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Internal orthotic

Posted by Pauline on 2/06/03 at 15:44 (108242)

I just saw an advertisement by a Podiatrist addressing flat feet by using an 'Internal Orthotic'. No explaination was given. Can one of our doctors comment on this procedure? How is it done and what are they implanting. Whats the material and what have the results been from using this procedure.

Interesting to say the least.

Re: Internal orthotic

Dr. Z on 2/06/03 at 16:14 (108247)

This sounds like a plastic plug that is inserted into the subtalar joint
It stops or reduces the excessive pronation in the child's foot. This procedure is old. It is called a Grice Procedure. The different today is that instead of having to harvest bone from the hip the doctor uses the plugs

As for long term results I am not sure. Many of my podiatric friends have told me this is an excellent procedure. I believe this internal orthosis procedure has been out for about five years. It is a very sound procedure with very little complications and disability. I am sure that some of our doctors on this board could give you more information from their own experience. I did one Grice procedure in my residency program twenty odd years ago.
I have never heard of the term internal orthosis used. IF my child had painful excessive pronatory feet that failed to respond to orthosis I would allow them to undergo this surgical procedure.

Re: Internal orthotic

Pauline on 2/06/03 at 17:59 (108265)

Dr. Z,
Do you know what material it's made of and does it remain in place for life? Here is how the ad reads 'If you have been told that nothing can be done with your flat feet or you just have to live with it...give the office a call. The correction is achieved with an 'internal orthotic' that is inserted into the foot during a brief outpatient surgery. This procedure is producing amazing results on adults and children with a very rapid recovery time'.

I question the 'rapid recover time'. Doesn't seem like anything to do with the feet is ever rapid.

I had never seen ads for an internal orthotic so I thought this was interesting. Does it go in the arch or heel? What happens if a person can't tolerate it later on? How large is the implant?

If the build up of scare tissue is causing P.F. patients pain how is it possible to inplant something like this into such a small space without causing additional pain?

Re: Internal orthotic

BrianG on 2/06/03 at 19:57 (108276)

Hi Pauline,

I took a look around the Net, and there is some information about the Grice procedure, as DrZ remembered. From what I read, it looks like it's mostly used for children, with flat feet. I didn't see anything were it would be used for PF. It is indeed a plug, which is surgically implanted into the foot. It is also reversable. It appears the healing period is 4-6 weeks, if only the one procedure is done. Sounds like someone might be using this procedure off label. More snake oil for the PF suffer's? I don't know, maybe!

The following is cut and pasted:
BrianG

Grice Arthrodesis:

- Discussion:
- extra-articular arthrodesis which is useful in blocking subtalar
motion in those patients who have no gross skeletal deformities but
have instability of the hindfoot;
- this arthrodesis is particularlly applicable in children, since there
is little interference with future growth of the foot;
- spastic pes valgus is most common in pts who have spastic diplegia and is generally resistant to orthotic management;
- subtalar extra-articular arthrodesis that was originally devised by
Grice for the management of pes valgus due to flaccid paralysis
muscle imbalance has also been widely used in patients who have
cerebral palsy;
- Grice procedure is simple method of obtaining fusion of subtalar joint;
- it was originally described for use in the immature foot deformed
with a hindfoot valgus secondary to CP, poliomyelitis, and other
paralytic foot deformities;
- on occassion it may also be used for degenerative disorders of the hindfoot;
- this procedure can be used for calcaneocavus, calcaneovalgus,
talocalcaneal coalition, congenital vertical talus, and isolated
post traumatic arthritis of the sub talar joint;
- should triple arthrodesis be necessary later in life, it is felt that
early correction w/ Grice procedure makes the operation easier
because it restores the anatomy more nearly to normal;
- Grice procedure has been used in the treatment of varus deformities of the hindfoot in children;
- varus deformity, however, has tended to recur in these cases, and Grice procedure is not currently recommended for varus deformity
- degree of valgus deformity is difficult to define;
- progression of deformity is a chief indication for treatment;
- children w/ the valgus deformity rarely present with pain;
- goal of operation for growing child is to perform definative procedure on hindfoot that corrects deformity, restores height of foot, and yet does not interfere w/ subsequent growth of the foot;
- triple arthrodesis, interferes with subsequent growth of the foot,
and does not restore the height of the foot;
- Radiographs:
- lateral radiograph of the foot, held in slight equinus and inversion, will confirm whether the valgus deformity of the subtalar joint is fully corrected;
- Contraindications:
- it is necessary that the hindfoot by flexible and corretable passively to a plantigrade position;
- rigid deformed hindfoot is a contraindication to the Grice procedure;
- most older children ( > 10 years) & adults with pathologic hindfoot valgus, will show evidence of secondary degenerative changes of the talonavicular and calcaneocuboid joints;
- these are relative contraindications for the Grice procedure;
- Grice procedure is not recommended for varus deformities;
----------------
The Grice procedure. Extra-articular subtalar arthrodesis.

Re: Internal orthotic

Dr. Z on 2/06/03 at 20:16 (108280)

Pauline,
I have no personal experience with this procedure, however here is what I remember from my reading. The internal orthosis is like a very small, short bolt. It goes into the areas between the heel and the talus bone. It blocks motion that is causing pain. The implant can be removed
at a later date if needed. It is a very simple procedure to perform. Rapid recovery. I would agree but you are always going to one at least one patient that won't get better fast, may get rejection, may get an infection.

This could be a very good procedure in the right patient. I just don't have the experience to tell you this is true. On paper this should be a fairly rapid recovery procedure due to the area that it is used in.
Due to this being done on a non-weight area it should have very little pain and a fairly fast recvery provided nothing goes wrong like infection, rejection. I think the material is either steel or silicone. I am not sure

Re: Internal orthotic

Dr. Z on 2/06/03 at 20:17 (108281)

This procedure isn't indicated for plantar fasciitis. It is only for flatfeet due to excessive motion called pronation

Re: Internal orthotic- MBA implant the link

Dr. Z on 2/06/03 at 20:32 (108284)

http://www.visitkmi.com/mbaphy.html

Here is the link from the company that makes this device. It is called an MBA implant.

Re: Internal orthotic

BrianG on 2/06/03 at 21:47 (108294)

Sometimes I think that I have PF of the brain! Thanks :*)

BrianG

Re: Internal orthotic- MBA implant the link

BGCPed on 2/07/03 at 22:44 (108433)

A few questions I have is to treat a severe pronated fot as they claim seems a bit of a stretch. As we know there are many other factors in the severe pronated foot. If you just put this plug in and ignored the other common factors seen in this foot type what would the results be?

A few questions I have based on their claims

If it deals with a manual corrected ff varus then why not use an orthotic?

For severe pronated foot as they claim what about the usual ff abductus, hindfoot valgus, ff varus, tight gastroc, ? a lag screw thru that joint cant address the entire pathology.

I think the main thing is to read the 'secondary contraindications' very close. that alone will shine some light on the claims of this device. I can see for a peds application, but the claims for all the adult and more severe conditions it is a bit of a stretch

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 11:35 (108471)

BG, Pauline:

The MBA implant (Maxwell-Branch Arthroeresis) is something I am very familiar with.

Rearfoot overpronation occurs at the subtalar joint. The MBA implant is a screw-like device that is inserted into the sinus tarsi, an opening between segments of the subtalar joint. It basically acts as a 'stop' to limit excess motion at the subtalar joint. It is not used for PF.

It, unfortunately, is being 'oversold' in some areas. The important thing to understand is that it is often not effective as a 'stand alone' procedure. BG aptly pointed out the various elements involved in a unstable foot and the MBA only addresses one element. Many isolated MBA insertions which I have seen have failed and may lead to subtalar joint pain. The successful MBA insertions are usually those in which the MBA is combined with another, larger, procedure which addresses the primary plane of the flatfoot deformity, eg. medial column fusion.
Ed

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 11:39 (108472)

ps.
It is a metal implant.
Ed

Re: Internal orthotic- MBA implant the link

Dr. Z on 2/08/03 at 13:30 (108482)

Is it a stand alone procedure for child?

Re: Internal orthotic- MBA implant the link

BGCPed on 2/08/03 at 14:00 (108484)

Thanks Dr Ed. I always wonder when i see something presented as a bit of pie in the sky solution. If you think of an old barn with a sagging unstable roof, and put one steel truss in the middle of 30 you still have an unstable roof all around it. I am sure it is indicated and works well in some cases, but I would hate to see a few poor folks with complex collapes foot be told that a screw/plug will have them dancing in a few weeks.

I also wonder about the possible failures using it on a cavus foot ( I believe I saw that mentioned also) Putting that into a foot with varus calc position would, I think create an even more rigid stiff foot. Most all cavus feet have a plantarflexed 1st and some tight tendon issues.

I am sure we all see several post polio patients per year that had procedures done on the foot during childhood. I dont know all the intent behind the procedure back then but I dont think they considered the long term damage to the knee and hip.

I have seen more than a few pt that have minimal shoe/fo support and heel ht is not proper. When they walk the knee many times has a nasty hyperextension due to equinus not being dealt with. Perhaps some of the Dr can shed a bit of info on the thinking back then. I dont mean to say that any of the Dr on here are that old to have performed the procedures, just have some knowledge about them

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 14:47 (108485)

BG:
The MBA would not be performed on a cavus foot. Untreated equinus would cause major problems with an MBA -- usually a gastroc. recession or achilles lengthening is combined with an MBA in such circumstances.
Ed

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 15:01 (108486)

Dr. Z:
Sometimes. I feel though, that if an individual has a flatfoot deformity of sufficient severity to warrant surgery, the MBA will generally not be sufficient. On the other hand, if the MBA did the job, as an isolated procedure, one needs to ask if that foot could not have been controlled via orthotics.

I have watched the technique and application develop through the last few years. There is some degree of discretion as to the proper size implant to use -- very far from being as clear cut as a 1st MTP joint implant. An MBA implant that is too small in diameter often results in minimal results. Usually, the implant is inserted and subtalar motion tested on the table. Larger diameter implants cause more restriction of subtalar pronation and look better on the table but may cause pain and have to be removed later. Surgeons are inclined to be willing to place a smaller diameter MBA when they are performing other procedures to deal with the flatfoot deformity.

Consideration needs to be given not just to planal dominance but also to the phase in gait that is to be modified -- this gets forgotten sometimes.
The MBA is working in late midstance as a 'stop.' One great combination is the MBA plus a medial calcaneal slide. The calcaneal tuberosity is translated medially which moves the achilles medial to the subtalar joint axis. The slide is technically simple to perform, heals reasonably rapidly and has few complications. The important thing is that the slide procedure results in reduction of the rate of pronation early in contact phase and early midstance -- that takes a lot of load off the MBA implant, often preventing the 'stop' from being too abrupt and painful.
Ed

Re: post-polio

Ed Davis, DPM on 2/08/03 at 15:13 (108488)

ps. Keep in mind that the post-polio patients we see now had the procedures done a long, long time ago when the armamentarium of procedures was much smaller. Also: long term predictability of the effects of fusions and tendon transfers is not very good. Ideally, those patients needed follow up and revisions every five years in order to maintain functionality. Gastrosoleus equinus is a destructive force on the midfoot and is difficult to deal with in orthotic therapy. I use a physical therapist skilled in manual therapy to work on the equinus and while I tend to be conservative from a surgical standpoint, I would encourage tendo-achilles lengthening or gastrocnemius recession procedures when needed.

If a patient has a tight gastrosoleus achilles and needs an orthotic, I will often cast them somewhat pronated to allow tolerance. As the equinus is resolved, I may progessively raise the orthotic. I think that lack of ankle dorsiflexion is one of the main causes of orthotic intolerance so that needs to be dealt with aggressively.
Ed

Re: Internal orthotic- MBA implant the link

BGCPed on 2/08/03 at 15:51 (108493)

I did note in the post by brian g that they said it could be used on both calcaneovalgus and calcaneovarus. perhaps I am missing something here. Thank you for the informative posts Dr Ed, its nice to see a Dr that knows his knife but not in a hurry to use it........so to speak

I had a pt recently that had a total collapsed foot that was rigid. Somebody did a ptti procedure and nothing else. Needless to say it worked like a square wheel. When I see someting like that I wonder if the person that performed it slept through biomech 101 or just doesnt care. If they were not skilled enough to fix the whole foot then they should have sent the pt to someone that did

Re: polio / Stretching the gastrocsoleus group

A Manoli, MD on 2/09/03 at 19:47 (108629)

i'm old enough!!!!!!!

1. polio gave number of people a quadriceps muscle (front of thigh, knee extensor) weakness in addition to foot muscle imbalance. also, usually had a short leg. the idea was to set the ankle/foot in some equinus, to stabilize the knee by forcing it into extension, and make up for the shortening. worked ok, until the knee capsule stretched out in the back.

if one attempts to correct any equinus in a paralytic siutuation, must be sure the knee fully extends, is strong and the lengths are pretty close.

2. someone please give me a reference when it shows that one can stretch a contracted gastroc-soleus group with a lasting effect.

of interest, someone sent me this abstract recently:

Authors: Harvey L. Herbert R. Crosbie J.

Institution
School of Physiotherapy, University of Sydney, Australia.

Title
Does stretching induce lasting increases in joint ROM? A systematic
review. [Review] [41 refs]

Source
Physiotherapy Research International. 7(1):1-13, 2002.

Abbreviated Source
Physiother Res Int. 7(1):1-13, 2002.

Abstract
BACKGROUND AND PURPOSE: Stretching (that is, interventions that apply
tension to soft tissues) induces increases in the extensibility of soft
tissues, and is therefore widely administered to increase joint mobility
and reverse contractures. However, it is not clear whether the effects
of stretching are lasting. A systematic review was conducted to
determine if stretching (either self-administered, administered manually
by therapists or by some external device such as a splint) produces
lasting increases in the mobility of joints not directly affected by
surgery, trauma or disease processes. METHOD: In order to determine the
lasting effects of stretching, only studies that measured joint range of
motion (ROM) at least one day after the cessation of stretching were
included. MEDLINE (from 1966 to June 2000), EMBASE (from 1988 to June
2000), the Cochrane Controlled Trials Register and PEDro databases were
searched, and citation tracking was used to identify randomized studies
that met the inclusion criteria. Each study was rated by two independent
assessors on the PEDro scale, which rated trials according to criteria
such as concealed allocation, blinding and intention-to-treat analysis.
RESULTS: Thirteen studies satisfied the inclusion criteria. All examined
the effect of stretching (median number of stretch sessions = eight) on
joint ROM in healthy subjects without functionally significant
contractures. Four studies were of 'moderate' quality and the remaining
nine were of 'poor' quality. The 'moderate' quality studies suggest that
regular stretching increases joint ROM (mean increase in ROM = 8
degrees; 95% CI 6 degrees to 9 degrees) for more than one day after
cessation of stretching and possibly that the effects of stretching are
greater in muscle groups with limited extensibility. CONCLUSIONS: The
results of four 'moderate' quality studies show a convincing effect of
stretching in people without functionally significant contracture. These
findings require verification with high-quality studies. Lasting effects
of intensive stretching programmes (for example, stretching applied for
more than six weeks or for more than 20 minutes a day) or of stretching
on people with functionally significant contracture have not yet been
investigated with randomized studies. [References: 41]

Re: To Dr. Manoli polio / Stretching the gastrocsoleus group

Pauline on 2/09/03 at 20:39 (108634)

Dr. Manoli,
Thank you for posting again. Your posts are always appreciated and well referenced which is really great. I think we all wish you'd post on a more regular basis. We have no other Orthopedic Foot and Ankle Specialist contributing their expertise here. Some of the posters expressed this factlast week and I know they would love to see you posting more often.
Please think about it.

Could you tell us if your using ESWT in your office? If you are what type of results are you seeing with your P.F. patients?

Re: To Dr. Manoli polio / Stretching the gastrocsoleus group

BGCPed on 2/09/03 at 23:10 (108643)

Out of respect for elders I didnt point out any names. I always wonder about gastroc stretching for long term. I bet that some genetic/body types respond better than others. Not sure of how long the stretch lasts after doing it but I have had many patients with poor results.

You have the sedentary folks that get forced to go to pt and they improve sometimes. I also see many hardcore runners that say they stretch every day, you check range and they are tight as a drum with no increase in rom.

it is a difficult question indeed

Re: To BGCPed - Stretching the gastrocsoleus group

Julie on 2/10/03 at 04:19 (108652)

It is possible to stretch the gastrocsoleus if that is the aim, and if it's focused on, and maintained for a considerable period of time (throughout life, actually). And - importantly - if high impact activity, which shortens muscles, is avoided.

Hard core runners would be very hard put to lengthen gastrocsoleus! Even if they did pre- and post-running stretches religiously, I'd guess the most they could hope for would be to maintain the status quo and not get tighter. Most of the runners I've known have really only paid minimal attention to stretching - they're usually in a hurry to get running.

Re: To BGCPed - Stretching the gastrocsoleus group

Julie on 2/10/03 at 04:30 (108653)

PS

The study quoted says:

'Lasting effects of intensive stretching programmes (for example, STRETCHING APPLIED FOR MORE THAN SIX WEEKS OR MORE THAN 20 MINUTES A DAY...have not yet been investigated...'

And if they were investigated, the results would be disappointing. A six-week programme would scarcely be enough to show significant results, and if stretching stopped after the six weeks, there would be no lasting effects: the person would quickly lose whatever gain in flexibility/length had been attained. Stretching is for life.

Re: long term effect of stretching the gastrosoleus

Ed Davis, DPM on 2/10/03 at 15:06 (108709)

Dr. Manoli:

Very few physical therapists have technique sufficient to achieve a meaningful increase in ankle dorsiflesion. There is a subgroup of manual therapists who are though.

Long term? Only if the the patient keeps up the stretching will long term results be possible. Obviously, if spasticity is involved, the equinus will recur but that is true for surgery too -- I have post-polio patients who have had multiple tendo-achilles lengthenings.
Ed

Re: To BGCPed - Stretching the gastrocsoleus group

Ed Davis, DPM on 2/10/03 at 15:09 (108710)

Julie:

The focus that manual therapists use is the posterior midleg area -- basically the aponeurosis of the gastrocnemius. I don't think much elongation occurs in the achilles itself but rather at the level of the aponeurosis.
Ed

Re: Internal orthotic

Dr. Z on 2/06/03 at 16:14 (108247)

This sounds like a plastic plug that is inserted into the subtalar joint
It stops or reduces the excessive pronation in the child's foot. This procedure is old. It is called a Grice Procedure. The different today is that instead of having to harvest bone from the hip the doctor uses the plugs

As for long term results I am not sure. Many of my podiatric friends have told me this is an excellent procedure. I believe this internal orthosis procedure has been out for about five years. It is a very sound procedure with very little complications and disability. I am sure that some of our doctors on this board could give you more information from their own experience. I did one Grice procedure in my residency program twenty odd years ago.
I have never heard of the term internal orthosis used. IF my child had painful excessive pronatory feet that failed to respond to orthosis I would allow them to undergo this surgical procedure.

Re: Internal orthotic

Pauline on 2/06/03 at 17:59 (108265)

Dr. Z,
Do you know what material it's made of and does it remain in place for life? Here is how the ad reads 'If you have been told that nothing can be done with your flat feet or you just have to live with it...give the office a call. The correction is achieved with an 'internal orthotic' that is inserted into the foot during a brief outpatient surgery. This procedure is producing amazing results on adults and children with a very rapid recovery time'.

I question the 'rapid recover time'. Doesn't seem like anything to do with the feet is ever rapid.

I had never seen ads for an internal orthotic so I thought this was interesting. Does it go in the arch or heel? What happens if a person can't tolerate it later on? How large is the implant?

If the build up of scare tissue is causing P.F. patients pain how is it possible to inplant something like this into such a small space without causing additional pain?

Re: Internal orthotic

BrianG on 2/06/03 at 19:57 (108276)

Hi Pauline,

I took a look around the Net, and there is some information about the Grice procedure, as DrZ remembered. From what I read, it looks like it's mostly used for children, with flat feet. I didn't see anything were it would be used for PF. It is indeed a plug, which is surgically implanted into the foot. It is also reversable. It appears the healing period is 4-6 weeks, if only the one procedure is done. Sounds like someone might be using this procedure off label. More snake oil for the PF suffer's? I don't know, maybe!

The following is cut and pasted:
BrianG

Grice Arthrodesis:

- Discussion:
- extra-articular arthrodesis which is useful in blocking subtalar
motion in those patients who have no gross skeletal deformities but
have instability of the hindfoot;
- this arthrodesis is particularlly applicable in children, since there
is little interference with future growth of the foot;
- spastic pes valgus is most common in pts who have spastic diplegia and is generally resistant to orthotic management;
- subtalar extra-articular arthrodesis that was originally devised by
Grice for the management of pes valgus due to flaccid paralysis
muscle imbalance has also been widely used in patients who have
cerebral palsy;
- Grice procedure is simple method of obtaining fusion of subtalar joint;
- it was originally described for use in the immature foot deformed
with a hindfoot valgus secondary to CP, poliomyelitis, and other
paralytic foot deformities;
- on occassion it may also be used for degenerative disorders of the hindfoot;
- this procedure can be used for calcaneocavus, calcaneovalgus,
talocalcaneal coalition, congenital vertical talus, and isolated
post traumatic arthritis of the sub talar joint;
- should triple arthrodesis be necessary later in life, it is felt that
early correction w/ Grice procedure makes the operation easier
because it restores the anatomy more nearly to normal;
- Grice procedure has been used in the treatment of varus deformities of the hindfoot in children;
- varus deformity, however, has tended to recur in these cases, and Grice procedure is not currently recommended for varus deformity
- degree of valgus deformity is difficult to define;
- progression of deformity is a chief indication for treatment;
- children w/ the valgus deformity rarely present with pain;
- goal of operation for growing child is to perform definative procedure on hindfoot that corrects deformity, restores height of foot, and yet does not interfere w/ subsequent growth of the foot;
- triple arthrodesis, interferes with subsequent growth of the foot,
and does not restore the height of the foot;
- Radiographs:
- lateral radiograph of the foot, held in slight equinus and inversion, will confirm whether the valgus deformity of the subtalar joint is fully corrected;
- Contraindications:
- it is necessary that the hindfoot by flexible and corretable passively to a plantigrade position;
- rigid deformed hindfoot is a contraindication to the Grice procedure;
- most older children ( > 10 years) & adults with pathologic hindfoot valgus, will show evidence of secondary degenerative changes of the talonavicular and calcaneocuboid joints;
- these are relative contraindications for the Grice procedure;
- Grice procedure is not recommended for varus deformities;
----------------
The Grice procedure. Extra-articular subtalar arthrodesis.

Re: Internal orthotic

Dr. Z on 2/06/03 at 20:16 (108280)

Pauline,
I have no personal experience with this procedure, however here is what I remember from my reading. The internal orthosis is like a very small, short bolt. It goes into the areas between the heel and the talus bone. It blocks motion that is causing pain. The implant can be removed
at a later date if needed. It is a very simple procedure to perform. Rapid recovery. I would agree but you are always going to one at least one patient that won't get better fast, may get rejection, may get an infection.

This could be a very good procedure in the right patient. I just don't have the experience to tell you this is true. On paper this should be a fairly rapid recovery procedure due to the area that it is used in.
Due to this being done on a non-weight area it should have very little pain and a fairly fast recvery provided nothing goes wrong like infection, rejection. I think the material is either steel or silicone. I am not sure

Re: Internal orthotic

Dr. Z on 2/06/03 at 20:17 (108281)

This procedure isn't indicated for plantar fasciitis. It is only for flatfeet due to excessive motion called pronation

Re: Internal orthotic- MBA implant the link

Dr. Z on 2/06/03 at 20:32 (108284)

http://www.visitkmi.com/mbaphy.html

Here is the link from the company that makes this device. It is called an MBA implant.

Re: Internal orthotic

BrianG on 2/06/03 at 21:47 (108294)

Sometimes I think that I have PF of the brain! Thanks :*)

BrianG

Re: Internal orthotic- MBA implant the link

BGCPed on 2/07/03 at 22:44 (108433)

A few questions I have is to treat a severe pronated fot as they claim seems a bit of a stretch. As we know there are many other factors in the severe pronated foot. If you just put this plug in and ignored the other common factors seen in this foot type what would the results be?

A few questions I have based on their claims

If it deals with a manual corrected ff varus then why not use an orthotic?

For severe pronated foot as they claim what about the usual ff abductus, hindfoot valgus, ff varus, tight gastroc, ? a lag screw thru that joint cant address the entire pathology.

I think the main thing is to read the 'secondary contraindications' very close. that alone will shine some light on the claims of this device. I can see for a peds application, but the claims for all the adult and more severe conditions it is a bit of a stretch

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 11:35 (108471)

BG, Pauline:

The MBA implant (Maxwell-Branch Arthroeresis) is something I am very familiar with.

Rearfoot overpronation occurs at the subtalar joint. The MBA implant is a screw-like device that is inserted into the sinus tarsi, an opening between segments of the subtalar joint. It basically acts as a 'stop' to limit excess motion at the subtalar joint. It is not used for PF.

It, unfortunately, is being 'oversold' in some areas. The important thing to understand is that it is often not effective as a 'stand alone' procedure. BG aptly pointed out the various elements involved in a unstable foot and the MBA only addresses one element. Many isolated MBA insertions which I have seen have failed and may lead to subtalar joint pain. The successful MBA insertions are usually those in which the MBA is combined with another, larger, procedure which addresses the primary plane of the flatfoot deformity, eg. medial column fusion.
Ed

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 11:39 (108472)

ps.
It is a metal implant.
Ed

Re: Internal orthotic- MBA implant the link

Dr. Z on 2/08/03 at 13:30 (108482)

Is it a stand alone procedure for child?

Re: Internal orthotic- MBA implant the link

BGCPed on 2/08/03 at 14:00 (108484)

Thanks Dr Ed. I always wonder when i see something presented as a bit of pie in the sky solution. If you think of an old barn with a sagging unstable roof, and put one steel truss in the middle of 30 you still have an unstable roof all around it. I am sure it is indicated and works well in some cases, but I would hate to see a few poor folks with complex collapes foot be told that a screw/plug will have them dancing in a few weeks.

I also wonder about the possible failures using it on a cavus foot ( I believe I saw that mentioned also) Putting that into a foot with varus calc position would, I think create an even more rigid stiff foot. Most all cavus feet have a plantarflexed 1st and some tight tendon issues.

I am sure we all see several post polio patients per year that had procedures done on the foot during childhood. I dont know all the intent behind the procedure back then but I dont think they considered the long term damage to the knee and hip.

I have seen more than a few pt that have minimal shoe/fo support and heel ht is not proper. When they walk the knee many times has a nasty hyperextension due to equinus not being dealt with. Perhaps some of the Dr can shed a bit of info on the thinking back then. I dont mean to say that any of the Dr on here are that old to have performed the procedures, just have some knowledge about them

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 14:47 (108485)

BG:
The MBA would not be performed on a cavus foot. Untreated equinus would cause major problems with an MBA -- usually a gastroc. recession or achilles lengthening is combined with an MBA in such circumstances.
Ed

Re: Internal orthotic- MBA implant the link

Ed Davis, DPM on 2/08/03 at 15:01 (108486)

Dr. Z:
Sometimes. I feel though, that if an individual has a flatfoot deformity of sufficient severity to warrant surgery, the MBA will generally not be sufficient. On the other hand, if the MBA did the job, as an isolated procedure, one needs to ask if that foot could not have been controlled via orthotics.

I have watched the technique and application develop through the last few years. There is some degree of discretion as to the proper size implant to use -- very far from being as clear cut as a 1st MTP joint implant. An MBA implant that is too small in diameter often results in minimal results. Usually, the implant is inserted and subtalar motion tested on the table. Larger diameter implants cause more restriction of subtalar pronation and look better on the table but may cause pain and have to be removed later. Surgeons are inclined to be willing to place a smaller diameter MBA when they are performing other procedures to deal with the flatfoot deformity.

Consideration needs to be given not just to planal dominance but also to the phase in gait that is to be modified -- this gets forgotten sometimes.
The MBA is working in late midstance as a 'stop.' One great combination is the MBA plus a medial calcaneal slide. The calcaneal tuberosity is translated medially which moves the achilles medial to the subtalar joint axis. The slide is technically simple to perform, heals reasonably rapidly and has few complications. The important thing is that the slide procedure results in reduction of the rate of pronation early in contact phase and early midstance -- that takes a lot of load off the MBA implant, often preventing the 'stop' from being too abrupt and painful.
Ed

Re: post-polio

Ed Davis, DPM on 2/08/03 at 15:13 (108488)

ps. Keep in mind that the post-polio patients we see now had the procedures done a long, long time ago when the armamentarium of procedures was much smaller. Also: long term predictability of the effects of fusions and tendon transfers is not very good. Ideally, those patients needed follow up and revisions every five years in order to maintain functionality. Gastrosoleus equinus is a destructive force on the midfoot and is difficult to deal with in orthotic therapy. I use a physical therapist skilled in manual therapy to work on the equinus and while I tend to be conservative from a surgical standpoint, I would encourage tendo-achilles lengthening or gastrocnemius recession procedures when needed.

If a patient has a tight gastrosoleus achilles and needs an orthotic, I will often cast them somewhat pronated to allow tolerance. As the equinus is resolved, I may progessively raise the orthotic. I think that lack of ankle dorsiflexion is one of the main causes of orthotic intolerance so that needs to be dealt with aggressively.
Ed

Re: Internal orthotic- MBA implant the link

BGCPed on 2/08/03 at 15:51 (108493)

I did note in the post by brian g that they said it could be used on both calcaneovalgus and calcaneovarus. perhaps I am missing something here. Thank you for the informative posts Dr Ed, its nice to see a Dr that knows his knife but not in a hurry to use it........so to speak

I had a pt recently that had a total collapsed foot that was rigid. Somebody did a ptti procedure and nothing else. Needless to say it worked like a square wheel. When I see someting like that I wonder if the person that performed it slept through biomech 101 or just doesnt care. If they were not skilled enough to fix the whole foot then they should have sent the pt to someone that did

Re: polio / Stretching the gastrocsoleus group

A Manoli, MD on 2/09/03 at 19:47 (108629)

i'm old enough!!!!!!!

1. polio gave number of people a quadriceps muscle (front of thigh, knee extensor) weakness in addition to foot muscle imbalance. also, usually had a short leg. the idea was to set the ankle/foot in some equinus, to stabilize the knee by forcing it into extension, and make up for the shortening. worked ok, until the knee capsule stretched out in the back.

if one attempts to correct any equinus in a paralytic siutuation, must be sure the knee fully extends, is strong and the lengths are pretty close.

2. someone please give me a reference when it shows that one can stretch a contracted gastroc-soleus group with a lasting effect.

of interest, someone sent me this abstract recently:

Authors: Harvey L. Herbert R. Crosbie J.

Institution
School of Physiotherapy, University of Sydney, Australia.

Title
Does stretching induce lasting increases in joint ROM? A systematic
review. [Review] [41 refs]

Source
Physiotherapy Research International. 7(1):1-13, 2002.

Abbreviated Source
Physiother Res Int. 7(1):1-13, 2002.

Abstract
BACKGROUND AND PURPOSE: Stretching (that is, interventions that apply
tension to soft tissues) induces increases in the extensibility of soft
tissues, and is therefore widely administered to increase joint mobility
and reverse contractures. However, it is not clear whether the effects
of stretching are lasting. A systematic review was conducted to
determine if stretching (either self-administered, administered manually
by therapists or by some external device such as a splint) produces
lasting increases in the mobility of joints not directly affected by
surgery, trauma or disease processes. METHOD: In order to determine the
lasting effects of stretching, only studies that measured joint range of
motion (ROM) at least one day after the cessation of stretching were
included. MEDLINE (from 1966 to June 2000), EMBASE (from 1988 to June
2000), the Cochrane Controlled Trials Register and PEDro databases were
searched, and citation tracking was used to identify randomized studies
that met the inclusion criteria. Each study was rated by two independent
assessors on the PEDro scale, which rated trials according to criteria
such as concealed allocation, blinding and intention-to-treat analysis.
RESULTS: Thirteen studies satisfied the inclusion criteria. All examined
the effect of stretching (median number of stretch sessions = eight) on
joint ROM in healthy subjects without functionally significant
contractures. Four studies were of 'moderate' quality and the remaining
nine were of 'poor' quality. The 'moderate' quality studies suggest that
regular stretching increases joint ROM (mean increase in ROM = 8
degrees; 95% CI 6 degrees to 9 degrees) for more than one day after
cessation of stretching and possibly that the effects of stretching are
greater in muscle groups with limited extensibility. CONCLUSIONS: The
results of four 'moderate' quality studies show a convincing effect of
stretching in people without functionally significant contracture. These
findings require verification with high-quality studies. Lasting effects
of intensive stretching programmes (for example, stretching applied for
more than six weeks or for more than 20 minutes a day) or of stretching
on people with functionally significant contracture have not yet been
investigated with randomized studies. [References: 41]

Re: To Dr. Manoli polio / Stretching the gastrocsoleus group

Pauline on 2/09/03 at 20:39 (108634)

Dr. Manoli,
Thank you for posting again. Your posts are always appreciated and well referenced which is really great. I think we all wish you'd post on a more regular basis. We have no other Orthopedic Foot and Ankle Specialist contributing their expertise here. Some of the posters expressed this factlast week and I know they would love to see you posting more often.
Please think about it.

Could you tell us if your using ESWT in your office? If you are what type of results are you seeing with your P.F. patients?

Re: To Dr. Manoli polio / Stretching the gastrocsoleus group

BGCPed on 2/09/03 at 23:10 (108643)

Out of respect for elders I didnt point out any names. I always wonder about gastroc stretching for long term. I bet that some genetic/body types respond better than others. Not sure of how long the stretch lasts after doing it but I have had many patients with poor results.

You have the sedentary folks that get forced to go to pt and they improve sometimes. I also see many hardcore runners that say they stretch every day, you check range and they are tight as a drum with no increase in rom.

it is a difficult question indeed

Re: To BGCPed - Stretching the gastrocsoleus group

Julie on 2/10/03 at 04:19 (108652)

It is possible to stretch the gastrocsoleus if that is the aim, and if it's focused on, and maintained for a considerable period of time (throughout life, actually). And - importantly - if high impact activity, which shortens muscles, is avoided.

Hard core runners would be very hard put to lengthen gastrocsoleus! Even if they did pre- and post-running stretches religiously, I'd guess the most they could hope for would be to maintain the status quo and not get tighter. Most of the runners I've known have really only paid minimal attention to stretching - they're usually in a hurry to get running.

Re: To BGCPed - Stretching the gastrocsoleus group

Julie on 2/10/03 at 04:30 (108653)

PS

The study quoted says:

'Lasting effects of intensive stretching programmes (for example, STRETCHING APPLIED FOR MORE THAN SIX WEEKS OR MORE THAN 20 MINUTES A DAY...have not yet been investigated...'

And if they were investigated, the results would be disappointing. A six-week programme would scarcely be enough to show significant results, and if stretching stopped after the six weeks, there would be no lasting effects: the person would quickly lose whatever gain in flexibility/length had been attained. Stretching is for life.

Re: long term effect of stretching the gastrosoleus

Ed Davis, DPM on 2/10/03 at 15:06 (108709)

Dr. Manoli:

Very few physical therapists have technique sufficient to achieve a meaningful increase in ankle dorsiflesion. There is a subgroup of manual therapists who are though.

Long term? Only if the the patient keeps up the stretching will long term results be possible. Obviously, if spasticity is involved, the equinus will recur but that is true for surgery too -- I have post-polio patients who have had multiple tendo-achilles lengthenings.
Ed

Re: To BGCPed - Stretching the gastrocsoleus group

Ed Davis, DPM on 2/10/03 at 15:09 (108710)

Julie:

The focus that manual therapists use is the posterior midleg area -- basically the aponeurosis of the gastrocnemius. I don't think much elongation occurs in the achilles itself but rather at the level of the aponeurosis.
Ed