Post-Traumatic Hindfoot Arthritis.

The hindfoot is functionally defined as the articulations between the talus, calcaneus, navicular, and cuboid. It is a biomechanically important peritalar unit for shock absorption and propulsion with the subtalar and talonavicular joint essential to its function. The primary cause of hindfoot arthritis is post-traumatic. Other causes include long-term misalignment such as adult-acquired flatfoot, cavus foot, and inflammatory arthritis. Prevention of post-traumatic hindfoot arthritis is the primary objective. Anatomical reduction and fixation of articular hindfoot fractures is the preferred pathway. This article discusses the principles of treatment of hindfoot arthritis. When post-traumatic changes cannot be managed by nonsurgical means, an anatomical well-aligned arthrodesis is indicated. This article addresses the principles of managing this condition, which have been championed by Professor Sigvard T. Hansen. New approaches and techniques are discussed that achieve the goals of a stable, functional plantigrade foot.

Results of arthrodesis in neuropathic feet.

We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy. Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high.

[Injuries of the tibialis posterior tendon: diagnosis and therapy]. / Verletzungen der Sehne des M. tibialis posterior. Diagnostik und Therapie.

Complete traumatic rupture of the tibialis posterior tendon is absolutely rare. From the scarce case reports in the medical literature a extreme pronation-abduction or pronation-external rotation mechanism according to the Lauge-Hansen classification can be presumed, leading to a malleolar fracture because of forced pronation, external rotation and dorsiflexion of the foot. With primary suture the prognosis is favorable. Traumatic dislocations, mostly with luxatio pedis sub talo, are treated by atraumatic reduction and refixation of the retinaculum. Again, the prognosis is favorable. Incomplete traumatic rupture of the tibialis posterior tendon with development of posttraumatic pes plano valgus, according to case reports and our own experience result from severe pronation-external rotation-soft tissue injuries as well as with pronation-abduction or pronation-external rotation-type ankle fractures. In these cases no macroscopic rupture of the tendon is evident, however occult interstitial micro-ruptures can occur because of excessive stretching, which can be determined histologically. If conservative measures fail, a modified Evans osteotomy to lengthen the lateral foot column is indicated. Degenerative complete and incomplete ruptures of the tibialis posterior tendon are predominantly seen in women more than 42 years old. Staging of this entity can be achieved with clinical tests (muscular force, external rotation), ultrasound, weight-bearing x-rays, CT and MRT. According to the degree of decompensation of tendon function, treatment consists of augmentation, modified Evans procedure or triple arthrodesis of the hind-foot.

[Leprosy surgery in a bush hospital in Africa: experience in Madagascar]. / La chirurgie de la lèpre dans un hôpital de brousse en Afrique: expérience à Madagascar.

We report our experience of leprosy surgery in terms of feasibility and efficacy in a small hospital of bush in Madagascar during the period of September 1989 to January 1993. Operations of neurolysis, corrections of claw hands by the techniques of Lasso-Zancolli or Van Droogenbroeck, arthrodesis, resections and amputations have been performed. Our results suggest that at least a part of these surgical procedures may be performed by a non specialized medical team, taught on the premises. Thus, the cost of treatment will be low and accessible to more leprosy patients.

[Leprosy, an "exemplary" humanitarian disease?]. / La lèpre, maladie humanitairement "exemplaire"?

Leprosy still remains a dreaded disease despite the possibilities of permanent cure, the efficacy of surgical corrections, and its forthcoming disappearance. The authors conducted several surgical missions in Benin-Africa--over 4 years and report an interesting rate of control in the survey of patients as the results of their procedures were reviewed in 84% of them. Leprosy represents the perfect example of the difficulties of any humanitarian involvement with apparent contradictions between the aims of the medical wishes and the presence of a dreaded symbol that--fortunately or not--allow the existence of the many associations involved in the fight against leprosy.

Long-term follow-up of joint stabilization procedures in the treatment of fixed deformities of feet in leprosy.

This retrospective study of 52 patients, who underwent joint stabilization procedures for static deformities of the feet in leprosy between 1971 and 1985, was undertaken to asses the long-term results of joint stabilization of feet for fixed deformities in leprosy. The main purpose of joint stabilization is to make the feet plantigrade for weight bearing and to make the wearing of footwear possible. Deformities corrected include varus, equinus and equinovarus. Chronic ulceration occurs repeatedly if these deformities are not corrected and leads to inevitable bone destruction and eventual amputation.

Correction of severe foot deformities.

An arthrodesis between tibia and calcaneus was performed after extirpation of the lateral malleolus and the talus in 65 patients with severe stiff paretic feet in equinovarus position, 44 nonleprosy and 21 with leprosy. Early mobilization with weightbearing was allowed after 1 week. Bony fusion was achieved in 95% in the nonleprosy group and 76% in the leprosy group. The final appearance and function was very satisfying with a good range of motion in the Chopart joint.

The results of arthrodesis of the ankle for leprotic neuroarthropathy.

Twenty-four patients who had arthrodesis of one or both ankles for leprotic neuroarthropathy were followed for an average of nine years and five months. At operation, after the removal of cartilage, joint debris, and sclerotic bone, the ankle joint was transfixed with a Küntscher intramedullary nail, and staples or Kirschner wires were used to control rotation. Fusion of bone was obtained in nineteen (73 per cent) of the twenty-six ankles. Failure to obtain fusion was due to postoperative infection in four patients, deficiency of the site of arthrodesis in one patient, and refracture through the site of fusion in two patients. When arthrodesis was successful, additional neuroarthropathic destruction of the mid-tarsal joint was halted, and the preoperative clinical symptoms of dull pain, local warmth, swelling, and instability were relieved.

[Course of bone lesions of leprosic feet towards dislocation of the tarsus and metatarsus]. / Evolution des lésions osseuses du pied lépreux vers la dislocation du tarse et du métatarse.

The authors have observed 135 dislocations of the tarsus in leprosic feet. They recall the mechanism of the lesion and propose a classification. 42 cases were operated on to prevent further deformities. When early treated limited arthrodeses may be beneficial in some cases. In more severe cases rebuilding arthrodesis alone or associated to cancellous bone grafting is indicated. In very severe cases amputation is only indicated because the Wladimiroff-Mickulicz technique as well as grafts lead to failures related to the metatarsophalangeal joints stiffness.

Use of intramedullary polypropylene peg for joint stabilization in leprosy.

Joint arthrodesis is indicated when motion in a joint cannot be restored, and that joint requires stabilization in an optimal functional position. The Harrision Intramedullary peg has been used to advantage for this purpose in hand reconstruction in leprosy in a renal developing area. It is a method to be considered for selected cases requiring joint stabilization to improve total hand function.

Opponensplasty in intrinsic-muscle paralysis of the thumb in leprosy.

For eighty-six cases of leprous paralysis of the intrinsic muscles of the hand, a modified Bunnell opponensplasty (transfer of a finger flexor) was done. Good results were seen in eighteen and fair results in sixty-three. The five poor results occurred because of infection, weakness, or deformity. Adjuvant procedures, as needed, were interphalangeal arthrodeis of the thumb, capsulorrhaphy of the wrist, and additional tendon transfers.