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New implant puts arches in flatfeet

Tuesday, February 09, 1999

By Pohla Smith, Post-Gazette Staff Writer

Vicki Stimmel was born with flatfeet, and she suffered plenty with them as she grew up. She even had a complicated surgery that involved cutting out two bones and rerouting muscles and tendons, a procedure that kept her at home with a tutor for four months.

 
  After a surgeon recommended Kyle Coughenour, above, to another doctor using the MBA implant, the 7-year-old from Connellsville had two procedures that corrected his flatfeet. (Annie O'Neill, Post-Gazette)
The results were mixed.

"I don't have any pain, but I still don't have any arches," said Stimmel, 30, a medical assistant who lives in Connellsville. "They don't look as bad."

She vowed that if she ever had any children with flatfeet that she'd take advantage of every medical advance to correct them.

Her first child, a daughter, was born with flatfeet, but not as bad as hers. A few years in hightop shoes and Fiberglas shoe inserts called orthotics, which simulated an arch, Stimmel said, "and they kind of corrected themselves."

Younger brother Kyle Coughenour, 7, wasn't as lucky. Not only was he born with a dislocated hip, he had flatfeet that were painful and easily recognized by the untrained eye.

The second-grader at South Side Elementary School in Connellsville said his feet and legs would hurt "when I stopped running and when I was in stores."

He, too, got corrective shoes. "We went with several different kinds of orthotics, with no success," Stimmel said. As he grew, doctors expected the problem to worsen and that his unnatural gait would cause permanent shifts in his body's bone structure.

Finally Kyle's foot surgeon recommended Stimmel take her son to a doctor performing a new surgery that involved no bone removals, tendon procedures or long recoveries.

With the insertion of the titanium MBA prosthesis, approved by the Food and Drug Administration in 1995, Kyle would need just two brief out-patient surgeries, each involving a half-hour under anesthesia, six stitches, a couple of weeks walking on crutches and a couple more in a protective boot.

The MBA prosthesis, which comes in several sizes, is a tiny, screw-like pin that is inserted into a small opening between the heel bone and another bone on top of it, creating a natural arch. Tissue grows normally around it to hold it in place.

Kyle had his right foot done in August, the other at Thanksgiving. By early January, he was cruising around Walt Disney World in Orlando, Fla., on two nicely arched feet and two straight legs.

His legs still tire sometimes and he limps a bit at the end of a long day. But other times he feels so good he sneaks a lap or two on his bicycle, even though his surgeon, Dr. Karen Luther of Pittsburgh Family Footcare P.C., has ruled out such activities until April.


Consequences

 
Since receiving the MBA implants, Kyle Coughenour has been able to enjoy more activities, and can stand straighter and for longer periods with less tiring in his feet and legs.. (Annie O'Neill, Post-Gazette) 

There are about 20 combinations of flatfeet involving various deformities. But they fall into two categories: non-rigid, or flexible, flatfeet; and rigid, or inflexible flatfeet, which are more severe and may occur with congenital bone malformations.

Kyle has acquired non-rigid or flexible flatfeet, a condition that tends to run in families and is more common in Jewish, black and Hawaiian populations. According to some estimates, various degrees of flatfeet affect up to 25 percent of the U.S. population.

"You hear all babies have flatfeet," Luther said. "No, they don't. Their feet look flat because they have that fat pad."

The condition usually becomes visible when a baby starts standing or walking. Flexible flatfeet look flat sometimes when the child stands up. When he or she stands on tiptoe or the foot bears no weight, the arch is restored. They also tend to have toes that turn in.

If the feet are extremely flat, the child's physician may prescribe an arch support in a firm shoe. Although this will not correct the foot, it may permit long walks without foot strain. In severe cases, surgery may be required.

Unless a child complains of severe pain, fatigue or leg cramps, flexible flatfeet often are undiagnosed until more serious consequences result - sometimes years, even decades later.

The structure of a flatfoot arch is so weak that it can't support the weight of the body properly. As a result, the foot over-rotates to the side.

Years of walking with that pronation causes structural changes in the joints in and above the foot up to the spinal column.

"Your shock absorption decreases, so you're getting more of a pounding to the knees and the hips," Luther said. Those parts of the body also begin to change to adapt to the abnormality in the foot, causing more problems.

The consequences can be severe.

Adults with flatfeet develop stiffness in their joints, which may lead to back pain because the joints are out of alignment, Luther said. Eventually they may develop arthritis because their joints have been grinding abnormally, possibly requiring bone surgeries or fusions.

Another problem may be bunions, which are bony growths on the outside of the lower big toe, which occur because people are walking on the sides of their feet. In some cases, bunions become painful, stiff and can lead to osteoarthritis.

Some physicians believe that some of the knee and hip replacements being done stem from untreated flatfeet. Some doctors are trying to organize a study to examine the cause of these cases, according to Eric Cooper, president of C.E.A. Medical, a medical supplies company in Cuyahoga Falls, Ohio, and the local representative selling the MBA prosthesis, which is made by Kinetikos of San Diego, Calif.

"The doctors have residents pulling files of people who had knees and hips done to look for any flatfeet that may have been X-rayed," Cooper said. "We don't know if there is a direct correlation or not, but we suspect it may be a correlation."


Other treatments

There are many methods to treat flatfeet, even in adults who are suffering from such complications as arthritis and shortening of the Achilles tendon, which can cause pain and an odd gait, such as toe walking.

Most doctors first treat flatfeet with corrective shoes and orthotics, especially in children.

Kyle's orthotics helped ease his discomfort, Luther said, "but structurally they didn't do anything. He had them in his shoes and they pushed his arch up, but aside from that, summer would come and he'd go swimming and be outside horsing around in a sandal and there would be no support for the foot."

And there are other surgeries besides the MBA prosthesis, and advanced versions similar to the procedure Stimmel had.

Dr. Robert Mendicino, director of the Foot & Ankle Institute at The Western Pennsylvania Hospital, prefers other surgeries, even though his practice is one of three in the Pittsburgh region performing the MBA implant.

"I think the implant has a narrow implication," Mendicino said. He thinks it works best on a child with a flexible flat foot.

In the beginning, Luther limited her MBA surgeries to children with good flexibility who needed no additional restructural surgery, but she did her first adult before Christmas late last year and now plans to do more.

The man "had a flat foot because he had a fibrous, almost like a ligament, obstruction, keeping these bones from moving properly," Luther said. "We cleaned this thing out and put that peg in and he's doing very well."

Doctors in some parts of the country have been inserting the MBA prosthesis in adults since it became available in 1996.

"A lot of physicians start with kids first because it's more of a straightforward procedure for them," Cooper said. "Adults generally have other complications, like the Achilles has shortened and they have to lengthen them. Or other ligaments stretch, then you have to do tendon transfers and bone work."

And, in some cases, Cooper said, the MBA insert just doesn't work.

"The reality is not everyone can handle the implant," he said. "They can feel it; it's uncomfortable and not right for them."

But to Cooper and Luther, that's the beauty of the new procedure. Because no holes must be drilled to insert the peg, it can be unscrewed and removed easily. With other implants, bone grafts might be necessary.

Luther has done close to 40 of the surgeries since she was trained in the procedure a couple of years ago.

Cooper said about 50 MBA implants are done in his six-state territory each month and that he's probably seen 1,000 in the three years it's been available.



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