before and after intervention with an extraosseous talotarsal stabilization device-a retrospective study. J Foot Ankle Surg 2013;52:432-443.



  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

e-ISSN 2409-5141
Asia Press
Asia Press is a professional Science, Technology and Medicine publisher, who owns rapid publication, Peer-Reviewed, Open Access Journals. Asia Press aims to promote “knowledge sharing”. As you know, the main barrier for free “knowledge sharing” is the cost of publishing and transfer. In order to encourage scholars and scientists to the max, and devote whole power to realize the aim of “knowledge sharing” and the benefit of “all” mankind, Asia Press performs a permanent policy of no charge for publication and access, and always open its door for authors worldwide.
© 2013-2017 by the Asia Press. All rights reserved.