[Etiology, pathogenesis, clinical features, diagnostics and conservative treatment of adult flatfoot]. / Ätiologie, Pathogenese, Klinik, Diagnostik und konservative Therapie des adulten erworbenen Plattfußes.

BACKGROUND: On average, one in six adults is affected by an acquired flatfoot. This foot deformity is characterized by its progression of stages and in 10% of cases causes complaints that require treatment. Untreated, the loss of walking ability may result in the final stage. Correct staging is crucial to being able to offer a specific course of therapy including a wide spectrum of conservative and operative treatments. MATERIAL AND METHODS: This review is based on pertinent publications retrieved from a selective search in PubMed and Medline and on the authors' clinical experience. DIAGNOSTICS: The loss of function of static (spring ligament complex) and dynamic (tibialis posterior tendon) stabilizers causes the characteristic deformity with loss of the medial arch, hind foot valgus and forefoot abduction. In the late stage, severe secondary osteoarthritis in upper and lower ankle joints occurs and impedes walking ability. The essential physical examination is supplemented by weight-bearing dorsoplantar and lateral radiographs, which provide further information about axial malalignment (Meary's angle, Kite's angle). The long axis hind foot view allows analysis of the hindfoot valgus. MRI provides further information about the integrity of the tibialis posterior tendon, spring ligament complex and cartilage damage. THERAPY: The therapy aims to reduce pain, regain function and avoid development of secondary osteoarthritis and degenerative tendon disorders. Progress of the deformity should be stopped. Therefore, the main aspects of the deformity-loss of medial arch, hindfoot valgus and forefoot abduction should be addressed and corrected. In the acute phase, tendovaginitis of the tibialis posterior tendon can be treated sufficiently by anti-inflammatory measures, relieving mechanical loads on the tendon and muscle and physiotherapy.

Biomechanical results of percutaneous calcaneal osteotomy using two different osteotomy designs.

BACKGROUND: Percutaneous osteotomy of calcaneus has been proposed to reduce the complication rate and became more and more popular. The bone cut can be performed as a straight or chevron-like (V) osteotomy using a Shannon burr. Comparative studies of straight or V-osteotomy as like as one or two screws in percutaneous calcaneal osteotomies are missing in the literature. We hypothesize that the V-osteotomy will result in a higher stiffness in biomechanical testing as the straight osteotomy using single screw for fixation. METHODS: The straight osteotomy (9 fresh-frozen specimens) and V-osteotomy (9 fresh-frozen specimens) was performed and the calcaneal tuberosity was moved 10mm medially and slightly rotated. One 6,5mm cancellous compression screw was used for osteosynthesis. Specimens were preconditioned with 100N over 100 cycles. The force was increased after every 100N by 100N from 200 to 500N. This was followed by cyclic loading with 600N for 500 cycles. RESULTS: Despite the higher mean values of the group with V-osteotomy, no significant difference was registered between the two groups regarding the stiffness at all force levels. A higher failure rate was observed in the group with straight osteotomy. CONCLUSION: The moderate correlation of bone density and stiffness in the V-group, and significantly lower failure rate with no secondary dislocation in fluoroscopy indicates the superiority of the V-osteotomy in the present study. Whether the demonstrated advantages can be reflected in clinical practice should be investigated in further studies. LEVEL OF CLINICAL EVIDENCE: 5.

Posterolateral plate fixation with Pantalarlock® is more stable than nail fixation in tibiotalocalcaneal arthrodesis in a biomechanical cadaver study.

BACKGROUND: Despite the promising results of ankle joint arthroplasty, the tibiotalocalcaneal (TTC) arthrodesis remains an established procedure in treatment of combined pathology of the ankle and subtalar joint. Despite the promising results in biomechanical investigations, nonunion rates of up to 24% are described in recent studies. The objective of this work was a comparative study of the biomechanical properties of the posterolateral plate fixation with retrograde intramedullary nail fixation. METHODS: Twenty four fresh-frozen human lower leg specimens (12 pairs) were used for the comparative biomechanical testing. Every specimen was preconditioned with 100 N over 200 cycles. After every 250 cycles the force was increased by 50 N from 200 to 600 N. This was followed by cyclic loading in dorsi-/plantiflexion with 800 N for 3000 cycles. All specimens were subjected to bone densitometry (DXA) and computed tomography. RESULTS: Significantly higher number of spacimens with nails (4) failed during the cycling testing in dorsi-/plantarflexion and futher two during the cyclic testing with 800 N. Two specimens with plates failed during the cyclic testing with 800 N. Statistical analysis showed that the specimens with the plate were significantly more stable in each test direction. The Pearson correlation demonstrated for the specimens with plate a linear relationship between the stiffness and the determined bone density. CONCLUSIONS: The results demonstrate a significantly superior stiffness of the Pantalarlock®-plate in all testing directions compared with the HAN nail. Probably the position of the plate on the tension side of the joint and the combination of locking and lag screws provide the higher stiffness of the plate system. The correlation of the stiffness with bone density leads to more predictable results of the plate arthrodesis. We hope for a reduction of the pseudarthrosis rate and shorten the postoperative treatment phase. The authors expect advantages in the treatment of high risk patients with severe deformity of the ankle, bone defects, neuropathic deformity, poor bone quality and osteoporosis.

Preliminary results of a plantar plate for Lapidus arthrodesis.

The TMT I arthrodesis is an established procedure for the correction of hallux valgus deformity associated with the instability of the TMT-I joint. A risk of transfer metatarsalgia is reported in the literature associated with persistant elevation of MT-I. Detailed information for ideal positioning of the arthrodesis is missing so far. Clinical, radiological and padobarografical results and their correlations were analyzed with special consideration of the elevation position of the MT-I in a TMT-I arthrodesis using the plantar plate osteosynthesis. Postoperative changes in plantar pressure and force distribution occured after TMT-I arthrodesis. A postoperative increase of the load under the medial forefoot and the dependence on the positioning of MT-I in the sagittal plane has been shown. The authors suggest, that increased load of the medial forefoot and constant pressures and forces under the central forefoot may lead to a relative relief of the area, which might explain the postoperative reduction of metatarsalgia.

Posterolateral plate fixation with Talarlock® is more stable than screw fixation in ankle arthrodesis in a biomechanical cadaver study.

BACKGROUND: A number of studies report on limitations of the screw arthrodesis in severe malalignment of the hindfoot, neuropathic deformity, poor bone quality and osteoporosis. METHODS: Fourteen anatomically correct polyurethane foam models of the right leg (Sawbones Europe, Malmö, Sweden) and eighteen fresh-frozen human lower leg specimens (9 pairs) were used for the comparative biomechanical testing. RESULTS: The statistical analysis of the stiffness of the fixation developed a significant difference in favor of the plate in all test directions. CONCLUSIONS: The excellent biomechanical results are very promising and we hope for a reduction of the pseudarthrosis rate and shorten the postoperative treatment phase.

Influence of varus/valgus positioning of the Nanos® and Metha® short-stemmed prostheses on stress shielding of metaphyseal bone.

The aim of this study was to analyze bone remodeling around the Nanos® (Smith & Nephew) and Metha® (Aesculap AG) implants as a function of varus/valgus stem positioning. In 75 patients with diagnosed coxarthrosis, either Nanos® (n= 51) or Metha® (n= 24) prostheses were implanted. Digital assessment of plain radiographs immediately, 97 days, and 381 days after THA showed no clinically-relevant migration, angulation, or change in offset and center of rotation. The DEXA scans showed significant BMD changes in Gruen zones 1 (-12.8%), 2 (-3.3%), 6 (+6.4%), and 7(-7.8%)(t-test). The pre/postoperative CCD for the Nanos® was 129°/ 135° and for the Metha® 131°/ 127°. Linear regression analysis showed no prediction for BMD by postoperative CCD or stem type. In conclusion, there was no clinically-relevant influence on proximal femur BMD according to varus/valgus implantation of the Nanos® or Metha® prostheses.

Immediate fullweightbearing after tarsometatarsal arthrodesis for hallux valgus correction--Does it increase the complication rate?

BACKGROUND: The arthrodesis of the first tarsometatarsal joint has a high correction potential in the treatment of hallux valgus deformity. Compared to distal correction procedures, a pseudarthrosis rate of 12-20% is quoted, however. In a prospective study the results of two different treatment procedures after correction arthrodesis were compared. METHODS: In 17 cases the patients were mobilised with a short arthrodeses shoe with floor contact (NWB group) and in 17 cases in a short arthrodeses shoe with immediate fullweightbearing (FWB group). Clinical and radiological evaluation was done preoperatively, six weeks and one year postoperatively, including visual analogue pain scale and AOFAS score pre- and one year postoperatively. RESULTS: There was no increased complication rate in the group with FWB group. The patients in the FWB group were significantly earlier fit for work. CONCLUSION: Immediate fullweightbearing after TMT I arthrodesis using a plantar plate should be established as a standard posttreatment.

Is it feasible to rely on intraoperative X ray in correcting hallux valgus?

BACKGROUND: The aim of the study was to prove whether the intraoperatively taken fluoroscopy pictures compared to the X rays taken 8 weeks and 3 months postoperatively picture the achieved correction reliably. METHOD: In a prospective study, the pre- and postoperative standing foot X rays as well as the intraoperatively taken fluoroscopy pictures of 31 patients were analysed. The intermetatarsal angle (IMA) and the hallux valgus angle (HVA) were measured. In all cases, a tarso-metatarsal joint I arthrodesis combined with a distal soft tissue release was performed. The mean age was 54 (17-73) years. RESULTS: There was no significant difference between the measured angles in intraoperative fluoroscopy and standing X rays postoperatively taken. CONCLUSIONS: Despite the consideration that fluoroscopic pictures lack the loading criteria, we found reliable results in IMA and HVA.

Potentialities and limitations of a database constructing three-dimensional virtual bone models.

BACKGROUND: 3D bone reconstructions performed during general clinical practice are of limited use for preclinical research, education, and training purposes. For this reason, we are constructing a database of human 3D virtual bone models compiled from computer tomography (CT) scans. MATERIALS AND METHODS: CT data sets were post-processed using Amira(®) 5.2 software. In each cut, bone structures were isolated using semiautomatic labeling program codes. The software then generated extremely precise 3D bone models in STL format (standard triangulated language). These bone models offer a sustainable source of information for morphologic studies and investigations of biomechanical bony characteristics in complex anatomic regions. Regarding educational value and student acceptance models were introduced during bedside teaching and evaluated by medical students. RESULTS: The current database is comprised of 131 pelvises and 120 femurs (ø 60 years, ø 172 cm, ø 76 kg), and is continuously growing. To date, 3D morphometric analyses of the posterior ring and the acetabulum have been successfully completed. Eighty students (96 %) evaluated instruction with virtual 3D bone models as "good" or "very good". The majority of students want to increase learning with virtual bone models covering various regions and diseases. CONCLUSION: With consistent and steadily increasing case numbers, the database offers a sustainable alternative to human cadaver work for practical investigations. In addition, it offers a platform for education and training.

[Pedobarographic results of Girdlestone-Taylor tendon transfer in flexible small toe deformity]. / Ergebnisse der pedobarographischen Untersuchung nach Girdlestone-Taylor-Sehnentransfer bei flexibler Kleinzehdeformität.

AIM: The aim of the study was to analyze the biomechanical effects of flexible claw toe correction by tendon transfer with the Girdlestone-Taylor approach using dynamic pedobarography. MATERIAL AND METHODS: In the study 12 patients were examined preoperatively and 12 months postoperatively. The results obtained by pedobarography 12 months postoperatively were compared with those of a healthy control group of matched age and body mass index (BMI). For clinical evaluation the American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue pain scale (VAS) were evaluated. RESULTS: The results showed a significant increase in the average AOFAS score from 72 (range 63-79) preoperatively to 92 (84-96) points 12 months postoperatively. The pedobarography revealed significantly increased values in the force-time integral and the maximum force for the second and third toes 12 months postoperatively. Compared with preoperative measurement values a significantly increased peak pressure could be assessed for the third toe only. It is assumed that the combination of functional arthrodesis of the proximal interphalangeal (PIP) joint and the strain shift by tendon transfer causes this increase in peak pressure. CONCLUSION: Atter Girdlestone-Taylor tendon transfer reestablishment of floor contact of flexible claw toes could be demonstrated by dynamic pedobarography.

Comparative study of Lapidus bunionectomy using different osteosynthesis methods.

The treatment of hallux valgus in patients with pathology of the first tarsometatarsal (TMT I) joint by fusion is an established procedure. Multiple osteosynthesis methods for the fixation of the TMT I joint are available. In comparison to the distal procedures the Lapidus bunionectomy is associated with a pseudarthrosis rate of up to 12% [9-11]. We present results after TMT-I arthrodesis using an interfragmentary screw and a plantar plate compared with an interfragmentary screw and a dorsomedial locking plate. Clinical and radiological examinations were performed preoperatively, six weeks and one year postoperatively. The AOFAS (American Orthopaedic Foot and Ankle Society) score and Visual Analogue Pain Scale (VAS) were evaluated preoperatively and 12 months after surgery. We observed a significantly increased rate of undesirable effects in mediodorsal plate positioning.

[Correction arthrodesis of the proximal interphalangeal joint with wire cerclage for rigid small toe deformities : a prospective study]. / Korrekturarthrodese des PIP-Gelenks mittels Drahtcerclage bei fixierter Kleinzehdeformität : Eine prospektive Studie.

Deformities of the small toes often occur with complex forefoot deformities. Proximal interphalangeal joint arthrodesis is a reliable correction procedure for rigid flexed proximal interphalangeal joints. The most often performed technique by far is K-wire fixation; however, pin tract infections, malrotation due to deficient securing of the rotation and irritation of the metatarsophalangeal joints are common complications. By using a 0.4 mm wire cerclage an individual position of the proximal interphalangeal joint in slight flexion is enabled whereby good compression can be achieved and malrotation can be avoided. In 32 patients with 64 fixed claw or hammer toes such a proximal interphalangeal joint arthrodesis was performed. The follow-up time was 2 years. In all cases clinical and radiological osteotomy healing occurred 6 weeks postoperatively and there were no complications. This technically simple and cost-efficient procedure appears to be a good alternative to known proximal interphalangeal joint arthrodesis methods.

[One-stage aseptic revision of loosened metatarsophalangeal prosthesis]. / Einzeitiger aseptischer Wechsel gelockerter Grosszehengrundgelenkendoprothesen.

The high loosening rate of the Moje prosthesis in the treatment of hallux rigidus caused disappointing medium term results. Arthrodesis using an iliac crest bone graft is the standard salvage procedure. We present short-term results after one-stage revision of the metatarsophalangeal joint using the TOEFIT-PLUS™ prosthesis for implant revision. Clinical and radiological examinations were performed on three metatarsophalangeal joints after explantation of the Moje prosthesis and one-stage revision using the TOEFIT-PLUS™ prosthesis for implant revision. The AOFAS score and VAS were checked preoperatively and 6 and 12 months after surgery.Good to very good short-term results after one-stage revision of the metatarsophalangeal joint using the TOEFIT-PLUS™ prosthesis for implant revision could be demonstrated in this study. One-stage revision of the arthroplasty of the metatarsophalangeal joint can increase the range of motion and avoid arthrodesis entailing iliac crest bone graft morbidity.

[Cervical spine osteoblastoma in children: Selective diagnostics as the basis for effective surgical management]. / Osteoblastom der Halswirbelsäule im Kindesalter: Gezielte Diagnostik als Grundlage einer erfolgreichen operativen Therapie.

Expansively growing cervical spine osteoblastomas are rare but can cause severe neurological damage as a result of their anatomical relationship to nerve structures. Also, cerebral vessels, especially the vertebral artery in its transvertebral position, are often covered by tumor tissue. In complete resection of the tumor, it is sometimes possible to retain the affected vessel. In addition to conventional radiographic diagnostics, computed tomography, and magnetic resonance imaging, angiography and Doppler sonography of the intracranial arteries executed in parallel can provide evidence of the dimension of the neurological deficit to be expected during resection. This case report describes the staged diagnostic procedure and successful complete resection, retaining the affected vertebral artery, of an osteoblastoma of the 5th cervical body with massive intraspinal expansion in an 11-year-old child.

[Ankle arthrodesis with an posterolateral approach using a polyaxial angle stable Talarlock® plate]. / OSG-Arthrodese über einen posterolateralen Zugang mit der polyaxial-winkelstabilen Talarlock®-Platte.

OBJECTIVE: Safe arthrodesis of the ankle as well as load carrying capacity free of pain. INDICATION: Painful arthritis of the ankle joint occurring idiopathic or posttraumatic, resulting from rheumatoid arthritis or neuromuscular diseases. Extensive bony defects in varus or valgus ankle deformities and after failed prosthesis. Complex hindfoot deformities in neurological disease, paralysis and instabilities. Joint destruction after infection. CONTRAINDICATIONS: Active osteitis, extensive skin ulcers in the approach area, periphery artery occlusive disease. SURGICAL TECHNIQUE: Posterolateral skin incision. Sparing cartilage resection. Penetrating sclerosis zones. Reorientating anatomic positioning of the talus thereby correcting axis deformities. Talarlock(®) plate positioning and tibiotalar arthrodesis. POSTOPERATIVE MANAGEMENT: Full weight bearing in an arthodesis boot for 6 weeks. After bone grafting partial weight bearing (20 kg) in an arthrodesis boot for 8 weeks. Full weight bearing after 10weeks. RESULTS: Ten patients were operated on using this procedure. The follow-up time was 1 year. There were no complications requiring further surgical procedures. Ankle fusion and a good clinical outcome could be achieved in all cases.

[Is height restoration possible with a comparatively smaller amount of cement in radiofrequency kyphoplasty using a monopedicle approach?]. / Ist eine Höhenrekonstruktion mit vergleichsweise wenig Zement für die Radiofrequenz-Kyphoplastie über einen monopedikulären Zugang möglich?

BACKGROUND: Percutaneous cement augmentation systems have been proven to be an effective treatment for vertebral compression fractures in the last 10 years. A special form available since 2009 is the radiofrequency kyphoplasty (RF) in which the applied energy raises the viscosity of the cement. The aim of this study is to find out if a smaller cement amount in radiofrequency kyphoplasty can also restore vertebral body height in osteoporotic vertebral compression fractures. METHODS: The treatment was minimally invasive using the StabiliT® vertebral augmentation system by DFine. In a retrospective study from 2011 to January 2012, 35 patients underwent RF kyphoplasty for 49 fresh osteoporotic vertebral compression fractures. From the clinical side the parameters, demographics and pain relief using a visual analogue scale (VAS: 0 to 100 mm) were collected. For the radiological outcome the vertebral body height (anterior, mean and posterior vertebral body height with kyphosis angle) after surgery and after three months was measured and compared to the cement volume. RESULTS: All patients still had permanent pain on the fractured level after conservative treatment. The time from initial painful fracture to treatment was 3.0 weeks ± 1.3. Average visual analogue scale results decreased significantly from 71 ± 9.2 preoperatively to 35 ± 6.2 postoperatively (p < 0.001) and to 30 ± 5.7 (p < 0.001) after three months. With a mean cement volume in the thoracic spine of 2.9 ± 0.7 ml (1.8-4.1) and lumbar spine of 3.0 ± 0.7 ml (2.0-5.0) we had a significant vertebral body height restoration. Anterior and mean vertebral body heights significantly increased by an average of 2.3 and 3.1 mm, kyphosis angle significantly decreased with an average of 2.1° at three-month follow-up (p < 0.05). In two vertebrae (4.1 %) a minimal asymptomatic cement leakage occurred into the upper disc. In two patients (5.7 %) we had new fractures in the directly adjacent segment that were also successfully treated with radiofrequency kyphoplasty. CONCLUSION: With a mean cement volume of 3.0 ml radiofrequency kyphoplasty achieves rapid and short-term improvements of clinical symptoms with a significant restoration of vertebral body height. There was no correlation between restoration of vertebral body height and pain relief. With a cement leakage of 4.1 % RF kyphoplasty is a safe and effective minimally invasive percutaneous cement augmentation procedure. Our data confirm the higher safety described in literature for kyphoplasty in contrast to vertebroplasty.

[Influence of the surgical approach on postoperative rehabilitation after TKA]. / Der Einfluss des Zugangsweges auf die frühe postoperative Rehabilitationsphase nach Knieprothesenimplantation.

BACKGROUND: Minimising the soft tissue trauma and early rehabilitation are among the major aims using the MIS technique in joint replacement. AIM: The aim of this prospective randomised study is to compare the results after TKA using an MIS approach versus a standard approach. METHOD: We compared 30 TKA using a mini-midvastus approach (MIS group) with 30 conventionelly performed TKA using a midvastus approach (control group). In all cases the same implants (NexGen LPS) were used. The Knee Society score (KSS), an activity score, the visual analogue scale, myoglobin and creatinine kinase as well as the blood loss were measured up to 12 weeks postoperatively. Implant positioning was evaluated using the Knee Society Roentgenographic evaluation and scoring system. RESULTS: Advantages of the MIS group were measured in KSS and activity score up to 12 weeks postoperatively. The increase of myoglobin and creatinine kinase was lower in the MIS group up to 24 hours or 72 hours, respectively. No differences were found comparing the implant positioning and blood loss. CONCLUSION: The MIS technique in TKA with minimisation of the soft tissue trauma leads to better clinical and functional results in the early postoperative time and does not modify the implant positioning.