Endoprothetik am oberen Sprunggelenk.

Arthrosis of the upper ankle is usually the long-term consequence of an ankle fracture. In the case of advanced osteoarthritis - after all conservative therapy options have been exhausted - the therapeutical options are reduced to the choice between arthrodesis and prosthesis, the technique and follow-up treatment of which this article presents. The mobility achieved after endoprosthetic treatment is usually less than the normal physiological level, but still functionally sufficient.

[Reconstruction of the plantar plate of the metatarsophalangeal joint using a dorsal transarticular approach]. / Naht der plantaren Platte des Kleinzehengrundgelenks über einen dorsalen transartikulären Zugang.

OBJECTIVE: Reconstruction of the plantar plate to stabilize a dislocated or instable lesser metatarsophalangeal joint using a dorsal approach in combination with a Weil osteotomy. INDICATIONS: Dislocated or instable lesser metatarsophalangeal joint with rupture of the plantar plate. CONTRAINDICATIONS: Infection, circulatory disorders, symptomatic degenerative arthritis lesser metatarsophalangeal joint. SURGICAL TECHNIQUE: Weil osteotomy using a dorsal approach. Temporary dislocation of the metatarsal head as proximal as possible. Inspection of the plantar plate. Assessment and classification of type and extent of the rupture. Suturing of the plantar plate to the plantar bases of the proximal phalanx. Fixation of the Weil osteotomy with correction of the metatarsal alignment. POSTOPERATIVE MANAGEMENT: Weight bearing in a postoperative shoe as tolerated. X­ray control 6 weeks postoperative. Full weight bearing in a conventional shoe after bony consolidation. RESULTS: A total of 23 surgical reconstructions of the plantar plate (complete plantar plate repair) between 12/2012 and 10/2014 were performed. The mean follow-up was 18.6 (12-30) months. Five secondary dislocations were observed: one deep postoperative infection, one early dislocation of unknown cause, one secondary dislocation caused by severe hallux valgus recurrence, one massive foreign body reaction to the non-resorbable sutures, and one late secondary dislocation occurred between 6 weeks and 1 year postoperative. Normal function of the reconstructed joint was achieved in 13 of the 23 reconstructions (57%). A reduced toe purchase was observed in 3 reconstructions (13%). A floating-toe resulted after 7 reconstructions (30%).

[Joint-preserving surgical correction of advanced flexible planovalgus deformity of the adult foot]. / Gelenkerhaltende operative Korrektur der fortgeschrittenen flexiblen Planovalgusdeformität des erwachsenen Fußes.

BACKGROUND: Adult acquired flatfoot deformity is characterized by a progressive functional deficit of the foot that leads to an eversion of the subtalar joint complex with heel valgus, abduction of the forefoot and collapse of the medial arch. In the case of a flexible deformity, a joint-preserving operative reconstruction is advisable, which should correct all elements of the deformity. A calcaneal lengthening osteotomy can correct excessive abduction of the forefoot, which can be measured by the amount of talar head uncoverage visible on AP weight-bearing x­rays of the foot. THERAPY: Any calcaneal lengthening osteotomy leads to an incongruence between talar and calcaneal joint surfaces of the subtalar joint, which is a risk factor for secondary degenerative changes. It is, therefore, advisable to limit the amount of lengthening to the necessary minimum. A residual heel valgus can be corrected by an additional medial displacement osteotomy as adjunct to the calcaneal lengthening. Calcaneal osteotomies are usually part of a complex reconstruction of advanced but still flexible adult flatfoot deformities. In addition to the correction of the hindfoot deformity, persistent forefoot supination needs to be corrected. In cases of midfoot instability, which is frequently located in the naviculo-cuneiforme joint line, a corrective arthrodesis is recommended. Without midfoot instability forefoot a Cotton osteotomy is able to reduce forefoot supination and add to reconstruction of the medial arch of the foot. All bony corrections should be combined with soft tissue reconstruction, i.e. spring ligament repair, Flexor tendon transfer and, in cases of gastrocnemius shortening, a gastroc recession.

The Current S2e Guideline for Hallux valgus - Evidence-based Guideline Development Using Meta-analysis. / Die aktuelle S2e-Leitlinie zum Hallux valgus ­ eine evidenzbasierte Leitlinienentwicklung mittels Metaanalyse.

The hallux valgus deformity is untreated usually regarded as progressive deformity that does not necessarily lead to pain and suffering for the patient. Prevention primary: foot conforming footwear to avoid bruising and to avoid a forced progression of pathology. Functional stabilization of the foot by means of gymnastics or physiotherapy instructions. Secondary: orthotic and/or insoles to improve the functional stabilization. Tertiary: consistent adapted postoperative treatment, which is based on the operation procedure. The indication for initiation of a therapeutic measure is based on the suffering of the patient, age and presence of arthritis in the MTP-I-joint. More patient-specific pathologies may affect the initiation of treatment also. In the first stage of outpatient consultation and physiotherapy are at the forefront, additive analgesic or anti-inflammatory medication. Manual therapies, physiotherapy, orthotics or orthopedic measures adopted in view of the existing pathology and suffering pressure. In stage 2 of outpatient or inpatient surgical treatment therapeutic measures are indicated when symptomatic hallux valgus surgical therapy should be oriented on the severity of the pathology and the postoperative mobilization possibilities of the patient and other patient-specific criteria.

Local recurrence of giant cell tumor of bone after intralesional treatment with and without adjuvant therapy.

BACKGROUND: The use of adjuvants after curettage has been well established for the treatment of giant cell tumor of bone. The purpose of this study was to analyze the rates of recurrence following different types of treatment as well as the influence of various factors of tumor presentation on those rates. METHODS: The data regarding benign giant cell tumors of the appendicular skeleton from ten bone tumor centers were evaluated. Axial and malignant tumors were excluded. The recurrence rates associated with the different treatment modalities were analyzed, and hazard ratios for a recurrence were calculated for multiple factors of tumor presentation. RESULTS: The study included 384 surgical procedures, involving 256 primary and 128 recurrent tumors. The mean duration of follow-up was 64.2 months. Wide excision was performed in seventy-eight cases (20.3%), and an intralesional procedure was done in 306 (79.7%). Of the intralesional procedures, 103 (33.7%) were performed without the use of adjuvants, 102 (33.3%) included filling with polymethylmethacrylate, seventy-four (24.2%) included polymethylmethacrylate filling after phenolization, and twenty-seven (8.8%) included use of local toxins. The overall recurrence rate after the intralesional procedures was 49% when no adjuvants had been used, 22% when polymethylmethacrylate only had been used as an adjuvant, 27% when polymethylmethacrylate had been used after phenolization, and 15% when phenol or other local toxins had been used (without polymethylmethacrylate). The highest rate of recurrence (36%) after curettage with adjuvants was associated with extracompartmental tumors. Recurrent tumors were not at increased risk for another recurrence, even when they were extracompartmental. The recurrence rate following curettage of a primary tumor without the use of adjuvants (55%) was higher than that following the same treatment of a recurrent tumor (39%) (p = 0.033). CONCLUSIONS: Use of polymethylmethacrylate as an adjuvant significantly reduces the recurrence rate following intralesional treatment of benign giant cell tumors, and it appears to be the therapy of choice for primary as well as recurrent giant cell tumors of bone. The significantly better results following treatment of recurrent tumors without adjuvants compared with the results of the same treatment of primary tumors were probably related to increased surgical thoroughness brought about by the surgeon's awareness of dealing with a riskier tumor.