[Achilles tendon rupture-Part 1: etiology and diagnostics]. / Achillessehnenruptur ­ Teil 1: Ätiologie und Diagnostik.

The Achilles tendon is the strongest tendon in the human body. Rupture of the Achilles tendon prevents the transmission of forces from the calf muscles to the foot and thus the push-off phase of walking and running is no longer possible. The diagnostics of Achilles tendon rupture are typically based on the symptoms and clinical examination. A palpable gap and the Thompson test are sometimes difficult to evaluate in situations with a large hematoma. Benchmarking for a definitive rupture is the inability to perform a one leg heel raise. Sonography is used to determine the localization of the Achilles tendon and during the dynamic examination enables detection of a possible adaptation of the tendon ends. A complete adaptation of the tendon ends gives the possibility of conservative treatment. Sonographic control examinations after 4 and 8 weeks document the course of healing. A visible increase in volume, especially at the rupture site confirms a normal course of healing. Magnetic resonance imaging enables verification of an Achilles tendon rupture and provides more information about the tendon structure.

Outcome after operative treatment for chronic versus acute Achilles tendon rupture - A comparative analysis.

BACKGROUND: This study compared outcomes after treatment of acute Achilles tendon (AT) rupture via percutaneous suturing, with those after chronic AT rupture treated via open reconstruction. METHODS: This retrospective study included 30 patients who underwent either percutaneous suturing for acute AT rupture (group AR, n=16) or open reconstruction for chronic AT rupture (group CR, n=14). Function was evaluated by calf muscle circumference, and endurance through isokinetic measurement and single-leg heel-rise test. Score evaluation included AT Total Rupture Score, Victorian Institute of Sports Assessment-Achilles questionnaire, and visual analogue scale pain score. Postoperative tendon thickness was measured using ultrasonography and MRI. RESULTS: Follow-up was conducted 4.97±1.79 years postoperatively. The groups were similar in age and body mass index. There was no significant difference between groups in calf circumference, isokinetic measurement, heel-rise test, and score evaluation. There was significantly less mediolateral tendon thickening in group AR compared with group CR on ultrasonography (p=0.01) and MRI (p=0.001). CONCLUSIONS: Open reconstruction for chronic AT rupture may result in comparable clinical and functional outcomes, but a thicker tendon compared with percutaneous suturing after acute AT rupture.

Rivaroxaban versus high dose nadroparin for thromboprophylaxis after hip or knee arthroplasty.

UNLABELLED: Deep-vein thrombosis and subsequent pulmonary embolism are major complications in total joint arthroplasty of the lower limbs. New oral anticoagulants are increasingly prescribed as thromboprophylaxis due to their simple administration and encouraging phase III marketing studies. PATIENTS, METHODS: In this observational study, we compared the efficacy and safety of rivaroxaban with nadroparin in 1302 unselected patients receiving hip or knee arthroplasty. RESULTS: Venous thrombembolism occurred in 3.3% (2.3%; 4.7%, 95% CI, n = 838) of patients receiving rivaroxaban and in 4.3% (2.7%; 6.7%, 95% CI, n = 464) of patients receiving nadroparin resulting in an absolute risk reduction (ARR) of 1.0% (-1.4%; 3.3%, 95% CI). CONCLUSIONS: With an odds ratio of 0.6 (0.4; 1.0, 95% CI), rivaroxaban was associated with a decreased perioperative drop in haemoglobin exhibiting an improved thromboprophylactic profile when compared to high dose nadroparin. Furthermore, transfusion rates were 8.8% (-2.7%; 19.9%, 95% CI) lower in patients receiving rivaroxaban. However, as previous studies have shown, low preoperative haemoglobin remains the most predictive factor for postoperative transfusions (OR: 2.4 [1.3; 4.4, 95% CI]).

Minimum 5-year results of focal articular prosthetic resurfacing for the treatment of full-thickness articular cartilage defects in the knee.

INTRODUCTION: The purpose of this study was to evaluate the results of a contoured focal articular femoral condyle resurfacing prosthetic in the treatment of full-thickness cartilage and osteochondral defects at the medial femoral condyle of the knee beyond 5 years. METHODS: In a multicenter case series, preoperative and follow-up scores of the Knee Injury and Osteoarthritis Outcome Score (KOOS), SF-36 and Tegner activity scale were evaluated. Standard radiographs were performed to evaluate the progression of osteoarthritis. Patients were also asked to report their satisfaction. RESULTS: A total of 21 patients were included in this study. The average follow-up was 5.3 years. The average age at the time of resurfacing was 54 years. Average KOOS scores significantly (P ≤ 0.005) improved for pain (51.1 to 77.6), symptoms (57.9 to 79.5), activities of daily living (ADL) (58.8 to 82.4), sports (26.3 to 57.8) and quality of life (QOL) (34.4 to 55.0). The Tegner activity level improved significantly (P ≤ 0.02) from 2.9 to 4. The physical health value of the SF-36 increased by 15.2 to 46.9 compared to the preoperative value. The mental health value almost (51.2) remained unchanged. As many as 16/21 of the patients in this series were satisfied with their outcome and would have the operation again. Radiographic results demonstrated solid fixation, preservation of joint space and no change in the osteoarthritic stage. CONCLUSIONS: The device appears to be an effective reconstructive treatment option for large full-thickness cartilage and osteochondral lesions of the knee in middle-aged patients.

[Autologous chondrocyte transplantation in the treatment of articular cartilage lesions of the talus]. / Die autologe Knorpelzelltransplantation zur Behandlung von Knorpelläsionen am Talus.

In contrast to the knee joint, autologous chondrocyte transplantation (ACT) is rarely used for treating articular cartilage lesions in the ankle joint. Matrix-associated autologous chondrocyte transplantation (MACT) with the use of biomaterials as cell carriers has facilitated operative application and fixation within the lesion. We have gained experience in the use of two different MACT techniques. According to the Hannover scoring system for the ankle and visual analog scores, results improved significantly (p

[Microfracture technique for the treatment of articular cartilage lesions of the talus]. / Die Technik der Mikrofrakturierung zur operativen Therapie von Knorpelläsionen am Talus.

The microfracture technique is an established method for treating articular cartilage lesions of the talus. Symptomatic chondral or osteochondral lesions of grade II or higher with softening or fraying of the chondral surface or an unstable rim are indications for débridement of the lesion and use of the microfracture technique. In advanced degenerative lesions, the indication must be determined critically. In a prospective study, significant (p<0.001) improvement was observed at a mean follow-up of 5.2 years (range 3.8-6.6 years) in 23 ankles. According to the Hannover scoring system, 87% of the patients were rated as excellent or good. Results for patients older than 50 years were not inferior to those for younger patients. Results for overweight patients were significantly (p=0.03) worse compared with patients of normal weight. Magnetic resonance imaging findings revealed that filling of the defect is accomplished in the majority of cases with an inhomogeneous structure of the cartilage repair tissue and a high incidence of subchondral alterations. The microfracture technique appears to be a reliable method for treating chondral and osteochondral lesions of the talus, with good outcomes in a mid-term follow-up.

[Achilles tendon rupture--early functional and surgical options with special emphasis on rehabilitation issues]. / Frühfunktionell konservative und operative Behandlungsmöglichkeiten sowie Rehabilitationsoptionen bei der Achillessehnenruptur.

Achilles tendon ruptures are one end of a continuum starting with the healthy Achilles tendon via the thickened and painful tendinopathic Achilles tendon with neovascularisation to the complete tendon rupture. Often times chinolone antibiotics, cortisone therapy and valgus foot axis are associated risk factors. Incidence of Achilles tendon ruptures is estimated to be 10/100 000 per year with a mean age of 35-40 years. Physical activity is encountered in 75 % cases of Achilles tendon ruptures. Running is associated with Achilles tendinopathy as the predominant overuse injury in an analysis among 291 athletes with 10 million kilometers exposure. The Achilles tendinopathic rate was 0.016/1000 km differentiated in 0.008/1000 km mid-portion tendinopathy and 0.005/1000 km insertional tendinopathy. Achilles tendinopathy in running overuse injuries is followed by runner's knee (0.013/1000 km), shin splint (0.0104/1000 km) and plantar fasciitis (0.0054/1000 km). Dynamic ultrasound in 20 degrees plantar flexion is of utmost importance for therapeutic decision making. With an adaptation rate of 75 % or more of the ruptured tendon in 20 degrees plantar flexion and a high patient's compliance we perform an early functional conservative treatment regimen in Achilles tendon ruptures. In almost all other cases the percutaneous Achilles tendon repair is indicated, where nervus suralis lesions have to be appreciated. The vulnerable zone is 10-12 cm proximal to the calcaneus at the lateral border of the Achilles tendon with the sural nerve in close proximity with the tendon. Early functional rehabilitation is not associated with a higher risk of rerupture but with improved subjective assessments and should therefore be advocated.

[Microfracture technique for treatment of osteochondral and degenerative chondral lesions of the talus. 2-year results of a prospective study]. / Die Technik der Mikrofrakturierung zur Behandlung von osteochondralen und degenerativen chondralen Läsionen am Talus. 2-Jahres-Ergebnisse einer prospektiven Studie.

The microfracture technique has become an established method for the treatment of chondral lesions in the knee. The aim of this study was to determine its usefulness in the treatment of osteochondral (OCL) and degenerative chondral lesions (DCL) of the talus. In a prospective study, 32 patients with an osteochondral lesion (22 patients) or degenerative chondral lesion (10 patients) were operated arthroscopically and treated with the microfracture technique. All patients were evaluated preoperatively as well as 3, 6, 12, and 24 months postoperatively with the Hannover scoring system and a visual analog score (VAS). MRI scans were performed at all points. Statistical analyses were performed using the Wilcoxon sign rank-sum test with a level of significance of p < or = 0.05. At a mean follow-up of 2 years (range: 22-27 months), 23 patients (14 OCL, 9 DCL) were available for follow-up. The average age of the 17 male and 15 female patients at the time of operation was 39 years (range: 16-74 years). The results according to the Hannover scoring system were 43% excellent, 35% good, and 22% satisfactory with 93% excellent or good results for OCL. Older patients (>50 years, n=8) had slightly better results than younger patients. VAS revealed an average of 7.84 (preoperative: 3.53) for pain, 7.85 for function (preoperative; 3.38), and 7.78 for satisfaction (preoperative: 2.41). MRI and arthroscopic assessment showed a visible regeneration of the cartilage in the microfractured area. In a short-term follow-up, the microfracture technique has proven to restore severe cartilage damage with a good functional outcome. Age is not a limiting factor. However, longer-term results remain to be evaluated.

[Restoration of the ability to walk through bilateral triple arthrodesis in marked spastic pes equinovarus]. / Wiederherstellung der Gehfähigkeit durch beidseitige Korrekturtriplearthrodese bei hochgradigem Pes equinovarus und Tetraspastik. "Mutti muss laufen"

A tendon transfer is the method of choice in easily reducible pes equinovarus. However, in long-time persisting deformities with spasms, a plantigrade position can not be maintained with these procedures. Therefore, we perform an additional bilateral triple arthrodesis in a patients with such bilateral deformities. A 55-year-old woman developed, within the scope of several surgical procedures on the cervical spine, marked bilateral pes equinovarus and flexion contractures of the knees. The patient's ambulation was limited to a wheelchair for 3 years. Then, in an interval of 1 year, we performed an unilateral soft tissue release, z-tenotomy of the Achilles tendon, triple arthrodesis with correction of the deformity, and posterior tibial tenden transfer. At follow-up 5 years after the second procedure, the 61-year-old patient was able to walk alone with two walking sticks. In the case described, the correction of a marked pes equinovarus with spasms, which was achieved by an extensive soft tissue release, could be stabilized through a triple arthrodesis in such way that the plantigrade position of the foot could be controlled through a posterior tibial tendon transfer.

Healing of Achilles tendon, an experimental study: part 2--Histological, immunohistological and ultrasonographic analysis.

In 105 rabbits the course of healing was examined at one, two, four, eight and 12 weeks (21 rabbits per group) after an experimental Achilles tendon rupture. The following treatment modalities were compared: A) primary functional treatment; B) operative functional treatment (resorbable suture); and C) operative functional treatment with fibrin glue. For the functional (after)-treatment a special orthosis was applied. A 7.5 MHz Ultrasound probe was used for ultrasonographic evaluation. The histological specimens were stained in Masson-Goldner and Azan technique. Collagen Type III was depicted immunhistologically. A semiquantitative fibrocyte count was performed. The histological results showed a smooth healing in the primary functional treatment group (A), reaching parallel orientation of collagen fibers at 12 weeks. In the suture group (B), a secondary gapping of the tendon stumps was detectable after one week as in all other groups. In the fibrin group (C), the fibrin was resorbed after four weeks without essential influence to the course of healing. At 12 weeks the histological evaluation in all groups showed approximately normal tendon pattern. Immunohistochemically, all groups showed cell-associated positive reactions for type-III collagen after one week with a maximum after two weeks. The semiquantitative fibrocyte count in the primary functional group showed a maximal number after one week. In the fibrin glue and suture groups the maximal number could be found after two weeks. Sonographically an increase in tendon thickness was detectable up to the fourth week in all groups. The secondary gapping of the tendon stumps in the suture group could also be detected sonographically. The echogenicity of the tendon during the course of healing showed increasing homogeneity and parallelism in all groups. At 12 weeks the echogenicity was comparable in all groups. The experiment suggests the equivalence of primary functional treatment to a combination of operative and functional therapy in Achilles tendon rupture.

EMG monitoring during functional non-surgical therapy of Achilles tendon rupture.

After surgical therapy of Achilles tendon rupture, neuromuscular changes may persist, even one year after surgery. We were interested whether these changes are also evident following a non-surgical functional therapy (Variostabil therapy boot/Adidas). Twenty-one patients with complete Achilles tendon rupture were enrolled in the study (mean age 38.5 years, range 24 to 60; 18 men, three women) and followed-up clinically and with surface EMG of the gastrocnemius muscles after four, eight, 12 weeks, and one year after rupture. EMG differences between the affected and non-affected side could only be observed at baseline and after four weeks following Achilles tendon rupture. The results from our study show that EMG changes are not found following non-surgical functional therapy.

[Prosthetic replacement of the upper ankle joint]. / Endoprothetischer Ersatz des oberen Sprunggelenks.

Results after total ankle arthroplasty in the 1970s and 1980s were poor. The outcomes of these surgeries deteriorated rather dramatically with time. Causes of failure were multifactorial, but the two main reasons for failure were constrained designs and cement fixation. Today, the design of total ankle arthroplasty is unconstrained and the fixation is uncemented. Total ankle arthroplasties are considered technically demanding procedures, with relatively high early postoperative complication rates. As yet, the ideal total ankle patient remains to be defined. Good alignment and ligamentous stability are essential. Osteonecrosis and profound osteoporosis are associated with poor results due to problems with bony fixation. Patients should be advised that the implant may fail and that this may require further surgery, including the potential need for an ankle fusion. The results of ankle fusions, although usually initially good, seem to deteriorate with time. Not uncommonly, patients frequently develop peritarsal degenerative joint disease several years after an ankle arthrodesis. Because of the associated pain and functional limitations that can follow ankle fusion, efforts to develop a workable total ankle replacement continue. At present, the long-term results of new designs are unknown. Today, total ankle arthroplasty should be limited to centers where patient volume and infrastructure allows critical review and prospective clinical trials to determine the factors leading to successful and unsuccessful outcomes.

Plantar impact causing midfoot fractures result in higher forces in Chopart's joint than in the ankle joint.

PURPOSE: Force effect (impact, extent of foot compartment deformation) and result (fracture pattern) for midfoot fractures in car occupants is known. An analysis of the processes in the foot was intended to improve car safety. MATERIALS AND METHODS: Eleven fresh, unfrozen, unpreserved intact human cadavers (age: 36.8 (16-61) years, gender: male, race: Caucasian) were studied 24-72 h after death. In 3 cadavers (5 feet) the experimental design was established: entire cadaver fixed on a special tray in supine position, pendulum with bar impactor hitting the foot plantar to Lisfranc's joint. A custom-made pressure sensor was inserted in the ankle (A), talonavicular (TN) and calcaneocuboid (CC) joints (resolution: 1 cm2, sampling rate: 500/s). RESULTS: Sixteen feet were measured: midfoot fractures were induced in 11 feet. The maximum pressure amounted to 1.22-2.55 MPa (2.04+/-0.412) at 0.005 0.195 s (0.067+/-0.059) after impact. The maximum pressure occurred in 8 (50%) cases in the ankle, in 7 (44%) of the TN and 1 (6%) of the CC joints. A comparison of the first 200 pressure samples after impact of all sensor fields resulted in higher forces in Chopart's joint than in the ankle (t-test: p < 0.001). These force differences were higher in cases with midfoot fractures (mixed model analysis of variance: p = 0.003). CONCLUSION: Due to considerable forces in Chopart's joint we recommend a modification of the actual crash test dummy lower extremity model with an additional load cell that detects forces in the longitudinal direction of the foot axis.

[Bone segment transport of the femur. Biomechanical value of an unreamed titanium intramedullary nail with reference to stiffness of external distraction systems]. / Der Knochensegmenttransport am Femur. Der biomechanische Stellenwert eines unaufgebohrten Titanmarknagels bezüglich des Steifigkeitsverhaltens externer Distraktionssysteme.

The influence of an unreamed femur nail on axial and torque stiffness of nine different external fixator devices was investigated in a biomechanical study. With a newly developed femur bone model simulating segmental transport, 582 biomechanical tests were performed. The additional use of an unreamed femur nail (UFN) increased axial stiffness of the external fixator devices up to 8108% (average 1673.8-2631.8%) and increased torque stiffness up to 86% (average 47%). The best results could be achieved when combining a small-diameter UFN (9 x 360 mm, Synthes Co.) and external fixator devices with high torque and comparatively little axial stiffness. The use of stainless steel half-pins instead of titanium half-pins improved torque stiffness significantly. Concerning the biomechanical demands made on external fixator devices used for femoral segmental transport, the Hexfix fixator with steel bar and steel half-pins combined with an UFN achieved the best results.

Healing of the Achilles tendon: an experimental study.

Biomechanical properties of healing ruptures in the Achilles tendon of rabbits were examined after two, four, eight and 12 weeks. Treatment modalities were (n7): a) suture, b) fibrin-glue, c) non-surgical treatment. All animals received a functional aftertreatment consisting of a special orthotic support and free ambulation. For biomechanical testing a fixation-technique was applied that guaranteed intratendinous rupture. After two weeks, the tendons treated with fibrin glue showed better results (stiffness, maximum force to rupture, tensile stress to rupture) compared with the non-surgically treated group. The results for sutured tendons were in between those for the other groups. After four weeks, the results for sutured and for glued tendons were nearly equal and slightly better than the tendons in the non-surgical group. Late results revealed comparable biomechanical properties among all treatment groups and control tendons, suggesting our conclusion that non-surgical treatment is equal to repair using sutures or using fibrin glue as measured by stiffness and tensile stress.

Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years.

OBJECTIVES: To analyze the mechanism of injury for foot and ankle fractures resulting from automobile accidents to create a basis for developing an improved design for protection. DESIGN: Retrospective. SETTING: Level I trauma center with accident research unit. PATIENTS: Automobile accident reports and medical records of individuals injured in the accidents. MAIN OUTCOME MEASUREMENTS: Technical indicators (collision type, impulse angle, deltav, and extent of vehicle deformation) and clinical data (injury location and severity [abbreviated injury scale and injury severity score] and long-term outcome). RESULTS: From 1973 to 1996, 15,559 car accidents were analyzed. Two hundred sixty-one front seat occupants sustained fractures of the foot and ankle (ankle, 41 percent; forefoot, 29 percent; midfoot, 20 percent; and hindfoot, 10 percent). Seventy-five percent of the fractures were classified abbreviated injury scale(foot) 2. The incidence, location, and abbreviated injury scale(foot) category of fractures were similar between driver (n = 210) and front seat passenger (n = 51). Fifty percent of the fractures occurred in head-on collisions and 34 percent occurred in accidents with multiple collisions. The deltav ranged in 82 percent of car crashes between fifteen and sixty kilometers per hour. The deltav and extent of foot compartment deformation correlated with the abbreviated injury scale. During our investigation, deltav increased; the injury severity score decreased; and the extent of deformation did not differ significantly. CONCLUSIONS: Although overall car passenger safety has improved, the relative incidence of foot and ankle fractures has increased. Comparing drivers and front seat passengers, the foot pedals, steering wheel, or the asymmetric design of the dashboard did not influence injury incidence, mechanism, or severity. Foot fractures are mainly caused by the foot compartment deformation in head-on collisions, and therefore improvements in foot compartments are essential for fracture prevention.