Subjective outcome following neurostimulator implantation as drop foot therapy due to lesions in the central nervous system-midterm results.

BACKGROUND: Drop foot can be caused by many conditions. Stroke is one of the major causes of drop foot and 5% of stroke survivors suffer from hemiplegia, which in some cases, can manifest as drop foot. The abnormal gait resulting from the lack of innervation of the extensor muscles may result in a secondary malposition of the foot and lead to a steppage gait. Among the several therapy options for the treatment of drop foot, functional electrostimulation (FES) with a transcutaneous peroneal nerve stimulator (tPNS) or an implantable peroneal nerve stimulator (iPNS) represents the two recent approaches. OBJECTIVE: Although therapy with an iPNS has been proven to be effective, a subjective patient assessment has not yet been executed. The aim of this study was to assess the patient's satisfaction with the therapy by using two established surveys. METHODS: The Rivermead Mobility Index (RMI) and the Reintegration to Normal Life Index (RNLI) were used for this retrospective study. The RMI includes 15 questions which are to be answered as either "yes" or "no" and given a value of 1 or 0, respectively, with a maximum of 15 points possible. The RNLI includes 11 questions which are to be answered with the use of a visual analog scale (VAS, 0 to 10 cm). In this case, a maximum adjusted score of 100 points is possible. RESULTS: The total study cohort involved 56 patients treated with an iPNS. Thirty-five complete data sets for the RMI and 29 for the RNLI could be achieved. A significant difference in the total score of both surveys was observed between the deactivated and the activated iPNS (RMI: p = 0.02; RNL: p = 0.01). CONCLUSION: A significant improvement in patient satisfaction was detected with the use of an activated iPNS after a mean time span of 4 years. Due to the marked mobility, an increase in the social satisfaction and integration could be achieved. Both aspects represent essential components for the recovery and quality of life of the patients.

Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference?

BACKGROUND: Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically. OBJECTIVE: The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction. METHODS: A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted. RESULTS: A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary. CONCLUSION: The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.

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.

[Foot drop treatment by implantation of a neuroprosthesis (ActiGait®)]. / Behandlung des Fallfußes durch Implantation einer Neuroprothese (ActiGait®).

OBJECTIVE: Gait improvement by restoring dorsiflexion using a neuroprosthesis implant. INDICATIONS: Foot drop with damage to the 1st motor neuron; passive mobility in ankle is possible; adult patients. CONTRAINDICATIONS: Foot drop with peripheral damage and injury to the peroneal nerve; already implanted stimulators (e.g., defibrillator, pacemaker, or pain stimulator); severe anesthesia risks in multimorbid patients. SURGICAL TECHNIQUE: Surgery in lateral position. Searching for the peroneal nerve after dorsal incision in the popliteal fossa, using the medial edge of the biceps femoris as anatomic landmark. After identification of the motor branch of the peroneal nerve by positive dorsiflexion after using electrostimulation apply the electrode cuff on the nerve. Epifascial implantation of stimulation body lateral at the middle third of the thigh over the tractus iliotibialis. POSTOPERATIVE MANAGEMENT: Pain-adapted full weight bearing, no knee flexion more than 90° for 4-6 weeks, activation of neuroprosthesis 3 weeks after surgery, physiotherapy with gait training is required. RESULTS: Between 2013 and 2015, implantation of the neuroprosthesis was performed in 21 patients (13 men/8 women) with chronic foot drop due to a central lesion. Significant improvement in walking speed measured with the 10 meter walk test (11.8 ± 5.4 s to 7.9 s ± 3.4; p = 0.007), in gait endurance with 6 min walk test (212.2 ± 75.5 m to 306.4 ± 96.4 m; p ≤ 0.001), and in gait performance using the Emory Functional Ambulation Profile (105.9 ± 49.7 s to 63.2 ± 31. 3 s; p ≤ 0.001). No patient required surgical revision. Postoperative bleeding was recorded in one case (4%). Patient satisfaction and improvement in mobility and quality of life could be achieved (95% and 90%, respectively).

[Lapidus arthrodesis]. / Lapidus-Arthrodese.

The tarso-metatarsal 1 joint (TMT-I) arthrodesis is a treatment option or moderate to severe hallux valgus (HV) deformities. Instability of the TMT1 joint is still a debatable indication. Using stable osteosynthesis techniques allows early postoperative weight bearing. Plantar plating combined with a lag screw is the biomechanical most stable construct. An additional intermetatarsal screw can improve the horizontal stability. Clinical results are good and radiological parameters stay constant, even in the long term.

[Functional electrostimulation for drop foot treatment : Clinical outcome]. / Funktionelle Elektrostimulation zur Therapie des neurogenen Fallfußes : Klinisches Outcome.

INTRODUCTION: Neurologic paralysis of the foot due to damage to the central nervous system is primarily caused by a cerebral insult. The ankle-foot orthosis (AFO), which is the classical conservative treatment option, is associated with drawbacks, e.g., increased contractures, limited mobilization from the sitting position, and cosmetic aspects. METHODS: Functional external electrostimulation (FES) is an suitable treatment method for patients with a central lesion and intact peroneal nerve. Based on this method, the neuroprosthesis is a dynamic therapy option in the form of an implantable nerve stimulator (ActiGait® system, Otto Bock, Duderstadt, Germany) which is placed directly on the motor branch of the peroneus nerve and results in active foot lifting. The aim of the present study is to evaluate the clinical effect of the ActiGait® system with regard to its suitability for everyday use by means of gait tests with an emphasis on time-distance parameters and to compare it with the current literature. RESULTS AND CONCLUSION: In this retrospective study, the clinical results after implantation of the ActiGait® system are presented and evaluated. In summary, the implantation of a neuroprosthesis in patients with stroke-related drop foot represents a sensible and promising therapy option.

Restoring mobility after stroke: first kinematic results from a pilot study with a hybrid drop foot stimulator.

OBJECTIVE: The objective was to obtain first insights into the kinematic and kinetic walking patterns resulting from an implanted functional electrical stimulation system in subjects with a drop foot caused by stroke. METHODS: Four subjects who experienced a stroke were chosen due to a comparatively long/short time after surgery and young/old at the stroke event were examined retrospectively with gait analysis. Kinematics and kinetics of normal walking were assessed in comparison with and without activated drop foot stimulation. RESULTS: In general, an improvement regarding spatiotemporal parameters as a result of the stimulation could be observed. Walking speed was increased by 45 % and stride length by 22 % after a mean usage of 7 (2-14) months, whereas both younger subjects improved significantly more. Dorsiflexion increased in all subjects on average from 1.3° to 11.6° during initial contact as well as from 11.3° to 17.0° during mid-swing and therefore implies an advantage of around 5.5 inch foot clearance. Pathologic elements like knee hyperextension during loading response and mid-stance, leg circumduction during swing or the increased hip flexion of the contralateral leg during mid-stance could be in general adjusted with stimulation. CONCLUSION: An implantable functional electrical stimulation system seems to be a promising treatment of drop feet following strokes. Further clinical investigations are necessary to confirm these first insights.

[Hallux amputation]. / Amputation der Großzehe.

OBJECTIVE: Debridement of infected tissue with the main aim being the re-establishment of mobilization with preservation of standing and walking ability. Prevention of secondary pressure points or amputations due to inadequate resection or deficient soft tissue cover. INDICATIONS: In the case of increasing necrosis of the big toe, surgical abrasion and/or amputation is considered unavoidable. Other indications where surgery could be considered include diabetes and its associated angiopathies together with peripheral arterial angiopathy. CONTRAINDICATIONS: In the case of insufficient blood supply an expansion of the resection margins should be taken into account. If there are possible alternatives to amputation. Surgery for patients with renal failure requiring dialysis associated with increased complication rate. SURGICAL TECHNIQUE: A dorsal cuneiform resection is performed to facilitate implantation of a plantar skin transplant and wound healing. Important is the resection of bone in a slide oblique technique. Amputation scars should be outside pressure zones. Partial amputations in the area of the first ray as exarticulation or via the individual amputated segments possible (as opposed to toes 2-5). POSTOPERATIVE MANAGEMENT: Direct postoperative weight-bearing with rigid insole and dispensing aid for 6-8 weeks. Following complete wound healing, foot support with orthopedic arch and transverse strain relief should be advocated, together with a joint roll in ready-made individual shoes. RESULTS: Both trauma and nontrauma cases were included in our present cohort. A total of 7 cases were surgically revised in 2014 due to superficial skin necrosis that was likely the result of skin tension from the wound stitches.

Articulating spacers compared to fixed spacers for the treatment of infected knee arthroplasty: A follow-up of 37 cases.

BACKGROUND: The standard treatment of a periprosthetic infection after TKA involves a two-stage reimplantation with the intermittent implantation of spacers. Different designs of spacers have been described; currently articulating spacers and fixed spacers are used. The aim of the present study is to compare the advantages/disadvantages of the different spacers. PATIENTS AND METHODS: In this retrospective study we analyzed 37 cases after revision surgery of infected TKA. All patients that received spacers as part of the two-stage reimplantation were included. Exclusion criteria were massive bone loss prior to revision, because the implantation of a mobile spacer would not have been possible. RESULTS: The average ROM was 98.0 (± 14.9) degrees in the articulating spacer group (group 1) and 79.3 (± 22.5) in the group that received the fixed spacers (group 2) before revision surgery started. At a late follow up the average ROM for group 1 was 102.0 (± 8.4) and 79.0 (± 26) for group 2. CONCLUSION: The use of articulating spacers in the two-stage revision for infected total knee arthroplasty is a safe alternative to fixed spacers, that equally preserves ligament balancing and has equal infection eradication rates. A long term improvement of the range of motion following reimplantation of the new joint was, however, not observed.

[Alloarthroplasty versus above-knee amputation]. / Alloarthroplastik kontra transfemorale Amputation.

BACKGROUND: We report an unusual case of a 38-year-old physically active patient, who suffered a Ewing sarcoma during adolescence and was therefore treated with a tumor endoprostheses ex domo (replacement of distal femur and proximal tibia). Since then he had undergone a couple of surgical interventions for revision and is currently suffering from persistent pain in the leg concerned. An aseptic loosening of the tibial component was evident after radiologic examinations. Because he had suffered for so long our patient refused further surgery to retain the affected limb and he preferred amputation. OBJECTIVES: We would have taken the risk of a femoral residual limb that is much too short compared with a classical above-knee amputation. In this regard we saw difficulties in exoprosthetic treatment with functional limitations that could easily have influenced the outcome negatively. METHOD: Consequently, we decoupled the tibial component from the femoral one within the knee joint and thus performed a knee disarticulation leaving the femoral component. RESULTS: Postoperatively, we found a mostly harmonious gait pattern with a pure mechanical interim prosthesis regarding time-distance parameters, which may be even further improved with the final prosthesis. Sagittal joint angles are comparable to conventionally knee exarticulated ones. DISCUSSION: To date, no comparable case of such an alloarthroplasty, which could regain mobility with an exoprosthetic treatment has been highlighted in the literature. In the result, a knee disarticulation within the area of a knee arthroplasty leaving the femoral component is not inferior to"ordinary" knee disarticulation.

Huge sciatic neuroma presented 40 years after traumatic above knee amputation.

BACKGROUND: An amount of 70,000 minor/major amputees are annually performed for different reasons such as tumor, trauma, perivascular diseases or diabetic ulcera yearly in Germany. Over the course of time a lot of patients get problems with their stump, which leads to an incompatible prosthetic treatment and immobilisation. OBJECTIVE: Handicapped patients are often characterized by a long history of pain. The fact that they often had comorbidities as diabetes, vascular diseases or other metabolic affection, leads to the situation that no other differential diagnoses are taken into account. PATIENTS AND METHODS: We present a case of a 62 year old patient with a history of burning pain with punctum maximum at the dorso-medial part of the distal femur stump 40 years after a traumatic above-knee amputation. He had sought different medical consultations and had a lot of modifications on his prosthesis shaft with partial benefit. The clinical examination confirmed the suspected diagnosis of a stump neuroma from the sciatic nerve, which has been verified in the MRI. Concerning the symptoms and the increasing immobilisation caused by the burning pain, we indicated a surgical revision which includes a resection from the neuroma and a local flap graft correction. RESULTS: Postoperatively he described a complete pain relief. After 6 weeks under weight bearing mobilisation he was 100% free of pain in his new custom-made shaft prosthesis and could mobilised under full bearing. CONCLUSION: We conclude that neurinoma needs to be considered in handicapped patients with such symptomatology and has to be surgically revised, even if that decision especially for handicapped patients is often difficult for the surgeon.

[Diagnostics and therapy for periprosthetic joint infection in Germany - A survey of 450 hospitals and a comparison with the literature]. / Diagnostik und Therapie periprothetischer Gelenkinfektionen in Deutschland - Eine Umfrage an 450 Kliniken und Vergleich mit der aktuellen Literatur.

The diagnosis and treatment of periprosthetic joint infections is a difficult situation for the attending physician. From the extensive literature, algorithms for diagnosis and therapy can be created. The aim of this study was to collect a representative survey of current concepts in the Federal States of the former West Germany and to compare them with those in the current literature. In 2011 orthopaedic and trauma clinics were surveyed anonymously in western Germany about diagnosis and treatment of periprosthetic infections. 450 questionnaires could be evaluated. Septic hip arthroplasty revisions were performed on average 12 (± 20)/year, septic knee arthroplasty revisions were performed on average 9 (± 17)/year. On average 205 (± 178) primary hip and 167 (± 155) primary knee arthroplasties were implanted/year. The analysis of the collected parameters is summarised in three tables. In the field of diagnostics, parameters such as CRP are determined. The interpretation, however, differs in more than 50 % of the hospitals on the relevant literature. Some important diagnostic parameters are not used. Therapy concepts are largely consistent with the literature. To a non-negligible extent, the vacuum-assisted therapy (approximately 30 % of hospitals) is used. In the literature it is described only for early infection. But even for use in early infection, there are very few data available. A unified diagnostic algorithm would be desirable.

Intramedullary and total femur replacement in revision arthroplasty as a last limb-saving option: is there any benefit from the less invasive intramedullary replacement?

There has been a substantial increase in the number of hip and knee prostheses implanted in recent years, with a consequent increase in the number of revisions required. Total femur replacement (TFR) following destruction of the entire femur, usually after several previous revision operations, is a rare procedure but is the only way of avoiding amputation. Intramedullary femur replacement (IFR) with preservation of the femoral diaphysis is a modification of TFR. Between 1999 and 2010, 27 patients with non-oncological conditions underwent surgery in our department with either IFR (n = 15) or TFR (n = 12) and were included in this study retrospectively. The aim of the study was to assess the indications, complications and outcomes of IFR and TFR in revision cases. The mean follow-up period was 31.3 months (6 to 90). Complications developed in 37% of cases, 33% in the IFR group and 4% in the TFR group. Despite a trend towards a slightly better functional outcome compared with TFR, the indication for intramedullary femur replacement should be established on a very strict basis in view of the procedure's much higher complication rate.

Expression of vascular endothelial growth factor on chondrocytes increases with osteoarthritis - an animal experimental investigation.

OBJECTIVE: To evaluate the expression of VEGF by chondrocytes of hyaline cartilage during the course of osteoarthritis (OA). METHODS: In 12 white New Zealand rabbits the anterior cruciate ligament (ACL) was resected to create an anterior instability of the knee. In 12 control rabbits only a sham operation without resection of the ACL was done. Four animals of each group were killed at 3, 6, and 12 weeks. The load bearing area was evaluated histologically according to Mankin and by immunostaining for VEGF. RESULTS: In the experimental group, histological grades of OA showed a positive linear correlation with the time after surgery. Immunostaining showed an increased expression of VEGF in the control group after 3 weeks, which dropped to normal after 6 weeks. There was no difference in the progression of OA between control and experimental groups after 3 weeks, but a significant difference was seen after 6 (p=0,01) and 12 (p=0,05) weeks. A significant positive correlation between VEGF expression and the histological grade of OA was found (r = 0.767; p<0.01). CONCLUSIONS: An increase of VEGF expressing chondrocytes occurs during time course of OA.

[Comparison of medium-term clinical and radiological outcome between cemented and cementless medial unicompartmental knee arthroplasty]. / Mittelfristiger, klinischer und radiologischer Vergleich von zementierten und zementfreien, medialen, unikompartimentellen Knieendoprothesen.

AIM: Cementation of tibial implants in total knee arthroplasty is the gold standard considering the high loosening rates of cementless implants. In contrast, only sparse data exist regarding unicondylar arthroplasty due to its lesser use. In this study, we compare cemented with cementless unicondylar knee arthroplasty and aim to define both clinical and radiological differences in treatment outcome. MATERIALS AND METHODS: In a retrospective study, 106 patients who had undergone a medial unicondylar replacement were examined after a mean postoperative period of 8 years. Of these, 42 patients (median age 81 +/- 7 years) had received a cemented and 64 (median age 73 +/- 7 years) a cementless knee arthroplasty by the same surgeon while 7 patients were deceased or could not be reached. Well-established clinical (VAS, HSS, KSS, UCLA, WOMAC) and quality of life (SF-36) scores were used to evaluate treatment outcome. X-rays were performed to evaluate periprosthetic loosening zones, according to Ewald's criteria. RESULTS: The cementless patient group presented significantly better clinical scores (HSS, KSS, UCLA, WOMAC), except in the visual analogue scale (VAS) for pain assessment. The quality of life was significantly better in the cementless group except in the subgroups for physical function, vitality and social role, in that it resembles the normal population. Moreover, radiographic analysis using antero-posterior X-rays revealed significantly more and larger periprosthetic loosening areas in tibial zone 2 in the cementless group. CONCLUSION: The inferior clinical results characterising the cemented group could be attributed to the higher mean age. Regarding the radiological loosening zones, we did not detect any differences in the techniques of fixation, although physical activity and accordingly mechanical stresses were higher in the cementless group.

Approximate orientation steerability based on angular Gaussians.

Junctions are significant features in images with intensity variation that exhibits multiple orientations. This makes the detection and characterization of junctions a challenging problem. The characterization of junctions would ideally be given by the response of a filter at every orientation. This can be achieved by the principle of steerability that enables the decomposition of a filter into a linear combination of basis functions. However, current steerability approaches suffer from the consequences of the uncertainty principle: in order to achieve high resolution in orientation they need a large number of basis filters increasing, thus, the computational complexity. Furthermore, these functions have usually a wide support which only accentuates the computational burden. We propose a novel alternative to current steerability approaches. It is based on utilizing a set of polar separable filters with small support to sample orientation information. The orientation signature is then obtained by interpolating orientation samples using Gaussian functions with small support. Compared with current steerability techniques our approach achieves a higher orientation resolution with a lower complexity. In addition, we build a polar pyramid to characterize junctions of arbitrary inherent orientation scales.