[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.

Motion of the ankle in a simulated supination-external rotation fracture model.

UNLABELLED: An experimental study was undertaken with use of axially loaded, unconstrained cadaver ankles to determine the motion patterns seen with progressive stages of the supination-external rotation type of fracture. As described by Lauge-Hansen, these fractures were modeled by transection of the anterior aspect of the capsule and the anterior tibiofibular ligament (stage I), followed by oblique fibular osteotomy ending at the level of the ankle joint (stage II), transection of the posterior aspect of the capsule (stage III), and sequential sectioning of the superficial and deep fibers of the deltoid ligament (stage IV). Thirteen specimens were tested on an apparatus that allowed for controlled loading while the ankle was passed through a physiological range of dorsiflexion and plantar flexion. The ankles were unconstrained about the axial (internal and external rotation) and coronal (varus and valgus angulation) axes. Measurements were made throughout the range of motion in these axes in order to define the kinematic behavior. In the intact specimens, maximum plantar flexion was associated with a mean (and standard deviation) of 1.9 +/- 4.12 degrees of internal rotation of the talus and maximum dorsiflexion, with a mean of 7.2 +/- 3.88 degrees of external rotation. Varus angulation increased slightly with plantar flexion compared with the value in dorsiflexion (2.4 +/- 2.40 compared with 0.3 +/- 1.96 degrees). Internal and external rotation was not affected by fibular osteotomy or by transection of the superficial fibers of the deltoid ligament. Transection of the deep fibers of the deltoid ligament caused a significant (p < 0.02) increase in external rotation of the talus at maximum plantar flexion; this was corrected incompletely by insertion of an anatomical fibular plate. With the numbers available for study, we could not show that varus or valgus angulation was significantly affected by any combination of sectioning of the deltoid ligament and fibular osteotomy. These experiments were repeated with the addition of fixation of the subtalar joint with a talocalcaneal screw. With the number of specimens available, we could detect no significant difference, with respect to axial rotation, due to fixation of the subtalar joint. However, along the coronal axis, increased valgus angulation (p < 0.02) was seen during plantar flexion when either the deep or the superficial fibers of the deltoid ligament had been cut. CLINICAL SIGNIFICANCE: These results indicate that stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. Complete fibular osteotomy did not cause abnormal motion of the ankle in the absence of a medial injury. In the presence of a complete injury, lateral reconstruction only partially restored the mechanical integrity of the ankle. The results provide justification for the non-operative treatment of isolated fractures of the lateral malleolus. The data also suggest that a lateral fracture associated with a major injury of the deltoid ligament should be treated with anatomical lateral fixation followed by immobilization without early motion, to allow adequate healing of the deltoid ligament at its resting length.

[Follow-up results of adduction-derotation osteotomies in hip dysplasia]. / Nachuntersuchungsergebnisse nach Varisations- Derotations-Osteotomien bei Hüftdysplasie.

The first part of the investigation was concerned with the evaluation of radiographs of 64 children in whom 97 intertrochanteric adduction-derotation osteotomies were performed when the patients were between two and ten years old. Prior to surgery, immediately thereafter and two and six years later, the CCD, AC, ACM and CE angles of all the patients were measured on plain pelvic radiographs. On the radiographs made after six years 70% of the CCD angles were normal, while pathologic coxa valga was found in 15% and coxa vara also in 15%. The AC angle was normal in 32% , the ACM angle in 31%; however, these normal groups were only 76% identical. The CE angle had normalized in 32% of the cases. The second part of the paper deals with clinical and radiological follow-up findings in 46 of these patients in whom 64 hips had been treated. The follow-up period varied between six and 13 years. On clinical examination the result was found to be satisfactory in 59% and unsatisfactory in 41%. A comparison with radiological-anatomical findings showed that in 32% of the radiologically satisfactory cases there were some considerable functional limitations and subjective complaints. The author's own results are compared with communications in the literature, in particular with the Swiss collective statistics published by Jani (1973) and Reichelt and Hansen's publication (1975). To provide the reader with a survey of the number of cases, age at operation and periods of observation quoted by different authors, these data are presented synoptically in tabular form. Another table lists the criteria investigated by the individual authors (AC, ACM, CE, CCD and AT angles). The discussion is completed with conclusions relevant to clinical practice.