Double and Triple Tarsal Fusions in the Complex Cavovarus Foot.

The cavovarus (cavus) foot is one of the most perplexing and challenging of all foot deformities and may prove to be one of the most difficult conditions to treat. This deformity is characterized by increased plantar flexion of the forefoot and midfoot in relation to the hindfoot resulting in high foot arch. Because cavus foot rarely occurs in an isolated form, the term "cavus foot" rather describes a part of a complex multiplanar foot deformity. Because the underlying disease is mostly neurogenic characterized by muscle imbalance in almost every case a combined bony and soft tissue surgery is inevitable.

Effect of Glucosamine Sulfate on Osteoarthritis in the Cruciate-Deficient Canine Model of Osteoarthritis.

Objective Osteoarthritis (OA) is a major cause of musculoskeletal pain and disability worldwide. The investigation of disease-modifying treatment options for OA has become an important aspect of orthopedic care. To assess the effect of intra-articular and oral glucosamine sulfate (GS) versus placebo on osteoarthritis in a canine model. Materials In this randomized, placebo-controlled, double-blinded study, OA was induced by anterior cruciate ligament transection (ACLT) according to the Pond-Nuki model in 32 canines. All canines were allocated into 4 treatment subgroups with treatment administered for 8 weeks: GS (400 mg) intra-articular, placebo intra-articular, GS (200 mg/kg body weight) oral, and placebo oral. The contralateral nonoperated stifle (knee) served as control. After 8 weeks, the medial and lateral femoral condyles, the medial and lateral tibial plateau and patella were histologically examined and anatomic changes quantified by light microscopy using the modified Mankin score. Results After 8 weeks, mean Mankin score values significantly ( P < 0.002) decreased in the intra-articular GS group (8.1; range 7.9-8.8) compared with the intra-articular placebo group (13.9; range 11.6-15.9) and again significantly ( P < 0.002) in the oral GS group (12.1; range 9.9-12.7) compared with the oral placebo group (15.1; range 12.5-17.0). Mean Mankin score values were significantly ( P < 0.002) lower in the intra-articular GS group compared with the oral GS group. Conclusion Both, intra-articular and oral administered GS significantly reduced histological signs of OA in the Pond-Nuki model, with the intra-articular application being more effective compared to oral administration.

What's New in Severe Deformity Correction: The German Perspective.

Foot deformities are found in several neurologic conditions, most typically, but not exclusively, Charcot-Marie-Tooth disease. Posttraumatic deformities and undercorrection or overcorrection of congenital talipes equinovarus are also encountered. A severely deformed foot that cannot fit into normal shoes presents a significant day-to-day challenge to the young and active patient. This article presents some basic principles for evaluating the deformity and a toolkit of procedures to deal with these complex cases.

Surgical Treatment of Severe Cavovarus Foot Deformity in Charcot-Marie-Tooth Disease.

INTRODUCTION: A successful adjusted treatment algorithm for the correction of cavovarus foot deformity requires soft-tissue balancing procedures, in particular total split posterior tibial tendon transfer (T-SPOTT), in combination with adjunctive corrective procedures depending on the degree of deformity. STEP 1 SURGICAL PREPARATION: Place the patient in a supine position and follow a standard aseptic surgical disinfection and draping protocol, allowing access to the iliac crest. STEP 2 STEINDLER RELEASE OF THE PLANTAR APONEUROSIS: Use a medial approach to access and transect the plantar aponeurosis. STEP 3 RELEASE THE POSTERIOR TIBIAL TENDON AT THE FOOT: Transect the posterior tibial tendon near its insertion point. STEP 4 RETRACT AND SPLIT THE POSTERIOR TIBIAL TENDON AT THE CALF AND TRANSFER IT THROUGH THE INTEROSSEOUS MEMBRANE: Make a medial incision in the distal part of the calf, retract the posterior tibial tendon (and flexor digitorum tendon if necessary), split it longitudinally in half, and pass it through the interosseous space. STEP 5 REVEAL THE TARGET TENDONS AND PULL THE POSTERIOR-TIBIAL-TENDON HALVES TO THESE TENDONS: Expose the anterior tibial and peroneal tendons and pull the posterior-tibial-tendon halves (and flexor digitorum longus tendon of it is being used) to these tendons. STEP 6 CHOPART OR TRIPLE OR LAMBRINUDI ARTHRODESIS: Perform a Chopart, or triple or Lambrinudi 16 , arthrodesis when osseous correction and stabilization are required for fixed deformities. STEP 7 MODIFIED JONES PROCEDURE: If the cavovarus foot displays flexible clawing of the big toe, carry out a modified Jones procedure. STEP 8 EXTENSION OSTEOTOMY OF THE FIRST METATARSAL: If the first metatarsal remains in a fixed plantar flexed position and cannot be corrected with the Jones procedure, perform a dorsal-based wedge extension osteotomy. STEP 9 CLAWING OF THE LESSER TOES: Incise the plantar tendons, transect the long flexor tendons, and place a single Hohmann wire through the end of each claw toe. STEP 10 SOFT-TISSUE EQUINUS CORRECTION RARELY NEEDED: Depending on the severity of the remaining equinus, correct it with calf muscle or calcaneal tendon lengthening (the more severe the equinus, the more distal the corrective measure). STEP 11 SUPRAMALLEOLAR VARUS DEROTATION OSTEOTOMY: If foot external rotation is increased after foot correction, supramalleolar derotation osteotomy should be added to avoid lever-arm problems postoperatively. STEP 12 COMPLETE THE TENDON TRANSFERS: Attach the transferred tendons to their respective target tendons using a Pulvertaft needle with a Pulvertaft weave technique, while keeping the foot in a plantigrade position. STEP 13 WOUND CLOSURE: Reevaluate the foot and determine if all corrections have been made, perform necessary final radiographic documentation, release the tourniquet, perform hemostasis, clean the wounds, and close them. STEP 14 POSTOPERATIVE MANAGEMENT AND AFTERCARE: The achieved operative correction is only as good as the postoperative treatment allows. RESULTS: Various authors have recommended posterior tibial tendon transfer to the dorsum of the foot to correct foot drop.IndicationsContraindicationsPitfalls & Challenges.

Long-term effects after conversion of biarticular to monoarticular muscles compared with musculotendinous lengthening in children with spastic diplegia.

Adverse effects such as increased anterior pelvic tilt (APT) are reported after muscle-tendon lengthening (MTL) for the correction of flexed knee gait in cerebral palsy. The conversion of biarticular muscles (CBM) to monoarticular muscles represents an alternative treatment, but only few short-term results have been published, without comparison with MTL. The long-term outcome of 21 diplegic patients treated with CBM in a prospective study was compared with the results in MTL patients in a matched-pair analysis. Standardized clinical examination and three-dimensional gait analysis were done before surgery, 1 year thereafter, and at long-term follow-up a mean of 9.2 years postoperatively. Mean APT increased one year after surgery in both groups. This increase was higher in MTL patients and statistically significant only for this group. Knee flexion at initial contact and minimum knee flexion in stance were significantly decreased in both groups, while in swing the CBM group tended to show more of a decrease in knee flexion but at the cost of reduced peak flexion. Both groups showed deterioration of kinematic knee parameters through to long-term follow-up; the favourable effects of CBM disappeared, and the two groups displayed comparable average pelvic and knee kinematics. Considering individual patterns the prevalence of increased APT was lower in the CBM group 1 year after surgery, indicating that sparing the semitendinosus may have a positive effect on pelvic stability. However, after 9 years 30% of the patients in both groups showed increased APT indicative of persistent hamstring insufficiency. These results demonstrate that CBM, a significantly more extensive procedure, has no long-term advantage over MTL.

Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy.

BACKGROUND: The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. METHODS: This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion in swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). RESULTS: A significantly increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up in the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. CONCLUSIONS: Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. However, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be indicated in these patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery in spastic diplegic cerebral palsy.

BACKGROUND: Equinus of the foot at the ankle is one of the most common deformities in patients with spastic diplegic cerebral palsy, leading to gait disturbances and secondary deformities. During single-event multilevel surgery, equinus is commonly corrected by calf muscle lengthening, such as gastrocnemius-soleus intramuscular aponeurotic recession. Various studies have described satisfactory short-term results after gastrocnemius-soleus intramuscular aponeurotic recession. However, there is no evidence for maintenance of equinus correction because of the small and heterogeneous case series and short follow-up time previously reported. METHODS: The present study provides long-term results after gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery for the treatment of equinus in forty-four patients with spastic diplegia who were able to walk (forty-eight legs had lengthening of the gastrocnemius and thirty-four legs had lengthening of the gastrocnemius and soleus). Standardized three-dimensional gait analysis and clinical examination were done preoperatively and at one year, a mean (and standard deviation) of 3 ± 1 years, and a mean of 9 ± 2 years after surgery. RESULTS: Significant improvements in kinematic and kinetic ankle parameters on gait analysis as well as passive dorsiflexion in clinical examination were found one year after surgery. While there was a significant loss of passive dorsiflexion at the time of long-term follow-up, the improvements in gait analysis parameters were maintained. The endurance of gait improvements was accompanied by a persistent increase of dorsiflexor muscle strength without relevant loss of plantar flexor strength. Although it was not significant, there was a tendency for deterioration of gait analysis parameters over the nine years. The analysis of individual patterns showed recurrence of equinus at the ankle in 24% of the legs. Early-onset calcaneal gait was found one year after surgery in seven legs (9%), but without secondary crouch gait, and there was recovery at the time of the long-term follow-up. Late-onset calcaneal gait was seen at the time of long-term follow-up in eight legs (10%), of which four had an accompanying crouch gait. CONCLUSIONS: Gastrocnemius-soleus intramuscular aponeurotic recession as a part of multilevel surgery leads to satisfactory correction of mild and moderate equinus deformity in children and adolescents with spastic diplegia without relevant risk for overcorrection and should be preferred over Achilles tendon lengthening to avoid overlengthening. The long-term results in the present study demonstrate that the improvements are long-lasting on average, but individual patients tend to develop recurrence and may need secondary gastrocnemius-soleus intramuscular aponeurotic recession.

Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study.

BACKGROUND: Hamstring lengthening commonly is performed for the treatment of flexed knee gait in patients with spastic diplegic cerebral palsy. Satisfactory short-term results after hamstring lengthening have been demonstrated in various studies. However, evidence for the effectiveness of hamstring lengthening to correct flexed knee gait is scant because of small and inhomogeneous case series, different surgical techniques, and short follow-up. METHODS: The long-term results for thirty-nine patients with spastic diplegia and flexed knee gait who were managed with intramuscular hamstring lengthening as a part of multilevel surgery are presented. Standardized three-dimensional gait analyses and clinical examinations were performed for all patients preoperatively and at one, three, and six to twelve years postoperatively. RESULTS: Significant improvements in kinematic parameters and the popliteal angle were noted at short-term follow-up (p < 0.01), supporting the results of previous studies. Long-term results showed significant deterioration of minimum knee flexion in stance and the popliteal angle (p < 0.01), whereas the improvements in the Gross Motor Function Classification System and Gillette Gait Index were maintained. This recurrence of flexed knee gait is partial and measurable. Increased pelvic tilt was found in 49% of the limbs postoperatively, which may represent one factor leading to recurrence of flexed knee gait. Genu recurvatum was seen in eighteen patients (twenty-seven limbs; 35%) one year postoperatively, especially in the patients with a jump knee gait pattern preoperatively. At long-term follow-up, genu recurvatum resolved in many limbs, but 12% of the limbs showed residual genu recurvatum, indicating that overcorrection represents a problem following hamstring lengthening. CONCLUSIONS: The results of the present study are crucial for the prognosis of knee function after hamstring lengthening as a part of multilevel surgery. Recurrence and possible overcorrection should be considered in treatment planning.

Skewfoot.

Skewfoot is a rare deformity characterized by forefoot adduction and hindfoot valgus. Its etiology and natural history are unknown, although congenital and syndromic forms are observed. Currently, there is no consent about the treatment of skewfoot. Due to its potential resistance to the effects of therapy, it must be differentiated from other, more common deformities. Treatment involves conservative and, most often, operative measures.

Reconstruction of multiplanar deformity of the hindfoot and midfoot with internal fixation techniques.

Reconstruction surgery of the midand hindfoot is a demanding challenge for foot surgeons. Satisfactory results depend not only on surgical technique and skills but also on the knowledge of underlying disorders, pathomechanics, and indication criteria. The cavovarus foot, the planovalgus foot, and Charcot's foot are some of the most challenging foot deformities, requiring different surgical strategies for their correction. Most of the osteotomies and fusions in children and adults can be fixed with transcutaneous Kirschner wires, which are inexpensive and easy to use and remove. The use of alternative fixation systems such as cannulated screws, compression screws, or angle-stable locking plates depends on patient age, vascular situation, risk for nonunion, and underlying pathology.

Complete tendon transfer and inverse Lambrinudi arthrodesis: preliminary results of a new technique for the treatment of paralytic pes calcaneus.

BACKGROUND: Paralytic pes calcaneus is commonly associated with myelomeningocele and continues to be one of the most difficult deformities to treat. The purpose of the present study is to describe and report the preliminary results of a new procedure to dynamically correct paralytic pes calcaneus. MATERIALS AND METHODS: Since 2002, the senior surgeon operated on six patients with myelomeningocele and developed a new procedure to dynamically correct paralytic pes calcaneus. This new procedure combines a complete tendon transfer (tibialis anterior and posterior, peroneus brevis and longus, and extensor digitorum and hallucis longus) to the Achilles tendon and an additive triple arthrodesis. The extent of the calcaneus deformity was evaluated by measuring the talocalcaneal angle. The mean followup was 32 months. RESULTS: Excellent results were achieved in five of the six patients with a mean age of 17.5 years. Using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scale, pain and function improved from an average of 41.6 preoperatively to 72.0 postoperatively. The deformity as assessed by the talocalcaneal angle, the calcaneal pitch, and the talometatarsal I angle improved after surgery significantly (p < 0.004). After 12 months, an additional surgery was required in two patients due to disabling drop-foot. CONCLUSION: This new surgical technique to correct paralytic pes calcaneus including complete tendon transfer and triple arthrodesis is promising. Although this is a technically demanding procedure, it provides an excellent functional result without the residual complications associated with ankle arthrodesis.

Early and stable upregulation of collagen type II, collagen type I and YKL40 expression levels in cartilage during early experimental osteoarthritis occurs independent of joint location and histological grading.

While morphologic and biochemical aspects of degenerative joint disease (osteoarthritis [OA]) have been elucidated by numerous studies, the molecular mechanisms underlying the progressive loss of articular cartilage during OA development remain largely unknown. The main focus of the present study was to gain more insight into molecular changes during the very early stages of mechanically induced cartilage degeneration and to relate molecular alterations to histological changes at distinct localizations of the joint. Studies on human articular cartilage are hampered by the difficulty of obtaining normal tissue and early-stage OA tissue, and they allow no progressive follow-up. An experimental OA model in dogs with a slow natural history of OA (Pond-Nuki model) was therefore chosen. Anterior cruciate ligament transection (ACLT) was performed on 24 skeletally mature dogs to induce joint instability resulting in OA. Samples were taken from different joint areas after 6, 12, 24 and 48 weeks, and gene expression levels of common cartilage molecules were quantified in relation to the histological grading (modified Mankin score) of adjacent tissue. Histological changes reflected early progressive degenerative OA. Soon after ACLT, chondrocytes responded to the altered mechanical conditions by significant and stable elevation of collagen type II, collagen type I and YKL40 expression, which persisted throughout the study. In contrast to the mild to moderate histological alterations, these molecular changes were not progressive and were independent of the joint localization (tibia, femur, lateral, medial) and the extent of matrix degeneration. MMP13 remained unaltered until 24 weeks, and aggrecan and tenascinC remained unaltered until 48 weeks after ACLT. These findings indicate that elevated collagen type II, collagen type I and YKL40 mRNA expression levels are early and sensitive measures of ACLT-induced joint instability independent of a certain grade of morphological cartilage degeneration. A second phase of molecular changes in OA may begin around 48 weeks after ACLT with altered expression of further genes, such as MMP13, aggrecan and tenascin. Molecular changes observed in the present study suggest that dog cartilage responds to degenerative conditions by regulating the same genes in a similar direction as that observed for chondrocytes in late human OA.

Early changes in experimental osteoarthritis using the Pond-Nuki dog model: technical procedure and initial results of in vivo MR imaging.

The purpose of this study was to prove the feasibility of combining in vivo MR imaging with the Pond-Nuki animal model for the evaluation of osteoarthritis. In an experimental study, 24 beagle dogs underwent transection of the anterior cruciate ligament of the left leg (modified Pond-Nuki model). The dogs were randomly assigned into four groups and examined by MRI after 6, 12, 24 and 48 weeks. MR imaging of both knees was performed under general anesthesia with the contralateral joint serving as control. In group 1 (6 weeks postoperatively), the first sign detected on MRI was subchondral bone marrow edema in the posteromedial tibia. After 12 weeks, erosion of the posteromedial tibial cartilage could be observed, followed by meniscus degeneration and osteophytosis after 24 and 48 weeks. The contralateral knee joint showed transient joint effusion, but no significant signs of internal derangement (P<0.001). By combining in vivo MR imaging with the Pond-Nuki model, it is possible to detect early signs of osteoarthritis. The first sign was posteromedial subchondral bone marrow edema in the tibia followed by progressive cartilage degeneration and joint derangement. The in vivo model therefore seems to be suitable for longitudinal studies or monitoring the therapeutic effects of osteoarthritis.