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Extraosseous Talotarsal Stabilization

      Dear Editor:
      We appreciated Dr Graham et al's 2 recent articles on arthroereisis [Graham ME, Jawrani NT, Chikka A. Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up. J Foot Ankle Surg 51(1):23–29, 2012; Graham ME, Jawrani NT. Extraosseous talotarsal stabilization devices: a new classification system. J Foot Ankle Surg 51(5):613–619, 2012]. Articles and research are needed to validate collective findings that this is an important procedure for flexible flatfoot and talotarsal dislocation. We applaud Dr Graham et al's articles and coding guidelines, which could potentially be applied to all subtalar implants.
      We do, however, have a few questions and comments about these articles.

      Article 1 (
      • Graham M.E.
      • Jawrani N.T.
      • Chikka A.
      Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
      )

      • 1.
        In the article about HyProCure® used in extraosseous talotarsal stabilizion (
        • Graham M.E.
        • Jawrani N.T.
        • Chikka A.
        Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
        ),Graham et al mentioned that the removal rate was 6%. However, if the 9 revision cases are added, it would indicate a total of 14% having additional surgery. Would that be correct?
      • 2.
        Also in this article, Graham et al (
        • Graham M.E.
        • Jawrani N.T.
        • Chikka A.
        Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
        ) stated that the pivot point shifts anterior and medially due to partial dislocation of the talus. Do the authors have any references or research to document this statement? It is our understanding that the pivot point would stay the same in mild to moderate cases with only the subtalar axis being altered (lowered with pronation).
      • 3.
        Finally, regarding this article (
        • Graham M.E.
        • Jawrani N.T.
        • Chikka A.
        Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
        ), if an object is positioned on both sides of a pivot point 180° to each other, mechanically we believe one would risk blocking all motion about that pivot joint.

      Article 2 (
      • Graham M.E.
      • Jawrani N.T.
      Extraosseous talotarsal stabilization devices: a new classification system.
      )

      • 1.
        In the article by Graham and Jawrani regarding a new classification system for extraosseous talotarsal stabilization devices (
        • Graham M.E.
        • Jawrani N.T.
        Extraosseous talotarsal stabilization devices: a new classification system.
        ), we found it interesting that they referenced the French anatomist Farabeuf and his claims regarding foot biomechanics. We subsequently paid to have this work translated into English. Graham and Jawrani stated, “it is advocated that the ‘cruciate pivot point’ is the ideal location where the excessive anterior-medical-plantar displacement of the talus within the tarsal mechanism should be eliminated or minimized,” and they referenced Farabeuf. The person who interpreted Farabeuf's treatise for us could not find that statement. Can Graham and Jawrani provide further information on who advocates this?
      • 2.
        Also in this article (
        • Graham M.E.
        • Jawrani N.T.
        Extraosseous talotarsal stabilization devices: a new classification system.
        ), Graham and Jawrani stated that after they cut the interosseous ligament, they insert the implant and the ligament heals back. Do they have any evidence that this occurs? We have observed that when the anterior talofibular ligament is torn at the lateral ankle, it doesn't always heal, and it often requires surgical repair.
      • 3.
        Graham and Jawrani (
        • Graham M.E.
        • Jawrani N.T.
        Extraosseous talotarsal stabilization devices: a new classification system.
        ) also stated that the medial cylindrical portion of the implant offers no resistance to talar motion. The calcaneus is the primary component moving as the talus is in the ankle mortise. If an object is placed too far into the Calais tarsi toward the tarsal canal, doesn't this risk limiting adduction of the calcaneal beak and resultant supination?
      • 4.
        In regard to the “cruciate pivot point,” Graham and Jawrani (
        • Graham M.E.
        • Jawrani N.T.
        Extraosseous talotarsal stabilization devices: a new classification system.
        ) referenced Henke and Henle, but we do not see references for them. Can they please provide these references?
      We thank Graham et al for their articles (
      • Graham M.E.
      • Jawrani N.T.
      • Chikka A.
      Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
      ,
      • Graham M.E.
      • Jawrani N.T.
      Extraosseous talotarsal stabilization devices: a new classification system.
      ) and look forward to them clarifying these issues and questions on this important topic. We appreciate their work and activities surrounding arthroereisis/talotarsal dislocation.

      References

        • Graham M.E.
        • Jawrani N.T.
        • Chikka A.
        Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up.
        J Foot Ankle Surg. 2012; 51: 23-29
        • Graham M.E.
        • Jawrani N.T.
        Extraosseous talotarsal stabilization devices: a new classification system.
        J Foot Ankle Surg. 2012; 51: 613-619

      Linked Article

      • Reply
        The Journal of Foot and Ankle SurgeryVol. 52Issue 5
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          Following are my responses to the questions and comments from Drs. Hatch and Tower regarding the 2 articles (1,2).
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      • Extraosseous Talotarsal Stabilization Using HyProCure® in Adults: A 5-year Retrospective Follow-up
        The Journal of Foot and Ankle SurgeryVol. 51Issue 1
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          The purpose of this retrospective study was to determine long-term functional outcomes and device tolerance achieved in adult patients who chose to undergo an extraosseous talotarsal stabilization procedure HyProCure® for the treatment of flexible talotarsal joint deformity. Eighty-three adult patients participated in this study. Postoperative subjective assessment of device performance was evaluated using Maryland Foot Scores, which were collected at a mean follow-up period of 51 months. The mean postoperative Maryland Foot Score was 88 out of 100; postoperatively, 52% of cases reported complete alleviation of foot pain, 69% of cases had no limitations on their foot functional abilities, and 80% of cases reported complete satisfaction with the appearance of their feet.
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      • Extraosseous Talotarsal Stabilization Devices: A New Classification System
        The Journal of Foot and Ankle SurgeryVol. 51Issue 5
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          Displacement of the articular facets of talus on the tarsal mechanism, or partial talotarsal dislocation, is a condition seen in children, adult, and geriatric populations. A characteristic of this pathologic condition is a prolonged period of and excessive amount of pronation (hyperpronation) on weightbearing. The ill effects of this condition may lead to a multitude of other foot pathologies and to pathologies associated with the proximal lower extremity musculoskeletal structures. A variety of conservative and operative treatment options have been used to eliminate or minimize hyperpronation.
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