[Cavovarus foot]. / Ballenhohlfuß.

The cavovarus foot (CF) is a complex three-dimensional foot deformity. In addition to primary forms, secondary forms can be distinguished. The diagnosis of CF is made clinically; however, anamnestic information, a targeted examination including neurological status and at least radiological imaging using the hindfoot-centered imaging technique are required to determine the treatment. Conservative treatment for CF consists of the provision of insoles up to the adaptation of an orthopedic custom-made shoe, depending on the severity of the deformity. The indications for a surgical procedure are present in the case of increasing complaints, although the timing should be extensively discussed with the patient in order to be able to achieve the best functional results. Surgical treatment is generally complex but a combination of soft tissue interventions and osteotomy/arthrodesis can usually be used to achieve a plantigrade foot position and thereby enable the patient to walk with a functionally improved gait.

[Stress fractures of the lower limbs]. / Stressfrakturen der unteren Extremität.

Stress reactions and fractures represent an important differential diagnostic entity, especially in patients active in sports. The lower extremities have predilection sites for stress fractures, which require special treatment in the context of the underlying risk factors. Clinically, patients usually complain of stress-dependent pain in the affected region and sport activities are mostly limited or even impossible. The detection of acute stress fractures is usually missed by conventional X­ray within the first 4-6 weeks. The gold standard diagnostic tool is magnetic resonance imaging (MRI). Depending on the location, a distinction must be made between low-risk and high-risk stress fractures. Low-risk fractures show a high healing rate after conservative treatment including load and stress reduction as well as avoiding risk factors. High-risk fractures can take a complicated course under conservative treatment measures and in some cases, surgical intervention is required.

[The talometatarsal-index ("TMT-Index") : A valuable X-ray parameter for differentiating between normal feet and planovalgus deformity in children and adolescents]. / Der Talometatarsalindex ("TMT-Index") : Ein wertvoller Röntgenparameter zur Differenzierung zwischen Normalfuß und Planovalgusdeformität beim Kind und Jugendlichen.

INTRODUCTION: The development of the shape of the shape from childhood to adulthood is a complex continuum. Deviations from this process occur frequently and, especially in asymptomatic patients, do not always include the need for therapeutic intervention. In the current S2-guideline on the juvenile flexible flatfoot, established x­ray parameters for assessing the flatfoot deformity were judged to be sensitive, whereby no statement was made regarding the value of the parameters among themselves. The aim of the present work is to assess the talometatarsal Index (TMTInd) in comparison to established angle measurements. METHODS: Twenty-two feet with and 22 feet without planovalgus deformity (age: 10-14 years) were investigated. Established radiological parameters (lateral view: talocalcaneal angle (TC-lat), calcaneal pitch angle (Calc-B), Costa-Bartani angle (Costa-B), talometatarsal­I angle (TMTI-lat); dorsoplantar view: talometatarsal-I-basis angle (TMTIB), talonavicular coverage (TNG), calcaneal metatarsal- V angle (Calc-MTV), talocalcaneal angle (TC-dp), and talometatarsal­I angle (TMTI-dp)) were measured on standardized X­ray images and compared with the values of the TMTInd. RESULTS: All parameters other than Calc-MTV, TC-dp, TC-lat and Calc­B, showed a statistically significant difference between normal and planovalgus feet, although for almost all values measured (apart from TMTI-lat and TMTInd) there was a large overlap area (>10°) between the two groups. The comparison of TMTInd to all other parameters showed the highest discrimination factor (area-under-the-curve) for the TMTInd in the distinction between the groups. CONCLUSION: Compared to conventional radiological parameters, the TMTInd shows the highest validity in the distinction between normal and planovalgus feet and can provide valuable information in clinical decision-making with regard to therapy specification.

[Avulsion injuries of the gluteus medius and gluteus minimus muscles]. / Avulsionsverletzungen des M. glutaeus medius und M. glutaeus minimus.

Avulsion injuries of the gluteus medius and gluteus minimus muscles represent a diagnostic and therapeutic challenge. Such injuries are rarely to be expected in high-energy trauma. Degenerative damage or iatrogenic injuries in the context of hip surgery are more frequently identified as the cause. Clinically, in addition to lateral hip pain, limping is an important finding and depends on the extent of the tendon damage. In addition to the medical history and clinical examination, imaging by means of sonography and, above all, magnetic resonance imaging (MRI, possibly with artifact-reduced sequences in the presence of an endoprosthesis) are diagnostically groundbreaking. Therapeutically, a stepwise approach is indicated according to the extent of rupture and quality of the gluteal tendon and muscle tissues. Specific conservative training regimens, mini-open/endoscopic anatomic reconstruction techniques in cases of gluteal muscle integrity and muscle transfer techniques as salvage option with chronic mass ruptures are available. The common goal is the restoration of everyday occupational and private activities to regain the quality of life.

[Minimally invasive components of the treatment of tibialis posterior insufficiency in adults : Tendoscopy of the Achilles tendon, minimally invasive calcaneus displacement osteotomy and the sinus tarsi spacer]. / Minimal-invasive Komponenten der Therapie der Tibialis-posterior-Insuffizienz des Erwachsenen : Tendoskopie der Achillessehne, minimal-invasive Kalkaneusverschiebeosteotomie und Sinus-tarsi-Spacer.

Minimally invasive medializing calcaneal osteotomy, the implantation of a tarsi spacer and the tendoscopy of the posterior tibial tendon have been established as treatment options for tibialis posterior insufficiency grade II. The minimally invasive medializing calcaneal osteotomy allows a correction of the hindfoot valgus like an open procedure with a significantly lower risk of wound healing problems. It has gained increasing popularity within recent years. There is also good evidence for arthroereisis, with the use of the sinus tarsi spacer being primarily an addition to calcaneus sliding osteotomy. The possibilities for tendoscopy of the posterior tibial tendon are limited to debridement and synovectomy. Various papers report minimally invasive alternatives to the strayer procedure for a shortened gastrocnemius muscle. The proximal lengthening of the medial head of the gastrocnemius muscle is particularly popular as a soft tissue-sparing, less traumatic procedure. So far, no reports of a minimally invasive cotton osteotomy have been found in the literature.

[Hindfoot-centred X-ray technique for the evaluation of cavovarus deformity : A proposal for the optimization of radiologic delineation]. / Die "rückfußzentrierte Röntgentechnik" zur Erfassung von Cavovarusdeformitäten : Vorschlag zur Optimierung der radiologischen Darstellung.

In surgical correction of cavovarus deformity bony hindfoot procedures are required in most cases. For treatment planning X­rays in two or more planes are usually used. In conventional X­ray-techniques the hindfoot and ankle joint are presented in a more or less outward rotated position. Moreover, the peritalar complex is not delineated in the most corrected position. Therefore, the frequently used talus-metatarsal-I-angle (Meary angle) cannot be measured correctly. By application of the Coleman block test and additional adjustment of the malrotation in the lateral view, the peritalar complex and ankle joint can be evaluated in the corrected and "hindfoot-centred" position. Also, the frequently seen anterior ankle impingement can be observed precisely. Planning of osteotomies or corrective peritalar fusions is supported thereby. Some treatment examples are presented.

[Gluteal insufficiency]. / Gluteale Insuffizienz.

Gluteal insufficiency or hip abductor mechanism deficiency mainly following (revision) total hip replacement is associated with highly painful complaints and severe suffering of patients. It represents a great diagnostic and therapeutic challenge. Differentiated conservative treatment pathways, open surgical and endoscopic anatomic repair techniques with intact gluteal musculature and muscle transfer are available as salvage procedures for chronic not anatomically reconstructable mass ruptures. A stepwise diagnostic and therapeutic approach is required for restoration of the quality of life and painless or almost painless mobility of affected patients in occupation and daily life.

Osteoinduction and -conduction through absorbable bone substitute materials based on calcium sulfate: in vivo biological behavior in a rabbit model.

Calcium sulfate (CS) can be used as an antibiotically impregnated bone substitute in a variety of clinical constellations. Antibiotically loaded bone substitutes find specific application in orthopedic and trauma surgery to prevent or treat bone infections especially in relation to open bone defects. However, its use as a structural bone graft reveals some concerns due to its fast biodegradation. The addition of calcium carbonate and tripalmitin makes CS formulations more resistant to resorption leaving bone time to form during a prolonged degradation process. The aim of the present study was the evaluation of biocompatibility and degradation properties of newly formulated antibiotically impregnated CS preparations. Three different types of CS bone substitute beads were implanted into the tibial metaphysis of rabbits (CS dihydrate with tripalmitin, containing gentamicin (Group A) or vancomycin (Group B); Group C: tobramycin-loaded CS hemihydrate). Examinations were performed by means of x-ray, micro-computed tomography (micro-CT) and histology after 4, 6, 8 and 12 weeks. Regarding biocompatibility of the formulations, no adverse reactions were observed. Histology showed formation of vital bone cells attached directly to the implanted materials, while no cytotoxic effect in the surrounding of the beads was detected. All CS preparations showed osteogenesis associated to implanted material. Osteoblasts attached directly to the implant surface and revealed osteoid production, osteocytes were found in newly mineralized bone. Group C implants (Osteoset®) were subject to quick degradation within 4 weeks, after 6-8 weeks there were only minor remnants with little osteogenesis demonstrated by histological investigations. Group A implants (Herafill®-G) revealed similar degradation within atleast 12 weeks. In contrast, group B implants (CaSO4-V) were still detectable after 12 weeks with the presence of implant-associated osteogenesis atlatest follow-up. In all of these preparations, giant cells were found during implant degradation on surface and inside of resorption lacunae. None of the analyzed CS preparations triggered contact activation. All implants demonstrated excellent biocompatibility, with implants of Group A and B showing excellent features as osteoconductive and -inductive scaffolds able to improve mechanical stability.

[Lateral ligament injuries]. / Außenbandverletzungen.

Due to the frequency and potentially complicated course distortion of the upper angle joint represents an important entity in the orthopedic patient clientele. The initial diagnosis includes a detailed anamnesis of the injury mechanism and an accurate clinical examination. To exclude bony, ligamentous and chondral lesions, besides basic diagnostics consisting of X­rays and ultrasound, magnetic resonance imaging (MRI) is considered the most important tool. Lateral ankle ligament injuries are generally treated conservatively. After a short period consisting of immobilization of the affected ankle, early functional therapy with semi-rigid orthoses and proprioceptive exercises should be performed. If conservative therapy fails and thus chronic instability develops the indications for operative treatment are given. Meanwhile, surgical techniques have been established with satisfactory results. Inadequate rehabilitation could be identified as a major risk factor for re-injury, therefore phase-adapted aftercare has gained significant importance.

[Osteoarthritis of the upper ankle joint]. / Arthrose des oberen Sprunggelenks.

The majority of cases of upper ankle joint (UAJ) osteoarthritis are due to secondary causes. Clinically, osteoarthritis is usually characterized by an increasing limitation in dorsal extension of the UAJ with often relatively mild symptoms. In the course of time the full scale of the typical symptoms and the progressive restriction of the global function of the joint develop. Conservative therapy is often able to provide long-term improvement of the symptoms for the majority of patients by means of intermittent analgesics and orthoses as well as shoe modifications. Operative treatment strategies for initial stages are based on joint-sparing methods. The most frequently used therapy for progressive destruction of the UAJ is still arthrodesis. Total ankle replacement is becoming an increasingly more competitive procedure. Total ankle replacement provides a valuable extension of therapeutic possibilities for UAJ osteoarthritis.

[Hip dislocation after revision arthroplasty : Risk assessment and treatment strategies]. / Luxation nach Hüfttotalendoprothesenrevision : Analyse von Risikofaktoren und Lösungsstrategien.

With a dislocation rate of up to 35% after revision total hip arthroplasty (THA), instability is one of the major causes why this procedure fails. Independent factors for patients at risk are age, sex, and the type of revision needed. The surgical approach, implant choice, and positioning of the components are factors that the surgeon can influence to keep the dislocation rate low. Large femoral heads or double mobility (DM) cups can increase the stability of the joint. After detailed failure analysis, targeted use of different technical innovations enhances stability in revision THA and prevents further revisions.

[Autologous fibula transplantation for reconstruction of bone defects]. / Die autologe Fibulatransplantation zur Rekonstruktion knöcherner Defekte.

The reconstruction of large bone defects following tumor resection, trauma or infection is difficult and subject to individual preferences of each surgeon. Free autologous fibula grafts are a reliable biological treatment method, whereas both a vascularised and a non-vascularised transplantation is possible. The use of either treatment option - vascularised or non-vascularised - is accompanied by individual advantages and/or disadvantages that should be taken into consideration during the preoperative planning process. Vascularised fibula transplants should be used especially for the reconstruction of large segmental defects and in patients, in whom adjuvant chemo- and/or radiation therapy is to be administered. Non-vascularised fibula grafts - which offer the advantage of a certain regeneration potential at the donor site as well as a shorter operation time - might be beneficial for bridging hemicortical defects and segmental defects with good soft tissue coverage.