1. 1. Pediatric Obesity The Foot ConnectionNew Treatment UpdatesMichael E. Graham, DPM, FACFAS, FSPS, FAENSMacomb, Michigan
2. 2. Childhood obesity is on the rise.www.HyProCure.com
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5. 5. Obesity leads to manyother health problems We have to eliminateobesity in order to treatthese other diseases,otherwise thesecondary healthproblems will continueto get worse, not better www.HyProCure.com
6. 6. Obesity TreatmentDid you know: Only 21% of 64 obesity programs resultedin a short-term weight-loss Of that 21%, it was only a small change WHY? www.HyProCure.com
7. 7. Obesity Treatment Decreased food intake Increase weightbearing activity Decrease sedentary behavior www.HyProCure.com
8. 8. Obesity Treatment Decreased food intakeis only part of theequation We have to get thesekids moving This increases theirmetabolismwww.HyProCure.com
9. 9. Exercise is important to maintainingproper body weight.Exercise leads to increased metabolismand decreased weight. www.HyProCure.com
10. 10. Sounds Good, BUTWhat if they have bad feet?www.HyProCure.com
11. 11. Feet are the foundation to the body.www.HyProCure.com
12. 12. Stability of the hindfoot mechanism iscritical for standing, walking, and running. www.HyProCure.com
13. 13. Bad Feet = Increased Pain = Decreased Exercise Majority of obese childrenalso have faulty footmechanics (talotarsaldislocation) Like driving your car withunbalanced, worn-out tiresand with the steering out ofalignment its not fun www.HyProCure.com
14. 14. They Suffer When They Exercise 4 to 5 times your body weighttravels through each foot whenwalking and up to 10 times whenrunning When everything is aligned, thisis still considerable force But when talotarsal dislocationoccurs: Muscles, tendons and ligaments have to compensate for the excessive, abnormal strain The soft tissues first have to bring the hindfoot bones back into normal alignment and then do their regular job to propel the foot www.HyProCure.com
15. 15. They Suffer When They Exercise Over time, the faultymechanics in the foot willcause symptoms to developthroughout the rest of thebody
16. 16. TaloTarsal Dislocation Syndrome This translates to excessive motion that can potentially affect the Knee Pelvis Hips Lower Back Spine NeckJaw(far more than just the foot)
17. 17. TaloTarsal Dislocation Syndrome Did you know the average person takes 7,000 steps/day 49,000 steps/week 196,000 steps/month 2,352,000 steps/yr 11,760,000 steps in 5 years 22,520,000 steps in 10 years 47,040,000 steps in 20 years 116,600,000 steps in 50 years www.HyProCure.com
18. 18. Think about it Even if our foot is slightly out ofalignment the years of standing,walking and running are going totake their toll Early on, dont feel the ill-effects,but eventually the signs andsymptoms will appear Just like this car tire Its not IF, its WHEN www.HyProCure.com
19. 19. Finally, most people will just give up Why keep torturing yourself? You are rewarded with pain.Increased activity = Increased painDecreased activity = Decreased pain www.HyProCure.com
20. 20. We have to stabilize their feet Brings us right back to thestability of our feet But how can we really dothis? www.HyProCure.com
21. 21. TaloTarsal Dislocation The dynamic displacement of the talus (anklebone) off the tarsal mechanism (hindfoot bones) Reducible/flexible: occurs when weight bearing(standing, walking, running) Results in excessive motion of the joint(hyperpronation) Leads to excessive forces on supporting tissues(tendons, muscles, ligaments)www.HyProCure.com
22. 22. TaloTarsal Mechanism Relationship of the articularfacets of the talus on thecalcaneus and navicular Four (4) articular contact points Posterior, middle & anterior talocalcaneal Talonavicular Supination/pronation There should be very littletalotarsal motion www.HyProCure.com
23. 23. Hindfoot Alignment TaloTarsal Mechanismwww.HyProCure.com
24. 24. Radiographic Evaluation TaloTarsal Dislocation Lateral view Talar declination > 26 degrees Anterior deviated cyma line Obliterated sinus tarsi Dropped" navicularNSP Compare Neutral vs. Relaxed Stance Position Sagittal plane dislocation deformityRSPwww.HyProCure.com
25. 25. Radiographic Evaluation AP view Talar 2nd metatarsal angle should be < 16 degrees > 16 degrees = pathologic displacementwww.HyProCure.com
26. 26. Pes PlanoValgus versus TaloTarsal DislocationCIA* is flat to negative CIA is normal to increasedPes PlanoValgus TaloTarsal Dislocation*Calcaneal Inclination Anglewww.HyProCure.com
27. 27. Treatment Options Observation Arch supports/orthoses Special shoes or braces Rearfoot reconstruction surgery Extra-Osseous TaloTarsal Stabilization (EOTTS)www.HyProCure.com
28. 28. Treatment Option- Observation Every step leads torepeated destructiveforces acting on the Foot Ankle Knee Hip Pelvis Back Shoulders Neck www.HyProCure.com
29. 29. Treatment Option- Observation The feet dontautomatically fixthemselves. They progressively getworse. www.HyProCure.com
30. 30. Benefit Risk AnalysisObservation Benefits: Risks: Non-surgical option Progression of the disease Relatively inexpensiveprocess (still have to follow these Every step is inefficient patients progress) Excessive abnormal strain Does not rely on patienton supporting soft tissue compliancestructures No anesthesia/surgical Mal-alignment to other risks structures within the foot & ankle and also up the musculoskeletal chain Leads to the worst possible long-term complicationswww.HyProCure.com
31. 31. Treatment Option- Orthoses/Shoes Do arch supports reallywork? Where is theradiographic proof ofrealignment of theosseous structures?www.HyProCure.com
32. 32. Benefit Risk Analysis Orthoses/Shoes Benefits Risks Non-surgical option Not proven to decrease Relatively inexpensive tissue strain (compared to surgical Not proven to improve options) radiographic No potential measurements anesthesia/surgical Can lead to other complicationsproblems- increased pain Patient compliance issues Need new devices maderegularly Have to be worn in shoes www.HyProCure.com
33. 33. Treatment Option- Rearfoot Surgerywww.HyProCure.com
34. 34. Benefit Risk AnalysisRearfoot Reconstructive Surgery Benefits: Risks: Radiographic correction Surgical risks Internal correction Non-union Infection Does not rely on patient Need for revision compliance Need to remove internal May be covered by hardware insurance companies Anesthesia risk (low) Expensive Long recovery www.HyProCure.com
35. 35. Now I would like to introduce you to theworld ofExtra-Osseous TaloTarsal Stabilizationwww.HyProCure.com
36. 36. What is EOTTS? The use of an internaldevice to preventexcessive motion of thetalus on the calcaneusand navicular Differentiated from inter-osseous intra-osseous Purely a soft tissueprocedure to improve thefunction of hindfootmechanism www.HyProCure.com
37. 37. EOTTS Devices Made of titanium Not screwed into bone Reversible Performed on childrenas young as 3 and older Tens of thousands havebeen performedExample EOTTS devicewww.HyProCure.com
38. 38. What can EOTTS Achieve?www.HyProCure.com
39. 39. What it cant fix.It cant fix everything, there are limitations. Have to have a flexible deformity, that isthe talus can be repositioned on the calcaneus. It will not increase CIA.www.HyProCure.com
40. 40. Who is a candidate for EOTTS Must have a flexibledeformity (talus can berepositioned on tarsalmechanism) Three years of age orolder (no upper agelimit)www.HyProCure.com
41. 41. Who is not a candidate for EOTTS Rigid deformity Less than three (3) years of age www.HyProCure.com
42. 42. Benefit Risk Analysis EOTTS Benefits: Risks: Internal solution Device displacement Minimally invasive, fast Over/Under-correction Extra-osseous Need for revision or (soft tissue) permanent removal Reversible Soft tissue adaptations Proven to decrease strain General surgical risks on supporting tissues Radiographic evidence Covered by most planswww.HyProCure.com
43. 43. We have to stabilize their feet EOTTS really is the bestoption Do not have issues withpatient compliance There is supporting clinical &radiographic evidence ofimprovement Reversible procedure www.HyProCure.com
44. 44. Conclusions Talotarsal dislocation is not normal (sometimes seenin children as flatfoot/navicular drop) There are better options now that are time testedand proven It is a team approach You have access to a great number of foot and anklespecialists who are here to do their best to keep ourchildren active, healthy, and happy www.HyProCure.com
45. 45. Because at the end of the day,we are just trying our bestto keep everyone walking. www.HyProCure.com
46. 46. Please visit www.HyProCure.com for more valuable information and tofind a HyProCure specialist near you.