Patient Selection 101 With Dr. Michael E. Graham

Jan 29, 2020

One of the most frequently asked questions is how to know if a patient is a potential candidate for EOTTS-HyProCure. Dr. Graham will enlighten viewers on how to identify ideal, less-than-ideal, and non-candidates. This information is extremely important to reduce removal rates and potential complications.

Questions & Answers

There have been cases of patients with a longer than the anticipated period of post-operative pain, what steps should be taken before proceeding to remove the implant?

First, it is very important to inject long-acting anesthesia combined with ¾ cc of short- to mid-acting steroid. The reason for pain is from the inflammatory reaction, so it is important to put the medication right where it needs to go. The injection of local anesthesia and steroid should be given prior to making the skin incision.

It is better to perform uni-lateral correction, but that foot will continue to have soreness until the contra-lateral limb is internally corrected with HyProCure.

Patients should be prescribed a post-op anti-inflammatory and should ice.

If pain out-of-proportion is affecting the patient, and both feet have been internally corrected with HyProCure:

  • Re-x-ray to make sure the implant has not displaced, or to ensure the talus has not been over-corrected. Make sure the patient's shoe gear is not worn-out, leading to over-supination of the hindfoot.
  • Give up to 3 superficial sinus tarsi injections of local anesthesia combined with short to mid-term acting steroids. The injections should provide almost immediate relief, typically within 20 minutes. If there is no improvement, consider downsizing or permanent removal.
  • Even though this is a rather short procedure, the recovery can take up to a year or more. Remember, the patient has been walking on misaligned feet for years, and it may take time for the tissues to adjust to the corrected foot position.
Parents are concerned about their child's flatfeet, but the child has no complaints. Do you still recommend performing HyProCure despite no symptoms? Is this within the standard of care?

The “standard of care” is to diagnose the true deformity and to provide treatment solutions/options to the parents/guardian/child. Recurrent talotarsal joint displacement (RTTJD) is not a life-threatening condition, but it is a disaster waiting to happen. It is not if the second pathology will happen - it is when that secondary pathology will happen. The sooner any treatment is provided, the less tissue damage will occur. There are risks with any surgical procedure, and there are benefits with every procedure. So it is up to the patient to decide if the benefits outweigh the risks.

What is below the standard of care is to spread misinformation that their child will outgrow this condition and that no treatment will ever be required. Or that the use of a shoe insert will “fix” the hindfoot misalignment as the child grows. Those statements are not backed by any published evidence.

Do you often perform an EOTTS with a bunionectomy?

It really depends on the first ray deformity. Many times, patients with a mild/moderate deformity will only require EOTTS, which could actually reduce the size of the bunion because the primary etiology is reduced. Other times, due to the severity of the first ray deformity, the combination of EOTTS with first ray corrective surgery is mandated. Ideally, it is better to first perform EOTTS and stage the 1st ray correction. “Fixing” both at the same time results in guarded supination of the hindfoot and forefoot during the recovery process. Performing both at the same time can compromise the success of the EOTTS procedure.

If you do perform an EOTTS with a bunionectomy, does that influence which bunionectomy you perform? Such as changing your thinking from performing a lapidus to a distal osteotomy?

It really depends on the flexibility and stability of the first ray. See the question, "Do you often perform an EOTTS with a bunionectomy?" If both have to be performed at the same surgical setting, always perform EOTTS first and then evaluate the first ray.

When it comes to the “1st ray lengthening” due to TTJD, have you ever seen an incidental finding of a decrease in shoe size after correction with putting in an implant?

Yes, absolutely. This can be easily measured on a pre- and post-EOTTS procedure. The reduction of the anteriorly deviated cyma will lead to a shortening on the medial column. That is the reason for the formation of a “short” lateral column.

What is your opinion on putting an implant into a patient with trisomy 21? What have you observed differently in the post-op period?

There are no studies to show that or anticipate any difference or effect trisomy 21 would have. The EOTTS procedure is not an osseous procedure, so the only reason for non-weight-bearing is to allow the tissues to respond to the inflammatory reaction from cutting the tissues. The patients with trisomy 21 would have the same recovery regardless of that finding.

What is the preferable sport activity (tennis or football or…) for children after HyProCure surgery? And after what time from surgery date it is allowed to do sport activities?

There is no particular preferred sport after HyProCure – it is what the child prefers there are no limitations to sports after the patient is fully recovered.

We suggest that there should not be any strenuous activity as far as running, jumping, etc. until a minimum of 6 to 8, that’s because the chance of stent displacement after 6 weeks is < 1%.

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