Assessment of pelvic tilt in anteroposterior radiographs by means of tilt ratios.

INTRODUCTION: In anteposterior (AP) radiographs, cup position in total hip arthroplasty and acetabular anatomy in hip-preserving surgery are highly influenced by pelvic tilt. The sagittal rotation of the anterior pelvic plane is an important measurement of pelvic tilt during hip surgery. Thus, correct evaluation of cup position and acetabular parameters requires the assessment of pelvic tilt in AP radiographs. METHODS: Changes in pelvic tilt inversely change the height of the lesser pelvis and the obturator foramen in AP radiographs. Tilt ratios were calculated by means of these two parameters in simulated radiographs for ten male and ten female pelvises in defined tilt positions. A tilt formula obtained by exponential regression analysis was evaluated by two blinded investigators by means of 14 simulated AP radiographs of the pelvis with pelvic tilts ranging from + 15° to - 15°. RESULTS: No differences were found between male and female tilt ratios for each 5° step of simulated pelvic tilt. Pelvic tilt and tilt ratios correlated exponentially. Using the tilt formula, the two blinded investigators were able to assess pelvic tilt with high conformity, a mean relative error of + 0.4° (SD ± 4.6°), and a mean absolute error of 3.9° (SD ± 2.3°). Neutral pelvic tilt is indicated by a tilt ratio of 0.5 when the height of the lesser pelvis is twice the height of the obturator foramen. CONCLUSION: The analysis and interpretation of cup position and acetabular parameters may be improved by our method for assessing pelvic tilt in AP radiographs.

What is the optimal valgus pre-set for intramedullary femoral alignment rods in total knee arthroplasty?

PURPOSE: In total knee arthroplasty (TKA), intramedullary guides are often used for aligning the distal femoral cutting block. Because of the highly varying angles between the mechanical axis and the anatomical femoral axis (AMA), different valgus pre-sets have been recommended. The present study investigated the optimal valgus pre-set (measuring the AMA in long-leg radiographs or at 5°, 6°, 7° or 8° valgus) to align the cutting block perpendicularly to the mechanical axis. METHODS: The AMA was preoperatively measured in weight-bearing long-leg radiographs. After alignment of the cutting block by means of an intramedullary rod, deviation of the block from the mechanical femoral axis was measured with a pinless navigation device. The true AMA (tAMA) was calculated by adding the valgus pre-set of the alignment rod to the deviation measured with the navigation device. Mean deviations between the tAMA and (a) the AMA measured by the surgeon, (b) the AMA calculated with the computer software, (c) 5°, (d) 6°, (e) 7° and (f) 8° valgus pre-sets were measured for each patient. The lowest mean differences were determined. RESULTS: The 40 knees measured showed a mean tAMA of 7.2° valgus (1.7 SD) (range 4°-11.5°). The following mean differences and 95 % limits of agreement were calculated: 2.2 (-1.2, 5.5) to the tAMA for the 5° valgus pre-set, 1.2 (-2.2, 4.5) for 6°, 0.2 (-3.2, 3.5) for 7° and -0.8 (-4.2, 2.5) for 8°. AMA measurements by the surgeon and with the digital medical planning software yielded mean differences of 0.6 (-3.1, 4.3) and 0.4 (-4.1, 4.8), respectively. CONCLUSION: In the present setting, the best mean distal femoral cutting block alignment perpendicular to the mechanical femoral axis could be achieved with a valgus pre-set of 7° and not by measuring the AMA. Nevertheless, we recommend conducting weight-bearing radiographs of the entire leg prior to TKA for easy detection of any anatomical varieties, old fractures, long stems of total hip arthroplasties or cement. However, surgeons must be aware that exact coronal component alignment can only be achieved by navigational devices. LEVEL OF EVIDENCE: Diagnostic study, Level II.

[Total knee arthroplasty in the elderly]. / Kniegelenkersatz des älteren Menschen.

BACKGROUND: The number of total knee arthroplasties in elderly patients is increasing in accordance with the demographic shift in the population. OBJECTIVE: Analysis of the special situation in the elderly, conservative treatment options, perioperative risk factors, preoperative preparation, special intraoperative features and outcome. METHODS: Analysis of currently available scientific data and presentation of own scientific study results. RESULTS: Total knee arthroplasty in elderly patients is related to an increased perioperative risk of complications. A thorough interdisciplinary preparation is required to reduce risk factors. Ligament stability of the knee does not correlate with age. The postoperative outcome after total knee arthroplasty in elderly patients is decisively influenced by the preoperative function and psychosocial parameters. CONCLUSION: Total knee arthroplasty in elderly patients is particularly challenging for orthopedic surgeons and requires close interdisciplinary cooperation.

[Patella navigation in computer-assisted TKA : Intraoperative measurement of patellar kinematics. Video article]. / Patellanavigation bei computerassistierter Knie-TEP-Implantation : Eine Technik zur intraoperativen Messung der Patellakinematik. Videobeitrag.

INTRODUCTION: Patellofemoral maltracking is a relevant problem after total knee arthroplasty (TKA). Patella navigation is a tool that allows real time monitoring of patella tracking. MATERIAL: This video contribution demonstrates the technique of patellofemoral navigation and a possible consequence of intraoperative monitoring. A higher postoperative lateral tilt is addressed with a widening of the lateral retinaculum in a particular manner. CONCLUSION: In selected cases of patellofemoral problems, patella navigation is a helpful tool to evaluate patellofemoral tracking intraoperatively. Modifications of implant position and soft tissue measurements can then prevent postoperative patellofemoral maltracking.

[Clinical examination of the hip joint in adults]. / Klinische Untersuchung des Hüftgelenkes des Erwachsenen.

Complaints in the region of the hips and pelvis are often difficult to classify. This is due to the fact that pain projection and overlapping can occur; therefore, the complete region of the lumbar spine, pelvis and hips must be considered as a single entity in which alterations can result in radiation throughout the whole region. There are many different anatomical structures within the pelvic region so that the function of various muscle components can be impaired and cause pathological alterations to positional relationships of bony structures or even alterations to other soft tissues, such as ligaments, tendons and labra. In terms of differential diagnostics the groin must be seen as the weak point of the peritoneum and vascular system and taken into consideration. Therefore, a detailed and targeted medical history, functional testing and specific examinations and tests are necessary to narrow down the pathology in question and reach a definitive diagnosis. Orthopedic surgeons must know which conspicuous features can lead to which problems and which anatomical structures are likely to be affected by irritation. The results of the clinical examination are the basis for targeted imaging diagnostics and subsequent therapy.

Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany.

INTRODUCTION: Heterotopic ossification (HO) after THA can lead to pain, impaired range of motion and possibly revision surgery. This article summarizes current literature on the pathogenesis of HO in THA and trauma. Second, it presents the results of a survey on prophylactic concepts for HO in Germany. MATERIALS AND METHODS: A narrative literature review was conducted by searching three databases (Pubmed, ScienceDirect, the Cochrane library) on the aetiology of HO. Between 2013 and 2014, a questionnaire was sent to 119 orthopaedic and trauma surgery departments in Germany. RESULTS: The acquired form of HO seems to develop after tissue trauma, which induces a local inflammation. A change in tissue conditions, multiple signalling pathways and involvement of several different cell types seem to promote enchondral ossification and finally HO formation. The feed back rate of the survey was 67%. Eighty-seven percent of all departments currently administer NSAIDs with a mean time span of 3 weeks after surgery for oral prophylaxis. Prophylactic perioperative irradiation is performed in 64% of trauma/orthopaedic departments if the patient is at risk for HO with a mean dosage of 7 Gy. CONCLUSIONS: Basic research detected new pathways and cell signalling mechanisms of HO pathogenesis, which could offer new treatment and prophylaxis options in the near future. So far, there is no uniform strategy for the clinical prophylaxis of HO in THA. Guidelines and new clinical trials need to be developed to further reduce HO rates in THA.

[Operative treatment of the rheumatic shoulder]. / Operative Therapie der rheumatischen Schulter.

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

[Bone defect adjusted strategy in revision arthroplasty of the hip : Wich implant in wich situation? Innovations and approved methods]. / Defektadaptierte Rekonstruktionsstrategien in der Hüftrevisionsendoprothetik : Welches Implantat in welcher Situation? Innovationen und Bewährtes.

BACKGROUND: Revision total hip arthroplasty is of rising importance, with 35,000 procedures a year in Germany. OBJECTIVES: Primary stability of the revision implant, reconstruction of the anatomical hip center, reconstruction of bone stock, and permanent secondary integration are the main priorities. METHODS: Current literature and examples from our own experience are presented. RESULTS AND CONCLUSIONS: Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. For an integrated therapy concept in implant selection criteria, such as situation and structure of the defect, combination with any remaining implants, causes of loosening and failure, implant allergy, and patient-specific parameters should be taken into consideration.

[Clinical examination of the hip joint in adults]. / Klinische Untersuchung des Hüftgelenkes des Erwachsenen.

Complaints in the region of the hips and pelvis are often difficult to classify. This is due to the fact that pain projection and overlapping can occur; therefore, the complete region of the lumbar spine, pelvis and hips must be considered as a single entity in which alterations can result in radiation throughout the whole region. There are many different anatomical structures within the pelvic region so that the function of various muscle components can be impaired and cause pathological alterations to positional relationships of bony structures or even alterations to other soft tissues, such as ligaments, tendons and labra. In terms of differential diagnostics the groin must be seen as the weak point of the peritoneum and vascular system and taken into consideration. Therefore, a detailed and targeted medical history, functional testing and specific examinations and tests are necessary to narrow down the pathology in question and reach a definitive diagnosis. Orthopedic surgeons must know which conspicuous features can lead to which problems and which anatomical structures are likely to be affected by irritation. The results of the clinical examination are the basis for targeted imaging diagnostics and subsequent therapy.

[Minimally invasive treatment of depression fractures of the tibial plateau using balloon repositioning and tibioplasty: video article]. / Die minimal-invasive Versorgung von Tibiakopfimpressionsfrakturen mit Hilfe der Ballonreposition und Tibioplastie : Videobeitrag.

BACKGROUND: The aim of surgical treatment of fractures of the tibial head is an exact reconstruction of the joint plateau. For this purpose the method of balloon tibioplasty is now available in selected cases. This article and the accompanying video material illustrate the minimally invasive technique of tibioplasty using an actual example of patient treatment. METHODS: This technique offers gentle reduction by slow expansion of the balloon. The large balloon surface ensures that more bone can be lifted carefully at once in order to achieve the anatomical position. The positioning of the balloon requires surgical precision. Balloon reduction creates a well-defined bone cavity of known volume and is stabilized using calcium phosphate cement. Possible risks are cement leakage and secondary loss of reduction. RESULTS: Thus far, results are promising, but long-term results are still lacking. Therefore, the indication should be made carefully and differentiated.

[Painful total knee arthroplasty. A treatment algorithm]. / Die schmerzhafte Knieprothese. Ein Behandlungsalgorithmus.

BACKGROUND: Persisting and newly occurring complaints after implantation of a total knee endoprosthesis (TKE) are common problems for orthopaedic surgeons in clinics and private practices. The search for the cause and the diagnostics are often difficult due to the many possible influencing factors. Painful TKE requires patience from the orthopaedic surgeon as well as from the patient. THERAPY MODALITIES: The indications for surgical revision should basically be considered with caution and conservative therapeutic procedures can contribute to a considerable improvement in complaints. The treatment algorithm presented in this article helps to adopt a therapeutic direction and if necessary in assessing the indications for revision or replacement surgery. The algorithm offers the possibility of a systematic classification according to clinical, radiological and laboratory testing aspects and assists in the decision for further procedures depending on the four differential diagnoses of limitations in movement, instability, loosening and infection. CONCLUSION: Revision operations should be performed in specialized centers and should be tailored to the individual patient. A comprehensive knowledge of knee joint biomechanics and experience with the large spectrum of modular and axis-linked revision systems are essential for revision surgeons.

[What medical students want - evaluation of medical recruitment ads by future physicians]. / Was Medizinstudierende wollen - Einschätzung ärztlicher Stellenanzeigen durch angehende Ärztinnen und Ärzte der Humanmedizin.

OBJECTIVE: Three-quarters of all hospitals in Germany are now struggling to fill open positions for doctors. The medical job ad is a vital tool for human resources marketing and an important image factor. The present study examines the importance of information and offers in medical recruitment ads on application decisions by medical students. METHOD: A total of 184 future physicians from clinical semesters participated voluntarily in an anonymous cross-sectional survey. Using a standardised questionnaire, the importance of 49 -individual items extracted from medical recruitment ads were rated with the help of a 4-point Likert Scale. Finally, the study participants prioritised their reasons for an application as a physician. RESULTS: Primary influence on the application decision on medical recruitment ads by medical students had offers/information in relation to education and training aspects and work-life balance. Payment rates for physicians and work load played an important role for the application motivation. Additional earnings for, e. g., emergency calls, providing of medical expertise and assistance with housing, relocation and reimbursement of interview expenses were less crucial. In prioritising key reasons for selecting a prospective employer "regular working hours," an "individual training concept" and an "attractive work-life balance" scored the highest priority. The "opportunity for scientific work" was assigned only a small significance. CONCLUSION: High importance for the application decision by future physicians on medical recruitment ads is placed on jobs with an opportunity for personal development and aspects that contribute to work-life balance.

[Bone marrow edema syndrome (BMES)]. / Das Knochenmarködemsyndrom (KMÖS).

Bone marrow edema (BME) syndrome represents a pathologic accumulation of interstitial fluid in bone - with a traumatic BME being differentiated from a non-traumatic, often ischemic, and a reactive as well as a mechanical BME. Atraumatic/ischemic BME is inconsistently described as a separate entity or as a reversible preliminary stage of osteonecrosis (ON). However, there is always the risk of transformation of BME into ON and subsequent joint destruction. The most common sites of BME are the hip, knee, and ankle. Magnetic resonance imaging is the diagnostic gold standard. Differential diagnoses of the transient BME as osteonecrosis, osteochondrosis dissecans, and a reflex dystrophy should be considered. Conservative or surgical treatment is considered, depending on the etiology of BME. BME syndrome is generally treated conservatively. Infusion of prostacycline or bisphosphonates is a promising option. Ischemic BME and early stages of ON can be successfully treated by core decompression. A combination of both treatment options may also offer advantages.

Central X-ray beam correction of radiographic acetabular cup measurement after THA: an experimental study.

PURPOSE: Accurate assessment of cup orientation on postoperative radiographs is essential for evaluating outcome after THA. However, accuracy is impeded by the deviation of the central X-ray beam in relation to the cup and the impossibility of measuring retroversion on standard pelvic radiographs. METHOD: In an experimental trial, we built an artificial cup holder enabling the setting of different angles of anatomical anteversion and inclination. Twelve different cup orientations were investigated by three examiners. After comparing the two methods for radiographic measurement of the cup position developed by Lewinnek and Widmer, we showed how to differentiate between anteversion and retroversion in each cup position by using a second plane. To show the effect of the central beam offset on the cup, we X-rayed a defined cup position using a multidirectional central beam offset. According to Murray's definition of anteversion and inclination, we created a novel corrective procedure to balance measurement errors caused by deviation of the central beam. RESULTS: Measurement of the 12 different cup positions with the Lewinnek's method yielded a mean deviation of [Formula: see text] (95 % CI 1.3-2.3) from the original cup anteversion. The respective deviation with the Widmer/Liaw's method was [Formula: see text] (95 % CI 2.4-4.0). In each case, retroversion could be differentiated from anteversion with a second radiograph. Because of the multidirectional central beam offset ([Formula: see text] cm) from the acetabular cup in the cup holder ([Formula: see text] anteversion and [Formula: see text] inclination), the mean absolute difference for anteversion was [Formula: see text] (range [Formula: see text] to [Formula: see text] and [Formula: see text] (range [Formula: see text] to [Formula: see text] for inclination. The application of our novel mathematical correction of the central beam offset reduced deviation to a mean difference of [Formula: see text] for anteversion and [Formula: see text] for inclination. CONCLUSION: This novel calculation for central beam offset correction enables highly accurate measurement of the cup position.

Measuring Acetabular Cup Orientation on Antero-Posterior Radiographs of the Hip after Total Hip Arthroplasty with a Vector Arithmetic Radiological Method. Is It Valid and Verified for Daily Clinical Practice?

PURPOSE: The aim of this prospective study is to validate a vector arithmetic method for measuring acetabular cup orientation after total hip arthroplasty (THA) and to verify the clinical practice. MATERIALS AND METHODS: We measured cup anteversion and inclination of 123 patients after cementless primary THA twice by two examiners on AP pelvic radiographs with a vector arithmetic method and compared with a 3D-CT based reconstruction model within the same radiographic coronal plane. RESULTS: The mean difference between the radiographic and the 3D-CT measurements was - 1.4°â€Š±â€Š3.9° for inclination and 0.8°±â€Š7.9° for anteversion with excellent correlation for inclination (r = 0.81, p < 0.001) and moderate correlation for anteversion (r = 0.65, p < 0.001). The intraclass correlation coefficient for measurements on radiographs ranged from 0.98 (95 %-CI: 0.98; 0.99) for the first observer to 0.94 (95 %-CI: 0.92; 0.96) for the second observer. The interrater reliability was 0.96 (95 %-CI: 0.93; 0.98) for inclination and 0.93 (95 %-CI: 0.85; 0.96) for anteversion. CONCLUSION: The largest errors in measurements were associated with an extraordinary pelvic tilt. In order to get a valuable measurement for measuring cup position after THA on pelvic radiographs by this vector arithmetic method, there is a need for a correct postoperative ap view, with special regards to the pelvic tilt for the future. KEY POINTS: • Measuring acetabular cup orientation on anteroposterior radiographs of the hip after THA is a helpful procedure in everyday clinical practice as a first-line imaging modality• CT remains the golden standard to accurately determine acetabular cup position.• Future measuring on radiographs for cup orientation after THA should account for integration of the pelvic tilt in order to maximize the measurement accuracy. Citation Format: • Craiovan B, Weber M, Worlicek M et al. Measuring Acetabular Cup Orientation on Antero-Posterior Radiographs of the Hip after Total Hip Arthroplasty with a Vector Arithmetic Radiological Method. Is It Valid and Verified for Daily Clinical Practice?. Fortschr Röntgenstr 2016; 188: 574 - 581.

Digital Planning Software Fails to Reflect Stem Torsion on Plain Radiographs after Total Hip Arthroplasty.

PURPOSE: The purpose of this study was to evaluate the validity of commercially available planning software on plain radiographs after THA compared to CT scans as the gold standard. PATIENTS AND METHODS: In a prospective clinical study, anteroposterior (AP) radiographs and three-dimensional CT scans (3D-CT) were obtained for 121 patients, who underwent minimally invasive, cementless THA with a straight tapered stem, in a lateral decubitus position. For measuring SV, we used digital planning software (TraumaCad 2.0, BrainLAB Feldkirchen, Germany). Two independent raters repeated the analysis after a six-week interval. Radiological measurements were compared with 3D-CT measurements by an independent, blinded external institute. This investigation was approved by the local ethics commission (no. 10 -121- 0263) and is a secondary analysis of a larger project (DRKS00 000 739, German Clinical Trials Register May-02 - 2011). RESULTS: The radiograph measurements showed very high intra- and interrater agreement. The intra-class correlation (ICC) of the intrarater agreement was 0.97 for rater 1 and 0.98 for rater 2. The intrarater reliability was 0.99 using the mean values of both rater measurements. The mean difference between the average radiograph measurement and the 3D-CT-based measurement was 0.41° (SD 11.24°) (range: -33.85°-22.50°; 95 % limits of agreement: -21.63 - 22.45), but there was no correlation found between both methods. CONCLUSION: Measuring stem version with the help of commercially available digital planning software on plain radiographs after THA has high intra- and interrater reliability but clinically inacceptable validity and reliability when compared to 3D-CT scans. KEY POINTS: • Measuring stem torsion after THA on plain radiographs with digital planning software is not valid. Citation Format: • Worlicek M, Weber M, Zeman F et al. Digital Planning Software Fails to Reflect Stem Torsion on Plain Radiographs after Total Hip Arthroplasty. Fortschr Röntgenstr 2016; 188: 763 - 767.

Difference in periprosthetic acetabular bone mineral density: Prior total hip arthroplasty: Osteonecrosis of the femoral head versus primary osteoarthritis.

BACKGROUND: Total hip arthroplasty (THA) could be associated with a higher failure rate in patients after osteonecrosis of the femoral head (ONFH) compared to a patient population with primary osteoarthritis prior THA, especially regarding the acetabular component. One major reason could be the compromised acetabular bone quality. Therefore, we performed a retrospective case matched study to assess: 1) Is there a difference in periprosthetic bone mineral density between patients with an ONFH prior THA and controls? 2) Do patients with an ONFH prior THA have a lower bone mineral density compared to controls? 3) Which region in the periprosthetic bone stock is more likely to present differences in periprosthetic bone mineral density between both groups? HYPOTHESIS: We hypothesized that there is a poorer bone mineral density (BMD) in the periacetabular bone stock in patients with an ONFH prior THA compared to controls receiving a THA due to primary osteoarthritis. PATIENTS AND METHODS: We compared the BMD of 50 patients with ONFH to 50 controls with primary osteoarthritis prior THA using the same implant in mean 5 years after surgery by means of dual energy X-ray absorptiometry (DXA). We analysed 3 acetabular ROIs according to DeLee and Charnley in a modified measurement technique. RESULTS: In ROI 3, representing acetabulum's upper aspect, statistically significant lower BMD values for the ONFH group could be found (P < 0.05). No difference was found for the modified ROIs 1 and 2 (respectively medial and lower acetabulum). DISCUSSION: The results indicate a poorer periacetabular BMD in patients with ONFH prior THA, which might be responsible for premature loosening of the acetabular cup in THA. Due to a lack of literature, further clinical investigations are required to confirm our results. LEVEL OF EVIDENCE: III: retrospective case-control study.

Association between infection with Helicobacter pylori and Chlamydia pneumoniae and risk of ischemic stroke subtypes: Results from a population-based case-control study.

BACKGROUND AND PURPOSE: Helicobacter pylori and Chlamydia pneumoniae have been associated epidemiologically and pathogenetically with coronary atherosclerosis. However, population-based data on chronic infection and stroke are lacking. Therefore, we investigated the association of both bacterial pathogens and ischemic stroke subtypes in a population-based case-control study. METHODS: Patients with first ischemic stroke in the population-based Erlangen Stroke Project were collected as cases. Neighborhood controls were drawn from the study population, matched for age, sex, and place of residence. IgG antibodies to H pylori were measured by enzyme immunoassay, and IgG antibodies to C pneumoniae were measured by microimmunofluorescence technique. Conditional logistic regression was used. Analyses were stratified for etiologic stroke subtypes according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. RESULTS: A total of 145 case and 260 control subjects were included. Chronic H pylori infection was associated with a higher risk of stroke caused by small-artery occlusion (adjusted odds ratio, 3.31; 95% CI, 1.15 to 9.56) and a lower risk of cardioembolic stroke (adjusted odds ratio, 0.21; 95% CI, 0.06 to 0.71). Overall, elevated H pylori as well as elevated C pneumoniae antibodies were not associated with ischemic stroke. CONCLUSIONS: Our population-based study does not provide evidence of any strong association between the immune response to C pneumoniae as a marker of prior infection and ischemic stroke. Further studies are required to reveal the role of chronic H pylori infection as an independent risk factor for the subgroup small-artery occlusion.

[Melorheostosis of the foot: a case report of a rare entity]. / Melorheostose des Fusses: Falldarstellung eines seltenen Krankheitsbildes.

INTRODUCTION: Melorheostosis is a rare bony dysplasia and often recognised just sporadically by chance. CASE REPORT: We present a case of a 15 year old girl who presented a melorheostosis of the left foot. After birth there was recognized a shortening and deformity of the 2nd toe on the left foot. Furthermore she had an interphalangeal hallux valgus that displaced the 2nd toe increasingly. Thus in the last years there were more and more difficulties to wear normal shoes. Conservative therapy was not successful. We performed a lengthening extending osteotomy of the 2nd toe (a modified Weil osteotomy) and an Akin osteotomy of the interphalangeal hallux valgus. Since the surgical procedure the patient is out of any complaints. DISCUSSION: We demonstrate the radiologic and histologic findings and discuss the relevant literature and possible etiology.