Insights into the Distribution Patterns of Foot and Ankle Tumours: Update on the Perspective of a University Tumour Institute.

The rarity of foot and ankle tumours, together with the numerous histological entities, presents a challenge in accumulating sufficient patients to draw reliable conclusions. Therefore, we decided to present an update of a retrospective analysis of their distribution patterns, comprising 536 cases of foot and ankle tumours presented to our tumour board between June 1997 and June 2023. Our aim was to provide a comprehensive overview of the prevalence and distribution patterns of benign and malignant bone and soft tissue tumours of the foot and ankle. A total of 277 tumours involved bone (51.7%). Of these, 242 (87.4%) were benign and 35 (12.6%) were malignant. In addition, 259 soft tissue tumours (48.3%) were found, of which 191 (73.7%) were benign and 68 (26.3%) were malignant. The most common benign bone tumours were simple bone cysts, enchondromas, osteochondromas, aneurysmal bone cysts, and lipomas of bone. Common benign soft tissue tumours included a tenosynovial giant cell tumour, haemangioma, plantar fibromatosis, schwannoma, and lipoma. The most common malignant soft tissue tumours were synovial sarcoma, malignant melanoma, and myxofibrosarcoma. In terms of anatomical location, the hindfoot was the most common site (28.7%), followed by the midfoot (25.9%), ankle (25.4%), and forefoot (20.0%). The distribution of benign entities often follows typical patterns, which may facilitate an early diagnosis even without biopsy (e.g., simple bone cyst, plantar fibromatosis). On the other hand, the distribution patterns of many rare or malignant entities are inconsistent. Individual soft tissue malignancies occur very sporadically, even over long periods of time and in specialized tumour centres. It is therefore important to recognise that any suspicious mass in the foot and ankle must be considered a possible malignancy until proven otherwise.

Recurrence rates for surgically treated insertional Achilles tendinopathy.

INTRODUCTION: Insertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery. MATERIALS AND METHODS: The authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed. RESULTS: Out of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence. CONCLUSION: IAT recurrence after primary surgery occurs in up to 14% of patients. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Allogenic Cancellous Bone versus Injectable Bone Substitute for Endoscopic Treatment of Simple Bone Cyst and Intraosseous Lipoma of the Calcaneus and Is Intraosseous Lipoma a Developmental Stage of a Simple Bone Cyst?

Simple bone cysts (SBCs) and intraosseous lipoma (IOL) of the calcaneus are rare tumor entities that are primarily diagnosed due to unspecific heel pain, incidental findings, or rarely due to pathological fractures. Compared to traditional open tumor resections, endoscopic resection of these benign tumors aims to minimize surgical morbidity and maximize surgical efficiency without compromising safety. Grafting is regularly performed to reduce the risk of recurrence and stimulate osseous consolidation of the lytic lesion. As the incidence is low and treatment strategies are heterogeneous, there is no clear consensus for the treatment of simple cysts or intraosseous lipomas of the calcaneus. The objectives of this study are (a) to present medium to long-term results after endoscopic resection and grafting with allogenic cancellous bone or bioresorbable hydroxyapatite and calcium sulfate cement, and (b) to add further evidence to the discussion of whether calcaneal SBC and IOL are the same entity at different developmental stages. Between 2012 and 2019, a total of 25 benign bone tumors consisting of 17 SBCs and 8 IOLs were treated by A.T. with endoscopic resection and grafting, comprising the largest cohort to date. For grafting, 12 patients received allogenic cancellous bone (group A) and 13 patients received injectable bone substitute (group B). Pre- and postoperative imaging using plain X-rays and MRI was retrospectively analyzed with a mean follow-up time of 24.5 months to assess tumor size, osseous consolidation (modified Neer classification), and tumor recurrence. A retrospective chart analysis focusing on adverse intra- and perioperative events and other complications associated with the surgical procedure was performed using the modified Clavien-Dindo classification (CD1-3). A total of 12/13 cases with allogenic bone grafting showed a Neer Type 1 osseous healing of the tumorous lesion after endoscopic resection, whereas only 5/11 cases with injectable bone substitute showed sufficient healing (types 1 and 2). There were three recurrent cysts (Neer 4) and two persistent cysts (Neer 3) after using injectable bone substitute. Two CD1 complications were observed in group A (prolonged wound drainage, sural neuritis) and eight complications were observed in group B (6× CD1, 2× CD3). At least two IOLs diagnosed preoperatively using MRI were ultimately identified as SBCs upon histopathologic examination. Allogenic cancellous bone grafting after endoscopic resection of calcaneal SBC or IOL showed a very low rate of complications and no tumor recurrence in our series. On the other hand, depending on the material used, injectable bone substitute showed a high rate of "white-out" (excessive drainage), resulting in multiple complications such as prolonged wound healing, insufficient permanent defect filling, recurrence, and revision surgery. Over time, calcaneal SBC may transform into IOL, exhibiting distinct features of both entities simultaneously during ossoscopy and histopathological analysis.

The distal metatarsal screw is not always necessary in third-generation MICA: a case-control study.

INTRODUCTION: To evaluate the clinical and radiological results after fixation of the first metatarsal head (MTH) with one or two screws as part of the third-generation minimally invasive Chevron-Akin osteotomy (MICA) for hallux valgus deformities. MATERIALS AND METHODS: Between August 2020 and November 2021, 55 MICA procedures (50 patients, male:female = 7:43), 22 with two (MICA2), 33 with one screw (MICA1) were performed for mild to severe hallux valgus deformities. Exclusion criteria were a concomitant pes adductus (Sgarlato angle > 20°) or hindfoot/midfoot deformities requiring treatment. In 27 cases, additional procedures on the forefoot (small toe corrections or metatarsal osteotomies II-V) were necessary. Pre- and post-operatively, hallux valgus angle (HVA) and intermetatarsal I/II angle (IMA) were measured. Clinically, subjective satisfaction, range of motion (ROM) of the first metatarsophalangeal joint (MTPJ), and pain level (NRS score) were evaluated. The minimum follow-up was 12 months. RESULTS: Displacement of MTH was 70-90% on average, all osteotomies showed full consolidation at latest follow-up. In one case of either group, a slight subsidence of MTH was documented. The radiological and clinical parameters showed no differences between the groups. The pain level improved by an average of three points. The mobility of the MTPJ showed a slight reduction in nine cases after three months (4 MICA2, 5 MICA1) which persisted in three cases. Fifty-two of 55 patients (95%) would opt again for the operation. CONCLUSIONS: Fixation of the first MTH with a single bicortical screw in MICA with moderate lateralization of MTH shows stable anchoring and good clinical results. The routine use of a second metatarsal screw can be omitted.

C-Reactive Protein Pretreatment-Level Evaluation for Ewing's Sarcoma Prognosis Assessment-A 15-Year Retrospective Single-Centre Study.

Background: A pathological/inflamed cellular microenvironment state is an additional risk factor for any cancer type. The importance of a chronic inflammation state in most diffuse types of tumour has already been analysed, except for in Ewing's sarcoma. It is a highly malignant blue round cell tumour, with 90% of cases occurring in patients aged between 5 and 25 years. Worldwide, 2.9 out of 1,000,000 children per year are affected by this malignancy. The aim of this retrospective study was to analyse the role of C-reactive protein (CRP) as a prognostic factor for Ewing's sarcomas. Methods: This retrospective study at Klinikum rechts der Isar included 82 patients with a confirmed Ewing's sarcoma diagnosis treated between 2004 and 2019. Preoperative CRP determination was assessed in mg/dL with a normal value established as below 0.5 mg/dL. Disease-free survival time was calculated as the time between the initial diagnosis and an event such as local recurrence or metastasis. Follow-up status was described as death of disease (DOD), no evidence of disease (NED) or alive with disease (AWD). The exclusion criteria of this study included insufficient laboratory values and a lack of information regarding the follow-up status or non-oncological resection. Results: Serum CRP levels were significantly different in patients with a poorer prognosis (DOD) and in patients who presented distant metastasis (p = 0.0016 and p = 0.009, respectively), whereas CRP levels were not significantly different in patients with local recurrence (p = 0.02). The optimal breakpoint that predicted prognosis was 0.5 mg/dL, with a sensitivity of 0.76 and a specificity of 0.74 (AUC 0.81). Univariate CRP analysis level >0.5 mg/dL revealed a hazard ratio of 9.5 (95% CI 3.5−25.5). Conclusions: In Ewing's sarcoma cases, we consider a CRP pretreatment value >0.5 mg/dL as a sensitive prognostic risk factor indication for distant metastasis and poor prognosis. Further research with more data is required to determine more sensitive cutoff levels.

[Implantation of a pseudo knee prosthesis after rotationplasty: a case report]. / Implantation einer "Pseudoknieprothese" nach Umkehrplastik: Ein Fallbericht.

Rotationplasty of the knee joint is an established biological reconstruction method with excellent clinical results for patients with tumor-associated resection of the knee joint. The changed biomechanics of the pseudo knee and high demand of the generally young patients commonly leads to the development of osteoarthritic changes in this area. We report on the implantation of an ankle prosthesis in the area of the pseudo knee joint, which made it possible to use a conventional exoprosthesis. Nine months postsurgery we found clinically good results and a satisfied patient.

One-year Follow-Up Results with Hydrogel Implant in Therapy of Hallux Rigidus: Case Series with 44 Patients. / Jahresergebnisse eines Hydrogelimplantats in der Therapie des Hallux rigidus: eine Fallserie von 44 Patienten.

BACKGROUND: The Cartiva implant (CI) is being increasingly used in the surgical therapy of hallux rigidus. Despite a growing number of studies, numerous questions regarding patient selection remain unanswered. PATIENTS AND METHODS: As part of a retrospective case series with prospective follow-up (average follow-up period: 12 months), a total of 44 patients (male/female = 16/28; mean age at the time of surgery: 55.4 years) with 44 CI were analysed (VAS, EFAS-, AOFAS-score). Using a correlation analysis and a machine learning algorithm, risk factors for therapy failure were investigated. RESULTS: The overall survival rate of the CI was 93% at 12 months. The VAS, EFAS and AOFAS scores showed a significant improvement in comparison to the preoperative condition. The mobility of the metatarsophalangeal joint showed no increase. Patients with a medium osteoarthritis grade and a medium level of clinical restraint showed the greatest improvement in relation to their preoperative condition. CONCLUSION: The CI can be seen as an effective therapy for hallux rigidus. Nonetheless, realistic patient expectations must be communicated.

Long-term Efficacy of Percutaneous Epidural Neurolysis of Adhesions in Chronic Lumbar Radicular Pain: 10 Year Follow-up of a Randomized Controlled Trial.

BACKGROUND: No long-term follow-up data exist in any treatment for chronic radicular pain occurring with disc pathology and after failed back surgery. A previous randomized controlled trial (RCT) has proven efficacy in short-term follow-up as an evidence-based effective therapeutic option. OBJECTIVES: Long term data is needed to determine the efficacy and cost- effectiveness of minimal invasive procedures. The present study reports 10 year follow-up results from the randomized trial. STUDY DESIGN: A prospective, randomized, placebo-controlled, interventional clinical trial. A power calculation was based on a previous feasibility trial. SETTING: University medical centers. METHODS: After a 4 year enrollment phase, 381 patients with chronic radicular pain persisting beyond 4 months, who failed conservative treatments, were screened. Ninety patients were enrolled. Patients were randomly assigned to receive percutaneous epidural lysis of adhesions or placebo with concealed allocation in permuted blocks of 4 to 8 patients each, and stratified by treatment center. The primary outcomes were a mean change of the Oswestry Disability Index (ODI) scores and Visual Analog Scale (VAS), one and 10 years after intervention. For each rating scale an analysis of variance with the within-patient factor time (baseline, one year follow-up, 10 year follow-up) and the between-patient factor treatment (lysis, placebo) was used. RESULTS: Homogeneity was shown at baseline between the groups. The ODI and VAS scores were significantly better one and 10 years in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 9.6 ± 9.3 after one year and to 11.7 ± 14.2 after 10 years. The placebo group also improved from 55.4 ± 11.5 to 30.7 ± 14.2 after one year and to 24.8 ± 12.0 after 10 years. The VAS improved from 6.7 ± 1.1 to 1.2 ± 1.1 after one year and to 1.5 ± 1.4 after 10 years in the lysis group and from 6.7 ± 1.1 to 2.8 ± 1.5 after one year and to 2.9 ± 1.3 after 10 years after placebo intervention. The statistical difference of the ODI and VAS between the treatment and control groups remain significant up to 10 years. No treatment-related severe adverse effects occurred within the 10 years, but minor transient neurological effects were seen directly after the intervention. LIMITATIONS: The long-term effects of single treatment components cannot be specified as no imaging examination was performed at 10 year follow-up. A large variety of unanalyzed noninvasive treatments were done within the 10 years. Some patients did not clearly remember the intervention after 10 years. Uncontrolled effects such as higher inhomogeneity of biometric properties, concomitant therapies, pain tolerance level, or just social effects could occur, but were not analyzed in the trial. CONCLUSION: This is the first 10 year follow-up report of a placebo-controlled RCT showing efficacy of the minimally invasive percutaneous adhesiolysis procedure for patients with chronic lumbosacral radicular pain. No alternative evidence-based treatment modality with 10 year follow-up is available to be recommended. This procedure should be considered as the first treatment option for patients with chronic lumbosacral radicular pain.

Patient-Reported Outcomes of Surgically Treated Insertional Achilles Tendinopathy.

BACKGROUND: The aim of this study was to assess the patient-reported outcome measures (PROMs) in patients with insertional Achilles tendinopathy (IAT) treated surgically by debridement of all pathologies through a midline-incision trans-achillary approach (MITA). METHODS: This is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, with at least 12 months of follow-up were included. Demographics, medical history, surgical details, and complications were recorded. Patient-reported outcomes were assessed using the Foot Function Index (FFI), Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A-G), visual analog scale foot and ankle (VAS-FA), and 12-Item Short-Form Health Survey (SF-12). Longitudinal FFI data were available for 48% of the patients. RESULTS: A total of 118 patients (63.4%) with a mean follow-up of 50 ± 25 months were included. The FFI improved from 53 (24) preoperatively to 2 (11) points at the final follow-up. The final VISA-A-G score was 93 (26), the VAS-FA score 93 (15), the SF-12 Physical Component Summary 56 (8), and the SF-12 Mental Component Summary 55 (12) points. There was an additional FFI improvement between 12 months and the final follow-up. Up to 47% (VISA-A-G) of patients had residual symptoms. A postoperative shoe conflict was the only parameter negatively affecting the PROMs (P < .001). CONCLUSION: Addressing all pathologies of IAT by the MITA resulted in overall good postoperative PROMs after 4 years. But up to 47% of patients remained impaired. The only parameter correlating with an impaired PROM was a postoperative shoe conflict. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Does vitamin D deficiency predict tumour malignancy in patients with bone tumours? Data from a multi-center cohort analysis.

Vitamin D deficiency is a global health concern that is estimated to afflict over one billion people globally. The major role of vitamin D is that of a regulator of calcium and phosphate metabolism, thus, being essential for proper bone mineralisation. Concomitantly, vitamin D is known to exert numerous extra-skeletal actions. For example, it has become evident that vitamin D has direct anti-proliferative, pro-differentiation and pro-apoptotic actions on cancer cells. Hence, vitamin D deficiency has been associated with increased cancer risk and worse prognosis in several malignancies. We have recently demonstrated that vitamin D deficiency promotes secondary cancer growth in bone. These findings were partly attributable to an increase in bone remodelling but also through direct effects of vitamin D on cancer cells. To date, very little is known about vitamin D status of patients with bone tumours in general. Thus, the objective of this study was to assess vitamin D status of patients with diverse bone tumours. Moreover, the aim was to elucidate whether or not there is an association between pre-diagnostic vitamin D status and tumour malignancy in patients with bone tumours. In a multi-center analysis, 25(OH)D, PTH and calcium levels of 225 patients that presented with various bone tumours between 2017 and 2018 were assessed. Collectively, 76% of all patients had insufficient vitamin D levels with a total mean 25(OH)D level of 21.43 ng/ml (53.58 nmol/L). In particular, 52% (117/225) of patients were identified as vitamin D deficient and further 24% of patients (55/225) were vitamin D insufficient. Notably, patients diagnosed with malignant bone tumours had significantly lower 25(OH)D levels than patients diagnosed with benign bone tumours [19.3 vs. 22.75 ng/ml (48.25 vs. 56.86 nmol/L); p = 0.04). In conclusion, we found a widespread and distressing rate of vitamin D deficiency and insufficiency in patients with bone tumours. However, especially for patients with bone tumours sufficient vitamin D levels seem to be of great importance. Thus, we believe that 25(OH)D status should routinely be monitored in these patients. Collectively, there should be an increased awareness for physicians to assess and if necessary correct vitamin D status of patients with bone tumours in general or of those at great risk of developing bone tumours.

Complications Associated With Midline Incision for Insertional Achilles Tendinopathy.

BACKGROUND: The midline-incision trans-achillary approach (MITA) is frequently used for addressing all pathologies of insertional Achilles tendinopathy (IAT). The aim of this study was to assess the complication rate and possible influencing factors following a MITA for IAT treatment. METHODS: Presented is a retrospective cohort study with current follow-up. Patients treated surgically by a MITA, addressing all pathologies of IAT, between January 2010 and October 2016 at a single reference center with at least 12 months of follow-up were included. General demographics (age, sex, and body mass index), medical history, surgical details (individual and sum of pathologies addressed), and duration of in-hospital stay were assessed. Patient satisfaction, shoe conflict, current employment status, time to return to sports, and type of sports were recorded using a custom questionnaire. Standard statistics, chi-square, and t tests were performed using SPSS. A total of 118 patients (follow-up, 63.4%) with a mean age (± SD) of 50 ± 12 years and a mean final follow-up time (± SD) of 4.2 ± 2.1 were included. RESULTS: Fourteen percent of patients had a minor complication, the majority (75%) of which were surgical site infections. Forty-one percent were limited in their shoe selection, and 32% reported a shoe conflict. Seventy-eight percent were very satisfied, and 89% would recommend the surgery. Neither the individual surgical procedures, their sum, nor any other parameter showed a significant influence on the complication rate. The only factor negatively affecting patient satisfaction was a shoe conflict (P < .001). CONCLUSION: The MITA for IAT treatment showed a moderate minor complication rate with good midterm patient satisfaction. However, the approach might predispose patients to shoe conflict, which negatively influences their satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Significant prevalence of peripheral artery disease in patients with disturbed wound healing following elective foot and ankle surgery: Results from the ABI-PRIORY (ABI as a PRedictor of Impaired wound healing after ORthopedic surgerY) trial.

Disturbed wound healing (DWH) following elective foot and ankle surgery is associated with a number of known risk factors. The purpose of this study was to determine if peripheral artery disease (PAD) is a potential risk factor that contributes to an increase in postoperative DWH. In a case-control study, we analyzed all patients undergoing elective foot and ankle surgery between January 1, 2014 and December 31, 2017 at two institutions and identified 51 patients with postoperative DWH. After matching with 51 control patients without DWH, all 102 patients were evaluated for PAD. The prevalence of PAD was significantly higher in the DWH group compared to the control group (41.2% vs 19.6%, p < 0.01). This difference was even more distinctive for patients with any abnormal ankle-brachial index (ABI) (51.0% vs 19.6%, p < 0.001). After adjustment for diabetes, hypertension, hypercholesterolemia, and smoking, any abnormal ABI or a history of PAD remained an independent risk factor for DWH (odds ratio 3.28; 95% CI 1.24-8.71). In this dual-center study, postoperative DWH was associated with significantly higher rates of PAD. These findings suggest that preoperative evaluation for PAD could be a helpful tool to identify patients at high risk for postoperative wound complications undergoing foot and ankle surgery. This trial is registered with drks.de, number DRKS00012580.

A cone beam CT based 3D-assessment of bony forefoot geometry after modified Lapidus arthrodesis.

BACKGROUND: Modified Lapidus arthrodesis (MLA) is a well-established treatment modality for hallux valgus deformities (HVD) associated with instability of the first ray. Although the three-dimensional (3D) nature of HVD has long been recognized, diagnostics still focus on plain radiographs. The objective of this study was to validate 3D Cone Beam CT (CBCT) in the perioperative assessment of HVD with focus on the alignment of the forefoot. METHODS: In a prospective clinical study, MLA was performed on 30 patients (25 females, 5 males; mean age: 63.2 years). Pre- and postoperatively standard radiographs and CBCT with full weight-bearing were acquired. For the CBCT based assessment, reproducible criteria have been defined, measured, and correlated with established radiological indicators. RESULTS: Evaluation of standard radiographic parameters (hallux-valgus angle [HVA], intermetatarsal angle 1-2 [IMA 1-2], distal metatarsal articular angle [DMAA], tibial sesamoid position [TSP]) showed significant improvement postoperatively. Comparison of measurements obtained from plain radiographs and CBCT were significantly correlated between both measuring techniques, indicating high reliability. Pronation of the first metatarsal and the sesamoids were significantly reduced by the procedure. Due to this repositioning effect, the second metatarsal head was elevated by 3.1mm, and the lateral sesamoid was lowered by 3.8mm. However, there was no correlation between the amount of pronation and conventional radiographic measures. CONCLUSIONS: Compared to plain radiographs, CBCT allows a more detailed view of the forefoot alignment in the coronal plain after MLA. MLA was able to recenter the sesamoids under der first metatarsal head and conversely led to elevation of the second metatarsal head.

Physical Performance and Quality of Life after Ankle Fusion. / Körperliche Leistungsfähigkeit und Lebensqualität nach Arthrodese des oberen Sprunggelenks.

INTRODUCTION: Ankle fusion is still considered as an established therapy for end-stage ankle osteoarthritis. To determine exact description of postoperative functioning, it is necessary to consult a variety of functional scores and quality of life questionnaires. METHODS/PATIENTS: 34 patients with 34 ankle fusions were investigated on average 5.9 years postoperatively by functional tests and health-related quality of life questionnaires (AOFAS hindfoot score [AOFAS: American Orthopaedic Foot/Ankle Society], Foot Function Index [FFI], Lower Extremity Functional Scale [LEFS], Lower Extremity Activity Scale [LEAS], Visual Analogue Scale Foot/Ankle Surgery [VAS FA], Short Form 36 [SF-36], EuroQol 5D [EQ-5D]). RESULTS: After ankle fusion: the majority of cases gain pain reduction, but residual symptoms may persist; the maximum walking distance (subjectively more than objectively) will be extended; rarely walking without any aids can be achieved; in most cases, the gait pattern is only slightly changed; the re-entry into working life is often possible; climbing stairs without any restrictions is not always possible; the psychological situation will be equalized with that of healthy people. CONCLUSION: The results of the study confirm the success rates of ankle fusions in the majority of cases. Well defined limitations and residual symptoms can be named on the basis of the available data.

[Treatment of plantar, neuropathic and metatarsal ulcers by minimally invasive metatarsal osteotomy]. / Behandlung von plantaren, neuropathischen und metatarsalen Ulzera mittels distaler minimalinvasiver metatarsaler Osteotomie.

BACKGROUND: The chronic-mechanical plantar ulcer in diabetic-neuropathic foot syndrome is the starting point for severe infections of the foot and amputations. Frequent predilection sites are the metatarsal heads (MTH); in the context of neuropathy increased plantar peak pressure occurs and leads to an ulcer. GOAL: In this paper, we will examine whether minimally invasive pressure-reducing osteotomies, such as distal, minimally invasive metatarsal osteotomy (DMMO), can lead to the healing of metatarsal ulcers. Furthermore, the frequency of postoperative complications will be analyzed. METHOD: In a prospective study, n = 26 consecutive patients with plantar grade IA, IIA, and IIIA ulcers according to Wagner/Armstrong were included in the study under MTH 2, 3, 4 and 5 and with an unsuccessful conservative therapy >6 months. All patients received a DMMO of MT 2, 3, and 4, unless the ulcer was under MTH 5, then isolated DMMO MT 5 was performed. Clinical radiological check-ups took place over a follow-up interval of 26 ± 18 months (8-43 months). RESULTS: In all patients, the plantar ulcera healed after 5 ± 1 week, the recurrence rate was 8% and 3 patients had a transfer ulcer. Complications such as infection, pseudarthrosis or neuroosteoarthropathy did not occur. CONCLUSION: DMMO is an effective method for the treatment of recalcitrant ulcers under the metatarsal heads. The rate of a long-term cure is high; the complication rate is low; in ulcers under MTH 5, the DMMO should possibly be extended to the other metatarsal heads to reduce the risk of a transfer ulcer.

Guided and Unguided Biopsy in the Diagnostic of Periprosthetic Infections of the Knee - Evaluation of an Evidence-based Algorithm. / Die gezielte und ungezielte Zupfbiopsie in der Abklärung periprothetischer Kniegelenksinfektionen ­ Evaluierung eines evidenzbasierten Algorithmus.

BACKGROUND: Periprosthetic joint infection (PPI) is one of the most common reasons for revision in total knee arthroplasty (TKA). Percutaneous synovial biopsy is considered as a well-established diagnostic tool in ambiguous cases of chronic pain after TKA. The exact number of undetected low-grade infections remains unclear. OBJECTIVES: The aim of this prospective study was to compare the diagnostic accuracy of arthroscopically guided and unguided synovial biopsy. Additionally, the prevalence of initially undetected PPI during synovial biopsy and revision surgery was assessed. MATERIALS AND METHODS: 40 patients suffering from chronic pain after TKA and the clinical suspicion of PPI were included in the study. Synovial biopsies were collected in a standardized manner first without and then with arthroscopic visual control. Using both techniques, six samples were collected each (5 for microbiology, 1 for histology). 19 patients, initially classified aseptic, underwent revision surgery later. RESULTS: The diagnosis of PPI was made in 10.0% of unguided biopsies (4 cases, 2× microbiologically, 2× histologically), 7.5% of arthroscopic biopsies (3 cases, 3× histologically) and 12.5% (5 cases, 3× histologically, 2× microbiologically) of all cases. Only histologic evaluation led to concordant positive findings using both techniques in two patients. The proportion of non-representative biopsies was twice as high after unguided tissue collection than after arthroscopic biopsy (30.0 vs. 15.0%). Microbiologic evaluation of arthroscopically collected biopsies did not lead to the diagnosis of PPI, which might have been essential to the selection of the appropriate antimicrobial therapy. During revision surgery the diagnosis of PPI was made in 22.2% of cases. CONCLUSIONS: In patients suffering from chronic pain after TKA, periprosthetic low-grade infection was diagnosed in a relevant proportion of cases. Therefore, synovial biopsies for histological and microbiological evaluation should be collected whenever there's clinical suspicion of PPI. For histological evaluation, samples should be collected using arthroscopic control and ideally multiple biopsies should be taken. For microbiological evaluation, excessive joint lavage should be avoided.

A 30-Year Single-center Experience of Cementless Total Hip Arthroplasty With Spongy Metal Structured Implants: A Follow-up of a Previous Report.

BACKGROUND/AIM: The aim of this study was to analyze survivorship and functional outcome of cementless spongy metal structured total hip arthroplasty (THA) after ultra-long-term follow-up. PATIENTS AND METHODS: A total of 100 THAs in patients under 65 years at initial surgery were performed between 1985 and 1989 at our Department. Twenty patients (23 hips) were available for final follow-up. Implant survivorship and functional results (Merle d'Aubigné, SF-12) were assessed. RESULTS: At a mean follow-up of 30 years (range=27.7-31.7 years), the overall stem survival rate was 82.6% (19/23 stems) and the overall cup survival rate was 52.2% (12/23 cups). Revision surgeries were performed for aseptic loosening in all cases. Functional evaluation revealed good to excellent results in 16 patients (80%) Conclusion: Spongy metal structured cementless THA provides remarkable survivorship and excellent functional results even after ultra-long-term follow-up. Further research regarding modern implants, bearing surfaces etc. is required to assess survivorship and clinical outcomes of different implant designs.

[Differential diagnosis of heel pain]. / Differenzialdiagnose des Fersenschmerzes.

"Heel pain" describes a very common reason for foot orthopedic consultation and the further differential diagnostic investigation is crucial for the choice of correct treatment. In the treatment of frequent underlying diseases, such as plantar fasciitis or insertional tendinopathy of the Achilles tendon, a variety of modern strategies are available. Rarer diseases, such as tumors or nerve entrapment syndromes must be delineated and correctly classified. This article provides the current state of the diagnostics and treatment of the most common entities of heel pathologies.

[Megaimplants of the Proximal Femur: Current Concepts]. / AE-Beitrag: Megaimplantate am proximalen Femur: aktuelle Evidenz, Systemunterschiede und Portfolioempfehlung.

In addition to their outstanding significance in the field of tumor orthopaedics, megaprostheses are becoming increasingly important for revision arthroplasty. Despite their wide application, the reported complication and failure rates remain high. The analysis of failure mechanisms roughly allows a breakdown into mechanical and non-mechanical causes; soft-tissue failure, loosening and periprosthetic infection play outstanding roles. Each type of failure can be associated to a specific prosthetic component: To avoid soft tissue failure, muscular connection to the prosthesis is essential; to avoid loosening, the anchoring technique on the stem is crucial; to prevent infection, the surface condition or possibly the coating of the prosthesis seem to play major roles. Some fully-fledged proximal femoral replacement systems have become established on the market and have similar clinical outcomes. However, there are significant differences in anchoring techniques, modularity or module connections and soft tissue connection. In any case, the high failure rates show that there is great potential for future developments. Innovative suggestions for each component are certainly possible through cross-linking to already functioning systems. Together with new findings from basic research, future systems should be able to significantly reduce the rate of prosthetic failures.

Distribution patterns of foot and ankle tumors: a university tumor institute experience.

BACKGROUND: Bone and soft tissue masses of the foot and ankle are not particularly rare but true neoplasia has to be strictly differentiated from pseudotumorous lesions. Diagnosis is often delayed as diagnostic errors are more common than in other regions. Awareness for this localization of musculoskeletal tumors is not very high and neoplasia is often not considered. The purpose of this study is to provide detailed information on the incidence and distribution patterns of foot and ankle tumors of a university tumor institute and propose a simple definition to facilitate comparison of future investigations. METHODS: As part of a retrospective, single-centre study, the data of patients that were treated for foot and ankle tumors between June 1997 and December 2015 in a musculoskeletal tumor centre were analyzed regarding epidemiologic information, entity and localization. Included were all cases with a true tumor of the foot and ankle. Exclusion criteria were incomplete information on the patient or entity (e.g. histopathological diagnosis) and all pseudotumoral lesions. RESULTS: Out of 7487 musculoskeletal tumors, 413 cases (5,52%) of tumors of the foot and ankle in 409 patients were included (215 male and 198 female patients). The average age of the affected patients was 36 ± 18y (min.3y, max.92y). Two hundred sixty-six tumors involved the bone (64%), among them 231 (87%) benign and 35 (13%) malignant. There were 147 soft tissue tumors (36%), 104 (71%) were benign, 43 (29%) malignant. The most common benign osseous tumor lesions included simple bone cysts, enchondroma and osteochondroma. By far the most common malignant bone tumor was chondrosarcoma. Common benign soft tissue tumors included pigmented villo-nodular synovitis, superifcial fibromatosis and schwannoma whereas the most common malignant members were synovial sarcoma and myxofibrosarcoma. Regarding anatomical localization, the hindfoot was affected most often. CONCLUSIONS: Knowledge of incidence and distribution patterns of foot and ankle tumors will help to correctly assess unclear masses and initiate the right steps in further diagnostics and treatment. Unawareness can lead to delayed diagnosis and inadequate treatment with serious consequences for the affected patient.