Experts' Perceived Patient Burden and Outcomes of Knee-ankle-foot-orthoses (Kafos) Vs. Microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot Orthoses (Mp-sscos).

BACKGROUND: Patients with neuromuscular knee-instability assisted with orthotic devices experience problems including pain, falls, mobility issues and limited engagement in daily activities. OBJECTIVES: The aim of this study was to analyse current real-life burden, needs and orthotic device outcomes in patients in need for advanced orthotic knee-ankle-foot-orthoses (KAFOs). METHODOLOGY: An observer-based semi-structured telephone interview with orthotic care experts in Germany was applied. Interviews were transcribed and content-analysed. Quantitative questions were analysed descriptively. FINDINGS: Clinical experts from eight centres which delivered an average of 49.9 KAFOs per year and 13.3 microprocessor-stance-and-swing-phase-controlled-knee-ankle-foot orthoses (MP-SSCOs) since product availability participated. Reported underlying conditions comprised incomplete paraplegia (18%), peripheral nerve lesions (20%), poliomyelitis (41%), post-traumatic lesions (8%) and other disorders (13%). The leading observed patient burdens were "restriction of mobility" (n=6), followed by "emotional strain" (n=5) and "impaired gait pattern" (n=4). Corresponding results for potential patient benefits were seen in "improved quality-of-life" (n=8) as well as "improved gait pattern" (n=8) followed by "high reliability of the orthosis" (n=7). In total, experts reported falls occurring in 71.5% of patients at a combined annual frequency of 7.0 fall events per year when using KAFOs or stance control orthoses (SCOs). In contrast, falls were observed in only 7.2 % of MPSSCO users. CONCLUSION: Advanced orthotic technology might contribute to better quality of life of patients, improved gait pattern and perceived reliability of orthosis. In terms of safety a substantial decrease in frequency of falls was observed when comparing KAFO and MP-SSCO users.

[Surgical procedures for the correction and stabilization of pes planovalgus]. / Stabilisierung und Korrektur der medialen Säule im Rahmen der operativen Pes-planovalgus-Therapie.

The medial column of the foot is a relevant factor of the pathogenesis of pes planovalgus. Crucial anatomic structures are the tibiocalcaneonavicular ligament complex, the naviculocuneiform joints, including the ossa cuneiformia, and the first tarsometatarsal joint. A combination of bony and soft tissue reconstructive techniques must, therefore, be taken into account when treating pes planovalgus. The present article presents stabilizing and correcting surgical procedures for the medial column of the foot, including basic anatomy and biomechanics.

Subjective outcome following neurostimulator implantation as drop foot therapy due to lesions in the central nervous system-midterm results.

BACKGROUND: Drop foot can be caused by many conditions. Stroke is one of the major causes of drop foot and 5% of stroke survivors suffer from hemiplegia, which in some cases, can manifest as drop foot. The abnormal gait resulting from the lack of innervation of the extensor muscles may result in a secondary malposition of the foot and lead to a steppage gait. Among the several therapy options for the treatment of drop foot, functional electrostimulation (FES) with a transcutaneous peroneal nerve stimulator (tPNS) or an implantable peroneal nerve stimulator (iPNS) represents the two recent approaches. OBJECTIVE: Although therapy with an iPNS has been proven to be effective, a subjective patient assessment has not yet been executed. The aim of this study was to assess the patient's satisfaction with the therapy by using two established surveys. METHODS: The Rivermead Mobility Index (RMI) and the Reintegration to Normal Life Index (RNLI) were used for this retrospective study. The RMI includes 15 questions which are to be answered as either "yes" or "no" and given a value of 1 or 0, respectively, with a maximum of 15 points possible. The RNLI includes 11 questions which are to be answered with the use of a visual analog scale (VAS, 0 to 10 cm). In this case, a maximum adjusted score of 100 points is possible. RESULTS: The total study cohort involved 56 patients treated with an iPNS. Thirty-five complete data sets for the RMI and 29 for the RNLI could be achieved. A significant difference in the total score of both surveys was observed between the deactivated and the activated iPNS (RMI: p = 0.02; RNL: p = 0.01). CONCLUSION: A significant improvement in patient satisfaction was detected with the use of an activated iPNS after a mean time span of 4 years. Due to the marked mobility, an increase in the social satisfaction and integration could be achieved. Both aspects represent essential components for the recovery and quality of life of the patients.

Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference?

BACKGROUND: Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically. OBJECTIVE: The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction. METHODS: A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted. RESULTS: A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary. CONCLUSION: The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.

[Rupture of the tendon of the tibialis anterior muscle : Etiology, clinical symptoms and treatment]. / Ruptur der Musculus-tibialis-anterior-Sehne : Ätiologie, klinische Symptome und Therapie.

Ruptures of the tendon of the tibialis anterior muscle tend to occur in the context of degenerative impairments. This mainly affects the distal avascular portion of the tendon. Owing to the good compensation through the extensor hallucis longus and extensor digitorum muscles, diagnosis is often delayed. In addition to the clinical examination, magnetic resonance inaging (MRI) diagnostics are of particular importance, although damage or rupture of the tendon can also be demonstrated sonographically. Therapeutic measures include conservative or operative measures, depending on the clinical symptoms. Conservative stabilization of the ankle can be achieved by avoiding plantar flexion using a peroneal orthosis or an ankle-foot orthosis. Subsequent problems, such as metatarsalgia or overloading of the medial foot edge can be addressed by insoles or a corresponding shoe adjustment. An operative procedure is indicated when there is corresponding suffering due to pressure and functional impairment. The direct end-to-end reconstruction of the tendon is only rarely possible in cases of delayed diagnosis due to the degenerative situation and the retraction of the tendon stumps. Depending on the defect size and the tendon quality, various operative techniques, such as rotationplasty, free transplants or tendon transfer can be used.

[Foot drop treatment by implantation of a neuroprosthesis (ActiGait®)]. / Behandlung des Fallfußes durch Implantation einer Neuroprothese (ActiGait®).

OBJECTIVE: Gait improvement by restoring dorsiflexion using a neuroprosthesis implant. INDICATIONS: Foot drop with damage to the 1st motor neuron; passive mobility in ankle is possible; adult patients. CONTRAINDICATIONS: Foot drop with peripheral damage and injury to the peroneal nerve; already implanted stimulators (e.g., defibrillator, pacemaker, or pain stimulator); severe anesthesia risks in multimorbid patients. SURGICAL TECHNIQUE: Surgery in lateral position. Searching for the peroneal nerve after dorsal incision in the popliteal fossa, using the medial edge of the biceps femoris as anatomic landmark. After identification of the motor branch of the peroneal nerve by positive dorsiflexion after using electrostimulation apply the electrode cuff on the nerve. Epifascial implantation of stimulation body lateral at the middle third of the thigh over the tractus iliotibialis. POSTOPERATIVE MANAGEMENT: Pain-adapted full weight bearing, no knee flexion more than 90° for 4-6 weeks, activation of neuroprosthesis 3 weeks after surgery, physiotherapy with gait training is required. RESULTS: Between 2013 and 2015, implantation of the neuroprosthesis was performed in 21 patients (13 men/8 women) with chronic foot drop due to a central lesion. Significant improvement in walking speed measured with the 10 meter walk test (11.8 ± 5.4 s to 7.9 s ± 3.4; p = 0.007), in gait endurance with 6 min walk test (212.2 ± 75.5 m to 306.4 ± 96.4 m; p ≤ 0.001), and in gait performance using the Emory Functional Ambulation Profile (105.9 ± 49.7 s to 63.2 ± 31. 3 s; p ≤ 0.001). No patient required surgical revision. Postoperative bleeding was recorded in one case (4%). Patient satisfaction and improvement in mobility and quality of life could be achieved (95% and 90%, respectively).

Comparative measurements of bone mineral density and bone contrast values in canine femora using dual-energy X-ray absorptiometry and conventional digital radiography.

BACKGROUND: Aseptic loosening due to bone remodelling processes after total hip replacement is one common cause for revision surgery. In human medicine, dual-energy X-ray absorptiometry (DEXA) is the gold standard for quantitative evaluation of bone mineral density, whereas in veterinary medicine conventional radiography is used for follow-up studies. Recently, a method has been described using digital X-ray images for quantitative assessment of grey scale values of bone contrast. Therefore, the aim of the present study was to evaluate the correlation of bone mineral density (BMD) measured by DEXA with grey scale values (GV) measured in digital X-ray images (RX50, RX66) ex vivo. RESULTS: The measured GV in the chosen X-ray settings showed on average a good correlation (r = 0.61) to the measured BMD with DEXA. Correlation between the two X-ray settings was very good (r = 0.81). For comparisons among regions of interests (ROIs) a difference of 8.2% was found to be statistically significant, whereas in the case of RX50 and RX66 differences of 5.3% and 4.1% were found to be statistically significant. CONCLUSIONS: Results indicate that measuring absolute changes in bone mineral density might be possible using digital radiography. Not all significant differences between ROIs detectable with DEXA can be displayed in the X-ray images because of the lower sensitivity of the radiographs. However, direct comparison of grey scale values of the periprosthetic femur in one individual patient during the follow-up period, in order to predict bone remodelling processes, should be possible, but with a lesser sensitivity than with DEXA. It is important that the same X-ray settings are chosen for each patient for follow-up studies.

[Lapidus arthrodesis]. / Lapidus-Arthrodese.

The tarso-metatarsal 1 joint (TMT-I) arthrodesis is a treatment option or moderate to severe hallux valgus (HV) deformities. Instability of the TMT1 joint is still a debatable indication. Using stable osteosynthesis techniques allows early postoperative weight bearing. Plantar plating combined with a lag screw is the biomechanical most stable construct. An additional intermetatarsal screw can improve the horizontal stability. Clinical results are good and radiological parameters stay constant, even in the long term.

[Distal osteotomy for the treatment of hallux valgus (Chevron osteotomy)]. / Distale Korrekturosteotomie zur Behandlung des Hallux valgus (Chevron-Osteotomie).

Distal osteotomies, like the Chevron osteotomy, is indicated for mild to moderate hallux valgus deformities. Splayfoot, painful pseudoexostosis, and transfer metatasalgia are observed in the clinical examination. Radiographic examination should be done with weight bearing in two planes. Preoperatively the intermetatarsal (IM), hallux valgus, and distal metatarsal articular (DMAA) angles should be measured. The operative technique is based on soft tissue and bony correction. Modifications of the osteotomy allow a shortening, lengthening, or neutral correction of the first metatarsal. With a modified Chevron osteotomy, an increased DMAA can be also corrected.

[Soft tissue techniques in hallux valgus surgery]. / Weichteiltechniken in der Hallux-valgus-Chirurgie.

The hallux valgus represents combined bony and soft tissue pathology. In addition to known bony surgical procedures, addressing the soft tissue with regard to the anatomical structures, the surgical technique and the extent of correction are discussed.The goal of the operation is the restoration of the physiological balance between the active and passive stabilizing factors of the MTP-I-joint. The joint capsule, the ligaments and the tendons of the first ray act directly as stabilizing structures, whereas the hind foot and the position of the upper ankle have an indirect influence on the MTP-I-joint.The present work gives an overview of the pathoanatomy of the MTP-I-joint in the hallux valgus pathology. The individual anatomical structures are presented with regard to their physiological and pathological influence and the possible therapeutic options.

[Functional electrostimulation for drop foot treatment : Clinical outcome]. / Funktionelle Elektrostimulation zur Therapie des neurogenen Fallfußes : Klinisches Outcome.

INTRODUCTION: Neurologic paralysis of the foot due to damage to the central nervous system is primarily caused by a cerebral insult. The ankle-foot orthosis (AFO), which is the classical conservative treatment option, is associated with drawbacks, e.g., increased contractures, limited mobilization from the sitting position, and cosmetic aspects. METHODS: Functional external electrostimulation (FES) is an suitable treatment method for patients with a central lesion and intact peroneal nerve. Based on this method, the neuroprosthesis is a dynamic therapy option in the form of an implantable nerve stimulator (ActiGait® system, Otto Bock, Duderstadt, Germany) which is placed directly on the motor branch of the peroneus nerve and results in active foot lifting. The aim of the present study is to evaluate the clinical effect of the ActiGait® system with regard to its suitability for everyday use by means of gait tests with an emphasis on time-distance parameters and to compare it with the current literature. RESULTS AND CONCLUSION: In this retrospective study, the clinical results after implantation of the ActiGait® system are presented and evaluated. In summary, the implantation of a neuroprosthesis in patients with stroke-related drop foot represents a sensible and promising therapy option.

Restoring mobility after stroke: first kinematic results from a pilot study with a hybrid drop foot stimulator.

OBJECTIVE: The objective was to obtain first insights into the kinematic and kinetic walking patterns resulting from an implanted functional electrical stimulation system in subjects with a drop foot caused by stroke. METHODS: Four subjects who experienced a stroke were chosen due to a comparatively long/short time after surgery and young/old at the stroke event were examined retrospectively with gait analysis. Kinematics and kinetics of normal walking were assessed in comparison with and without activated drop foot stimulation. RESULTS: In general, an improvement regarding spatiotemporal parameters as a result of the stimulation could be observed. Walking speed was increased by 45 % and stride length by 22 % after a mean usage of 7 (2-14) months, whereas both younger subjects improved significantly more. Dorsiflexion increased in all subjects on average from 1.3° to 11.6° during initial contact as well as from 11.3° to 17.0° during mid-swing and therefore implies an advantage of around 5.5 inch foot clearance. Pathologic elements like knee hyperextension during loading response and mid-stance, leg circumduction during swing or the increased hip flexion of the contralateral leg during mid-stance could be in general adjusted with stimulation. CONCLUSION: An implantable functional electrical stimulation system seems to be a promising treatment of drop feet following strokes. Further clinical investigations are necessary to confirm these first insights.

[Hallux amputation]. / Amputation der Großzehe.

OBJECTIVE: Debridement of infected tissue with the main aim being the re-establishment of mobilization with preservation of standing and walking ability. Prevention of secondary pressure points or amputations due to inadequate resection or deficient soft tissue cover. INDICATIONS: In the case of increasing necrosis of the big toe, surgical abrasion and/or amputation is considered unavoidable. Other indications where surgery could be considered include diabetes and its associated angiopathies together with peripheral arterial angiopathy. CONTRAINDICATIONS: In the case of insufficient blood supply an expansion of the resection margins should be taken into account. If there are possible alternatives to amputation. Surgery for patients with renal failure requiring dialysis associated with increased complication rate. SURGICAL TECHNIQUE: A dorsal cuneiform resection is performed to facilitate implantation of a plantar skin transplant and wound healing. Important is the resection of bone in a slide oblique technique. Amputation scars should be outside pressure zones. Partial amputations in the area of the first ray as exarticulation or via the individual amputated segments possible (as opposed to toes 2-5). POSTOPERATIVE MANAGEMENT: Direct postoperative weight-bearing with rigid insole and dispensing aid for 6-8 weeks. Following complete wound healing, foot support with orthopedic arch and transverse strain relief should be advocated, together with a joint roll in ready-made individual shoes. RESULTS: Both trauma and nontrauma cases were included in our present cohort. A total of 7 cases were surgically revised in 2014 due to superficial skin necrosis that was likely the result of skin tension from the wound stitches.

[Alloarthroplasty versus above-knee amputation]. / Alloarthroplastik kontra transfemorale Amputation.

BACKGROUND: We report an unusual case of a 38-year-old physically active patient, who suffered a Ewing sarcoma during adolescence and was therefore treated with a tumor endoprostheses ex domo (replacement of distal femur and proximal tibia). Since then he had undergone a couple of surgical interventions for revision and is currently suffering from persistent pain in the leg concerned. An aseptic loosening of the tibial component was evident after radiologic examinations. Because he had suffered for so long our patient refused further surgery to retain the affected limb and he preferred amputation. OBJECTIVES: We would have taken the risk of a femoral residual limb that is much too short compared with a classical above-knee amputation. In this regard we saw difficulties in exoprosthetic treatment with functional limitations that could easily have influenced the outcome negatively. METHOD: Consequently, we decoupled the tibial component from the femoral one within the knee joint and thus performed a knee disarticulation leaving the femoral component. RESULTS: Postoperatively, we found a mostly harmonious gait pattern with a pure mechanical interim prosthesis regarding time-distance parameters, which may be even further improved with the final prosthesis. Sagittal joint angles are comparable to conventionally knee exarticulated ones. DISCUSSION: To date, no comparable case of such an alloarthroplasty, which could regain mobility with an exoprosthetic treatment has been highlighted in the literature. In the result, a knee disarticulation within the area of a knee arthroplasty leaving the femoral component is not inferior to"ordinary" knee disarticulation.

Inflammatory response to burn trauma: nicotine attenuates proinflammatory cytokine levels.

OBJECTIVE: The immune response to an inflammatory stimulus is balanced and orchestrated by stimulatory and inhibitory factors. After a thermal trauma, this balance is disturbed and an excessive immune reaction with increased production and release of proinflammatory cytokines results. The nicotine-stimulated anti-inflammatory reflex offsets this. The goal of this study was to verify that transdermal administration of nicotine downregulates proinflammatory cytokine release after burn trauma. METHODS: A 30% total body surface area full-thickness rat burn model was used in Sprague Dawley rats (n = 35, male). The experimental animals were divided into a control group, a burn trauma group, a burn trauma group with additional nicotine treatment, and a sham + nicotine group with 5 experimental animals per group. The last 2 groups received a transdermal nicotine administration of 1.75 mg. The concentrations of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6 were determined in homogenates of hearts, livers, and spleens 12 or 24 hours after burn trauma. RESULTS: Experimental burn trauma resulted in a significant increase in cytokine levels in hearts, livers, and spleens. Nicotine treatment led to a decrease of the effect of the burn trauma with significantly lower concentrations of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6 compared to the trauma group. CONCLUSIONS: This study confirms in a standardized burn model that stimulation of the nicotinic acetylcholine receptor is involved in the regulation of effectory molecules of the immune response. Looking at the results of our study, further experiments designed to explore and evaluate the potency and mechanisms of the immunomodulating effects of this receptor system are warranted.

Huge sciatic neuroma presented 40 years after traumatic above knee amputation.

BACKGROUND: An amount of 70,000 minor/major amputees are annually performed for different reasons such as tumor, trauma, perivascular diseases or diabetic ulcera yearly in Germany. Over the course of time a lot of patients get problems with their stump, which leads to an incompatible prosthetic treatment and immobilisation. OBJECTIVE: Handicapped patients are often characterized by a long history of pain. The fact that they often had comorbidities as diabetes, vascular diseases or other metabolic affection, leads to the situation that no other differential diagnoses are taken into account. PATIENTS AND METHODS: We present a case of a 62 year old patient with a history of burning pain with punctum maximum at the dorso-medial part of the distal femur stump 40 years after a traumatic above-knee amputation. He had sought different medical consultations and had a lot of modifications on his prosthesis shaft with partial benefit. The clinical examination confirmed the suspected diagnosis of a stump neuroma from the sciatic nerve, which has been verified in the MRI. Concerning the symptoms and the increasing immobilisation caused by the burning pain, we indicated a surgical revision which includes a resection from the neuroma and a local flap graft correction. RESULTS: Postoperatively he described a complete pain relief. After 6 weeks under weight bearing mobilisation he was 100% free of pain in his new custom-made shaft prosthesis and could mobilised under full bearing. CONCLUSION: We conclude that neurinoma needs to be considered in handicapped patients with such symptomatology and has to be surgically revised, even if that decision especially for handicapped patients is often difficult for the surgeon.

[Extra-articular arthroereisis according to Grice/Green versus calcaneal lengthening according to Evans: retrospective comparison for therapy of neurogenic pes planovalgus]. / Extraartikuläre Arthrorise nach Grice/Green vs. Kalkaneusverlängerungsosteotomie nach Evans: Retrospektiver Vergleich zur Therapie des neurogenen Pes planovalgus.

BACKGROUND: Common reasons for juvenile neurogenic pes planovalgus are hypoxic brain damage, birth defects of the spinal canal, trauma and cerebral cancer. When symptoms persist despite conservative treatment of symptomatic pes planovalgus, surgery is indicated. Objectives of the operation are improved gait and mobilization as well as an improved basis for wearing shoes. Joint preserving and ankylosing procedures as well as combinations of both are available. The aim of this study was a retrospective comparison of the Grice/Green extra-articular arthroreisis versus the Evans calcaneal lengthening operation. MATERIAL AND METHODS: Between October 2001 and October 2009 a total of 75 arthroereisis operations were performed according to Grice/Green and in the period from April 2006 to February 2010 a total of 83 calcaneal lengthening operations according to Evans. The focus of the study was on patients with an underlying neurogenic disease which resulted in 72 cases in the Grice/Green group and 70 cases in the Evans group. The average age was 14.6 ± 5.0 years in the Evans group and 10.1 ± 3.4 years in the Grice/Green group. Of the patients in the Grice/Green group 17 had infantile cerebral palsy (ICP) and 25 had other neuromuscular diseases and in the Evans group 14 patients had ICP and 28 patients had other neuromuscular diseases. The medical records, preoperative and postoperative radiographs were analyzed. In addition information was obtained on the quality of life (EQ-5D), mobility and the supply of mobility aids using a specially designed questionnaire. The radiological evaluation was based on preoperative and postoperative lateral and dorso-plantar radiographs. The follow-up time for the questionnaire was on average 54 months (range 12-109 months) for the Grice/Green group and 22 months (range 9-53 months) for the Evans group. The postoperative treatment was similar in both groups. RESULTS: The talometatarsal (TMT) index could be improved by surgery according to Grice/Green from - 50.2° to - 28.1° and in the Evans group a correction from - 49.6° to - 31.8° was possible. Considering the cases with severe preoperative deformities (TMT index < -50°) there was a significantly greater correction of the lateral talocalcaneal (TC) angle by the method of Grice/Green. In 67 % of patients in the Grice/Green group and 57 % in the Evans group a significant improvement in terms of pain was possible. A significant improvement in gait and possible walking distance was found in 33 % of the Grice/Green group and 43 % of the Evans group and an average improvement was possible in 40 % and 43 %, respectively. The operation was considered to be very successful by 67 % of patients in the Grice/Green group and in 57 % of patients in the Evans group but the difference was not significant. In the Grice/Green group no revisions were necessary and revision was performed in two cases after surgery in the Evans group due to wound infections. CONCLUSIONS: Both of the processes investigated in this study are suitable for treatment of pes planovalgus. In cases of neurogenic pes planovalgus and also in extreme cases (TMT index < -50°) the procedure according to Grice/Green has radiological advantages for reconstruction of the lateral TC angle.