578514
research-articleXXXX
FASXXX10.1177/1938640015578514Foot & Ankle SpecialistFoot & Ankle Specialist
180
June 2015
Foot & Ankle Specialist
〈 Clinical Research 〉 2013 Subtalar Arthroereisis Survey The Current Practice Patterns of Members of the AOFAS Abstract: Background. Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA. Methods. Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate). Results. A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of nonUS respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are
Neil S. Shah, MD, Richard L. Needleman, MD, Omaima Bokhari, MD, and David Buzas, MD
painful congenital flatfoot, posterior adults and children.1-3It was a tibial tendon dysfunction, and flatfoot modification of the Grice procedure,4 associated with accessory navicular. first reported by Haraldsson in 1962, Conclusion. Many doctors have using allograft cortical bone wedges.5 performed SA, and a significant There have been different implants used number no longer perform this over the past 50 years, and they have procedure for various reasons. A greater varied by design and composition. Some percentage of non-US practitioners have implants have required small alterations performed and continue to perform to the anatomy of the subtalar joint; a SA than their counterparts in the few implants required fixation to bone. United States. There is a common list of Each of the implants can be classified surgical indications. Most doctors who still perform this procedure Some implants have required small have removed the implants, commonly for alterations to the anatomy of the subtalar pain. SA is still being joint; a few implants required fixation to performed in the United States and throughout bone.” the world.
“
Keywords: subtalar arthroereisis; flatfoot; survey
Introduction Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in
according to how it affects the biomechanics of the subtalar joint (according to the Vogler classification6). One popular advantage is that this procedure is performed through a small incision.7 Patients have less surgical pain, less trauma, and a more rapid recovery. Clinical studies of patients who had a SA
DOI: 10.1177/1938640015578514. From the Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB). Address correspondence to: Neil S. Shah, MD, Department of Orthopaedic Surgery, Wayne State University, 10000 Telegraph Road, Taylor, MI 48180; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
Foot & Ankle Specialist
are sparse and with mixed results and variable indications. Perhaps a procedure’s popularity can be indirectly determined by the number of new implants being introduced to the marketplace. The first mass produced implants for SA were the STA-peg implant8,9 and the Valenti “threaded” implant10 in 1976. A total of 4 implants were introduced between 1976 and 1979; 5 implants were introduced during the 1980s; 1 implant was introduced during the 1990s; and at least 17 have been introduced since 2000. A 2013 Google review shows that there are currently new implants entering the marketplace because some implants are advertised as “patent pending.” The purpose of this study is to establish the past and current practice of American Orthopaedic Foot and Ankle Society (AOFAS) members regarding the performance of SA surgery. We hope to be able to identify any differences in practice patterns between regions of the United States and between continents. We would like to clarify surgical indications and surgeon expectations of patient activity.
Materials and Methods A Web-based survey was developed by the senior author (RLN), a fellowshiptrained orthopaedic foot and ankle surgeon and a member of AOFAS. The study was reviewed and approved by our institutional review board. The first portion of the survey consisted of basic demographic questions: membership in the AOFAS, number of years in practice, and practice within or outside of the United States. If the responder practiced in the United States, then questions were directed in regard to location of orthopaedic residency training, fellowship training, and current practice. The second portion of the survey was directed as to whether the respondent ever performed a SA. If “yes” was selected, then questions included which implant was used, indications for surgery, whether this procedure was stand-alone or ancillary, patient ages, postoperative activity and goals, coding,
Table 1. US and non-US Practice Patterns.
Respondents
Have Performed Subtalar Arthroereisis
Still Perform Subtalar Arthroereisis
Total
100%
48%
33%
US respondents
70%
40%
24%
Non-US respondents
30%
66%
53%
n = 572 Respondents
reimbursement, and whether an implant was ever removed and why. If “no” was selected, the responder was asked why he/she no longer performs SA. Each question could have more than 1 response. The e-mail addresses of all 1818 AOFAS members in Fall 2013 were compiled from the AOFAS Web site at www. AOFAS.org. The members were divided into 4 equal-sized groups. An electronic survey was sent to each group as a blast e-mail over a 1-week period, so as to not overload the server with too many responses at once. A total of 23 e-mails were unable to be delivered. In all, 1795 AOFAS members received the survey; 5 out of the 1795 members wished to opt of the study. One month after the completion of the first mailing of the survey (by November 26, 2013), there were 404 responses. At this time, a second blast e-mail was sent as a reminder to complete the survey, which elicited an additional 168 responses by the time of official closure of the survey Web site on December 31, 2013, for a total of 572 responses. Responses were tabulated individually as data points and summed electronically for each question. Answers that required a “write-in” were also tabulated and summed electronically. A secure, dedicated return e-mail address was used for data collection to protect the identities of those surveyed. Data were deidentified, automatically tabulated on receipt of the survey, and loaded into a spreadsheet. Using data from the spreadsheet of collective
information, US and non-US responses were separated and further stratification performed with regard to demographics and responses to the nondemographic survey questions. Descriptive epidemiological analysis was performed for the entire cohort and its stratified subgroups.
Results Of the 1795 valid e-mail addresses, 572 were received. This was a 32% response rate. Among the respondents, 273 (48%) had performed SA, and 299 (52%) had not. A total of 187 respondents (69%) still performed this procedure (33% of the total respondents currently performed SA). Of the total respondents, 401 (70%) practiced in and 171 (30%) practice outside the United States. Of the US respondents, 40% had performed SA, and 60% of them still performed this procedure. Of the non-US respondents, 66% had performed SA, and 80% of those still performed this procedure (Table 1). The most common indications for SA are painful congenital flatfoot (63% US, 74% non-US), posterior tibial tendon dysfunction (67% US, 54% non-US), flatfoot associated with accessory navicular (39% US, 43% non-US), and tarsal coalition (29% US, 37% non-US). This procedure is performed on both children and adults (Figure 1). Respondents perform SA as an ancillary procedure (52% US, 33% non-US), as a stand-alone procedure (8% US, 16% non-US), and both (40% US, 52%
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
181
182
June 2015
Foot & Ankle Specialist
Figure 1.
Figure 2.
Whom Do You Perform This Procedure on?
What Activities Do You Expect Your Patients to Be Able to Do After Successful Surgery?
non-US). The questionnaire did not specifically ask the respondents to identify any additional procedures. A few of the respondents noted that (in addition to SA for acquired flat foot deformity caused by posterior tibial tendon dysfunction) ancillary procedures included calcaneal osteotomy and flexor digitorum longus tendon transfer. These respondents expect that (Figure 2) their patients will be able to walk (85%), golf (68%), and run (59%). A total of 80% of the US group and 27% of the non-US group has experienced problems with payment from health insurance companies; 83% of the responders who still perform this procedure have at some point had to remove the implant after the initial surgery, usually for local pain (85%; Figure 3). The responses for the implant used were listed by company and/or by name (Table 2). In the United States, the most commonly cited implants (Table 2) include the Arthrex implants (52%) and the Wright Medical implants (9%). Outside of the United States, the most commonly cited implants (Table 2) include Arthrex (27%), Integra (24%), and Wright Medical (10%). The most common CPT codes used were Code 28899 Unlisted Procedure, Foot (67%), and Code 28725 Subtalar Arthrodesis (15%). The primary reason for doctors no longer performing SA was because of its low success rate (68% US, 66% non-US; Figure 4).
Figure 3. Reasons for Removal of Implant.
Those AOFAS members from the United States who had performed SA and who currently perform the procedure were identified by country and by state. The United States was divided into its natural geographic regions (Northeast states, Southeast states, North Central states, South Central states, and Western states) with regard to having similar numbers of respondents in each region. The past and current performance of SA is identified by region (Figure 5). A world map was labeled according to continents, and the corresponding past and current practice patterns were
noted. The past and current performance of SA is identified by region (Figure 6).
Discussion Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. SA can be a minimally invasive procedure that does not involve the extensive surgical trauma associated with hindfoot osteotomies and arthrodesis.7 Its current use is controversial. The primary purpose of the study was to determine current practice patterns of the members of the AOFAS.
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
Foot & Ankle Specialist
Table 2. Which Company/Implant(s) Do You Use? Response By Company
By Implant
Arthrex
ProStop
Wright Medical
BIOARCH OrthoPro Subtalar Spacer System
Integra
Maxwell-Brancheau arthroereisis Kalix
Tornier
Futura Conical Subtalar Implant
GraMedica
US Respondents, n = 116
Non-US Respondents, n = 122
44
19
16
14
12
8
2
4
1
0
7
5
6
9
0
24
4
0
1
7
HyProCure
4
1
Modified Silastic
2
0
Biomet
1
1
Solana Surgical
1
0
1
0
14
20
Stryker
SubFix
“Screw(s)”
OsteoMed
Talar-Fit
0
5
Calcaneo-stop
0
2
Subtalar ARS
0
1
Staples
0
2
Figure 4. Why Did You Stop Performing This Procedure?
Past and current practice patterns vary based on demographics. In the United States, a higher percentage of East Coast respondents (Northeast and Southeast states) have performed and currently perform SA than their counterparts in other geographic regions. Worldwide, a larger percentage of AOFAS members outside of North America have performed and currently perform SA than their North American counterparts. The popularity of SA has declined overall in both US and non-US countries. However, there are still a considerable number of surgeons throughout the world using this procedure. The limitations of the study are inherent to the nature of an e-mail survey. Responses are voluntary and can
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
183
184
June 2015
Foot & Ankle Specialist
Figure 5. Past and Current Practice Patterns by US Regions.
Abbreviation: SA, subtalar arthroereisis.
and not-active surgeons, including basic science members, resident or fellow members, and emeritus members. Therefore, the percentage of active surgeon responders should actually be higher. A frequent response to the type of subtalar implant used was “screw” (34 responses, 14% of responses). A screw has been used to obtain a SA.13,14 Perhaps, some of the members responding misread the “SA” survey as a “subtalar arthrodesis” survey because some respondents had written subtalar arthrosis as an indication for the surgery. SA is also performed by surgeons outside of the AOFAS, including pediatric orthopaedists and podiatrists. Practice patterns may vary with other professional societies or affiliations. Future studies may include sending a similar survey to these groups. Individual group variations in practice patterns can be studied, and the total responses can be compiled.
Figure 6. Past and Current Practice Patterns by Continent.
Conclusion Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants. The most common reason is for pain. SA is still being performed in the United States and throughout the world.
References 1. Metcalfe SA, Bowling FL, Reeves ND. Subtalar joint arthroereisis in the management of pediatric flexible flatfoot: a critical review of the literature. Foot Ankle Int. 2011;32:1127-1139.
Abbreviation: SA, subtalar arthroereisis.
be limited by individual bias and recall. Data would be improved with a higher response rate. However, the 32% response rate obtained is consistent with or higher than other similar survey-based studies provided to AOFAS members.11,12 There were 23 incorrect or
undeliverable e-mail addresses out of the 1818 (1%), but it is not possible to know the true number of surveys that were actually never viewed. The survey was sent to all AOFAS members. The AOFAS membership consists not only of active surgeons, but also nonsurgeons
2. Needleman RL. Current topic review: subtalar arthroereisis for the correction of flexible flatfoot. Foot Ankle Int. 2005;26:336-346. 3. Schon LC. Subtalar arthroereisis: a new exploration of an old concept. Foot Ankle Clin. 2007;12:329-339. 4. Grice DS. An extra-articular arthrodesis of the subastragalar joint for correction of
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
paralytic flat feet in children. J Bone Joint Surg Am. 1952;34:927-940.
Foot & Ankle Specialist
tarsi implant. Foot Ankle Int. 2006;27: 9-18.
5. Haraldsson S. Operative treatment of pes planovalgus staticus juvinilis. Acta Orthop Scand. 1962;32:492-498.
8. Smith S. The STA operation for the pronated foot in childhood. Clinics in Podiatry. 1984;1(1):165-173.
6. Vogler H. Subtalar joint blocking operations for pathological pronation syndromes. In: Southerland J, Alder D, Boberg J, et al, eds. McGlamry’s Comprehensive Textbook of Foot Surgery. Baltimore, MD: Williams and Wilkins; 1987:466-482.
9. Smith S, Millar E. Arthroereisis by means of a subtalar polyethylene peg implant for correction of hindfoot pronation in children. Clin Orthop. 1983;181: 15-23.
7. Needleman RL. A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus
10. Langford JH, Bozof H, Horowitz BD. Subtalar arthroereisis: Valente procedure. Clin Podiatr Med Surg. 1987;4:153-161. 11. Gardner MJ, Streubel PN, McCormick JJ, et al. Surgeon practices regarding operative
treatment of posterior malleolus fractures. Foot Ankle Int. 2011;32:385-393. 12. Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int. 2011;32:394-399. 13. Magnan B, Baldrighi C, Papadia D, et al. Flatfeet comparison of surgical techniques: result of study group into retrograde endorthesis with calcaneus-stop. Ital J Ped Orthop. 1997;13:28-33. 14. Roth S, Sestan B, Tudor A, Ostojic Z, Sasso A. Minimally invasive calcaneo-stop method for idiopathic, flexible pes planicalgus in children. Foot Ankle Int. 2007;28:991-995.
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
185
research-articleXXXX
FASXXX10.1177/1938640015578514Foot & Ankle SpecialistFoot & Ankle Specialist
180
June 2015
Foot & Ankle Specialist
〈 Clinical Research 〉 2013 Subtalar Arthroereisis Survey The Current Practice Patterns of Members of the AOFAS Abstract: Background. Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in adults and children. Clinical studies of patients who had a SA are sparse and with mixed results and variable indications. The purpose of this study was to determine the current practice among orthopaedic foot and ankle specialists regarding SA. Methods. Web-based questionnaires were e-mailed to members of the American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and practice patterns in regard to performing SA surgery. A total of 572 respondents completed the survey (32% response rate). Results. A total of 273 respondents (48%) have performed SA. Of this group, 187 respondents (69%) still perform this procedure (33% of total respondents currently perform SA). Of the respondents, 401 (70%) practice in the United States, 40% have performed SA, and 60% of those still perform this procedure. Of nonUS respondents, 66% have performed SA, and 80% of those still perform it. The most common US indications are
Neil S. Shah, MD, Richard L. Needleman, MD, Omaima Bokhari, MD, and David Buzas, MD
painful congenital flatfoot, posterior adults and children.1-3It was a tibial tendon dysfunction, and flatfoot modification of the Grice procedure,4 associated with accessory navicular. first reported by Haraldsson in 1962, Conclusion. Many doctors have using allograft cortical bone wedges.5 performed SA, and a significant There have been different implants used number no longer perform this over the past 50 years, and they have procedure for various reasons. A greater varied by design and composition. Some percentage of non-US practitioners have implants have required small alterations performed and continue to perform to the anatomy of the subtalar joint; a SA than their counterparts in the few implants required fixation to bone. United States. There is a common list of Each of the implants can be classified surgical indications. Most doctors who still perform this procedure Some implants have required small have removed the implants, commonly for alterations to the anatomy of the subtalar pain. SA is still being joint; a few implants required fixation to performed in the United States and throughout bone.” the world.
“
Keywords: subtalar arthroereisis; flatfoot; survey
Introduction Subtalar arthroereisis (SA) has been a procedure used for the correction of painful flexible flatfoot deformity in
according to how it affects the biomechanics of the subtalar joint (according to the Vogler classification6). One popular advantage is that this procedure is performed through a small incision.7 Patients have less surgical pain, less trauma, and a more rapid recovery. Clinical studies of patients who had a SA
DOI: 10.1177/1938640015578514. From the Department of Orthopaedic Surgery, Wayne State University, Taylor, Michigan (NSS, RLN, OB, DB). Address correspondence to: Neil S. Shah, MD, Department of Orthopaedic Surgery, Wayne State University, 10000 Telegraph Road, Taylor, MI 48180; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s)
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
Foot & Ankle Specialist
are sparse and with mixed results and variable indications. Perhaps a procedure’s popularity can be indirectly determined by the number of new implants being introduced to the marketplace. The first mass produced implants for SA were the STA-peg implant8,9 and the Valenti “threaded” implant10 in 1976. A total of 4 implants were introduced between 1976 and 1979; 5 implants were introduced during the 1980s; 1 implant was introduced during the 1990s; and at least 17 have been introduced since 2000. A 2013 Google review shows that there are currently new implants entering the marketplace because some implants are advertised as “patent pending.” The purpose of this study is to establish the past and current practice of American Orthopaedic Foot and Ankle Society (AOFAS) members regarding the performance of SA surgery. We hope to be able to identify any differences in practice patterns between regions of the United States and between continents. We would like to clarify surgical indications and surgeon expectations of patient activity.
Materials and Methods A Web-based survey was developed by the senior author (RLN), a fellowshiptrained orthopaedic foot and ankle surgeon and a member of AOFAS. The study was reviewed and approved by our institutional review board. The first portion of the survey consisted of basic demographic questions: membership in the AOFAS, number of years in practice, and practice within or outside of the United States. If the responder practiced in the United States, then questions were directed in regard to location of orthopaedic residency training, fellowship training, and current practice. The second portion of the survey was directed as to whether the respondent ever performed a SA. If “yes” was selected, then questions included which implant was used, indications for surgery, whether this procedure was stand-alone or ancillary, patient ages, postoperative activity and goals, coding,
Table 1. US and non-US Practice Patterns.
Respondents
Have Performed Subtalar Arthroereisis
Still Perform Subtalar Arthroereisis
Total
100%
48%
33%
US respondents
70%
40%
24%
Non-US respondents
30%
66%
53%
n = 572 Respondents
reimbursement, and whether an implant was ever removed and why. If “no” was selected, the responder was asked why he/she no longer performs SA. Each question could have more than 1 response. The e-mail addresses of all 1818 AOFAS members in Fall 2013 were compiled from the AOFAS Web site at www. AOFAS.org. The members were divided into 4 equal-sized groups. An electronic survey was sent to each group as a blast e-mail over a 1-week period, so as to not overload the server with too many responses at once. A total of 23 e-mails were unable to be delivered. In all, 1795 AOFAS members received the survey; 5 out of the 1795 members wished to opt of the study. One month after the completion of the first mailing of the survey (by November 26, 2013), there were 404 responses. At this time, a second blast e-mail was sent as a reminder to complete the survey, which elicited an additional 168 responses by the time of official closure of the survey Web site on December 31, 2013, for a total of 572 responses. Responses were tabulated individually as data points and summed electronically for each question. Answers that required a “write-in” were also tabulated and summed electronically. A secure, dedicated return e-mail address was used for data collection to protect the identities of those surveyed. Data were deidentified, automatically tabulated on receipt of the survey, and loaded into a spreadsheet. Using data from the spreadsheet of collective
information, US and non-US responses were separated and further stratification performed with regard to demographics and responses to the nondemographic survey questions. Descriptive epidemiological analysis was performed for the entire cohort and its stratified subgroups.
Results Of the 1795 valid e-mail addresses, 572 were received. This was a 32% response rate. Among the respondents, 273 (48%) had performed SA, and 299 (52%) had not. A total of 187 respondents (69%) still performed this procedure (33% of the total respondents currently performed SA). Of the total respondents, 401 (70%) practiced in and 171 (30%) practice outside the United States. Of the US respondents, 40% had performed SA, and 60% of them still performed this procedure. Of the non-US respondents, 66% had performed SA, and 80% of those still performed this procedure (Table 1). The most common indications for SA are painful congenital flatfoot (63% US, 74% non-US), posterior tibial tendon dysfunction (67% US, 54% non-US), flatfoot associated with accessory navicular (39% US, 43% non-US), and tarsal coalition (29% US, 37% non-US). This procedure is performed on both children and adults (Figure 1). Respondents perform SA as an ancillary procedure (52% US, 33% non-US), as a stand-alone procedure (8% US, 16% non-US), and both (40% US, 52%
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
181
182
June 2015
Foot & Ankle Specialist
Figure 1.
Figure 2.
Whom Do You Perform This Procedure on?
What Activities Do You Expect Your Patients to Be Able to Do After Successful Surgery?
non-US). The questionnaire did not specifically ask the respondents to identify any additional procedures. A few of the respondents noted that (in addition to SA for acquired flat foot deformity caused by posterior tibial tendon dysfunction) ancillary procedures included calcaneal osteotomy and flexor digitorum longus tendon transfer. These respondents expect that (Figure 2) their patients will be able to walk (85%), golf (68%), and run (59%). A total of 80% of the US group and 27% of the non-US group has experienced problems with payment from health insurance companies; 83% of the responders who still perform this procedure have at some point had to remove the implant after the initial surgery, usually for local pain (85%; Figure 3). The responses for the implant used were listed by company and/or by name (Table 2). In the United States, the most commonly cited implants (Table 2) include the Arthrex implants (52%) and the Wright Medical implants (9%). Outside of the United States, the most commonly cited implants (Table 2) include Arthrex (27%), Integra (24%), and Wright Medical (10%). The most common CPT codes used were Code 28899 Unlisted Procedure, Foot (67%), and Code 28725 Subtalar Arthrodesis (15%). The primary reason for doctors no longer performing SA was because of its low success rate (68% US, 66% non-US; Figure 4).
Figure 3. Reasons for Removal of Implant.
Those AOFAS members from the United States who had performed SA and who currently perform the procedure were identified by country and by state. The United States was divided into its natural geographic regions (Northeast states, Southeast states, North Central states, South Central states, and Western states) with regard to having similar numbers of respondents in each region. The past and current performance of SA is identified by region (Figure 5). A world map was labeled according to continents, and the corresponding past and current practice patterns were
noted. The past and current performance of SA is identified by region (Figure 6).
Discussion Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. SA can be a minimally invasive procedure that does not involve the extensive surgical trauma associated with hindfoot osteotomies and arthrodesis.7 Its current use is controversial. The primary purpose of the study was to determine current practice patterns of the members of the AOFAS.
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
Foot & Ankle Specialist
Table 2. Which Company/Implant(s) Do You Use? Response By Company
By Implant
Arthrex
ProStop
Wright Medical
BIOARCH OrthoPro Subtalar Spacer System
Integra
Maxwell-Brancheau arthroereisis Kalix
Tornier
Futura Conical Subtalar Implant
GraMedica
US Respondents, n = 116
Non-US Respondents, n = 122
44
19
16
14
12
8
2
4
1
0
7
5
6
9
0
24
4
0
1
7
HyProCure
4
1
Modified Silastic
2
0
Biomet
1
1
Solana Surgical
1
0
1
0
14
20
Stryker
SubFix
“Screw(s)”
OsteoMed
Talar-Fit
0
5
Calcaneo-stop
0
2
Subtalar ARS
0
1
Staples
0
2
Figure 4. Why Did You Stop Performing This Procedure?
Past and current practice patterns vary based on demographics. In the United States, a higher percentage of East Coast respondents (Northeast and Southeast states) have performed and currently perform SA than their counterparts in other geographic regions. Worldwide, a larger percentage of AOFAS members outside of North America have performed and currently perform SA than their North American counterparts. The popularity of SA has declined overall in both US and non-US countries. However, there are still a considerable number of surgeons throughout the world using this procedure. The limitations of the study are inherent to the nature of an e-mail survey. Responses are voluntary and can
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
183
184
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Foot & Ankle Specialist
Figure 5. Past and Current Practice Patterns by US Regions.
Abbreviation: SA, subtalar arthroereisis.
and not-active surgeons, including basic science members, resident or fellow members, and emeritus members. Therefore, the percentage of active surgeon responders should actually be higher. A frequent response to the type of subtalar implant used was “screw” (34 responses, 14% of responses). A screw has been used to obtain a SA.13,14 Perhaps, some of the members responding misread the “SA” survey as a “subtalar arthrodesis” survey because some respondents had written subtalar arthrosis as an indication for the surgery. SA is also performed by surgeons outside of the AOFAS, including pediatric orthopaedists and podiatrists. Practice patterns may vary with other professional societies or affiliations. Future studies may include sending a similar survey to these groups. Individual group variations in practice patterns can be studied, and the total responses can be compiled.
Figure 6. Past and Current Practice Patterns by Continent.
Conclusion Many doctors have performed SA, and a significant number no longer perform this procedure for various reasons. A greater percentage of non-US practitioners have performed and continue to perform SA than their counterparts in the United States. There is a common list of surgical indications. Most doctors who still perform this procedure have removed the implants. The most common reason is for pain. SA is still being performed in the United States and throughout the world.
References 1. Metcalfe SA, Bowling FL, Reeves ND. Subtalar joint arthroereisis in the management of pediatric flexible flatfoot: a critical review of the literature. Foot Ankle Int. 2011;32:1127-1139.
Abbreviation: SA, subtalar arthroereisis.
be limited by individual bias and recall. Data would be improved with a higher response rate. However, the 32% response rate obtained is consistent with or higher than other similar survey-based studies provided to AOFAS members.11,12 There were 23 incorrect or
undeliverable e-mail addresses out of the 1818 (1%), but it is not possible to know the true number of surveys that were actually never viewed. The survey was sent to all AOFAS members. The AOFAS membership consists not only of active surgeons, but also nonsurgeons
2. Needleman RL. Current topic review: subtalar arthroereisis for the correction of flexible flatfoot. Foot Ankle Int. 2005;26:336-346. 3. Schon LC. Subtalar arthroereisis: a new exploration of an old concept. Foot Ankle Clin. 2007;12:329-339. 4. Grice DS. An extra-articular arthrodesis of the subastragalar joint for correction of
Downloaded from fas.sagepub.com at UNIVERSITE DE MONTREAL on July 27, 2015
vol. 8 / no. 3
paralytic flat feet in children. J Bone Joint Surg Am. 1952;34:927-940.
Foot & Ankle Specialist
tarsi implant. Foot Ankle Int. 2006;27: 9-18.
5. Haraldsson S. Operative treatment of pes planovalgus staticus juvinilis. Acta Orthop Scand. 1962;32:492-498.
8. Smith S. The STA operation for the pronated foot in childhood. Clinics in Podiatry. 1984;1(1):165-173.
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