Clinical and Radiological Mid- to Long-term Results Following Triple Arthrodesis.

BACKGROUND/AIM: Triple arthrodesis (TA) is a common procedure for stabilization of painful and unstable hind foot deformities. The aim of the study was to analyze postoperative changes in function and pain following isolated TA based on clinical outcomes, radiological findings, and pain scores. The study also considered economic aspects, such as the inability to work, before and after surgery. PATIENTS AND METHODS: This was a single-center retrospective study, with a mean follow-up of 7.8 (range=2.9-12.6) years, of isolated triple fusions was performed. Short-Form 36 (SF-36), Foot Function Index (FFI), American Orthopedic Foot and Ankle Society Score (AOFAS) were analyzed. Clinical examination and standardized radiographs pre- and post-surgery were evaluated. RESULTS: All 16 patients were very satisfied with the outcome after TA. In patients with secondary arthrosis of the ankle joint, AOFAS scores were significantly lower (p=0.012), whereas arthrosis in tarsal and tarsometatarsal joints did not affect the score. Body mass index (BMI) was associated with lower AOFAS, FFI-pain, FFI-function and increased hindfoot valgus. The non-union rate was approximately 11%. CONCLUSION: TA leads to good clinical and radiological outcomes. None of the study participants reported a deterioration in their quality of life after TA. Two thirds of the patients reported significant limitations when walking on uneven ground. More than half of the feet developed secondary arthrosis of the tarsal joints and 44% of the ankle joint.

[Hand and foot injuries in rheumatoid patients : Tips and tricks in operative and conservative treatment]. / Hand- und Fußverletzungen beim Rheumatiker : Tipps und Tricks in der operativen und konservativen Versorgung.

Since the introduction of biologicals and small molecules for the treatment of inflammatory rheumatic diseases, these patients are more active and therefore sustain more accidents. The hands and feet are most affected by inflammatory rheumatic diseases, especially rheumatoid arthritis, and are also very exposed to injuries. Therefore, rheumatoid patients have a high coincidence of injuries and rheumatic destruction of the hands and feet. For this reason, trauma surgeons should nowadays have a basic knowledge of rheumatoid diseases including immunosuppressive medication as well as the specific conservative and operative treatment of rheumatic hand and foot deformities. This is necessary to avoid fundamental errors in the treatment of fractures and optimally used anesthesia for the benefit of the patient. The close cooperation between trauma surgeons and orthopedic rheumatologists is urgently recommended in the treatment of these injuries. Whenever possible, the treatment should be carried out conservatively because surgical treatment has a higher risk compared to the normal population due to the immunosuppressive treatment.

[Primary stability of proximal interphalangeal joint arthrodesis: an in-vitro comparison of intraosseous wiring with and without a transverse Kirschner wire]. / Fingermittelgelenkarthrodese mittels Drahtnaht mit und ohne zusätzlichen Kirschnerdraht ­ Eine vergleichende biomechanische Studie.

BACKGROUND: Arthrodesis can be considered the fastest and safest surgical treatment for degenerative destruction of the proximal interphalangeal joint. For this procedure, a variety of surgical strategies have been described. Protocols for compression arthrodesis by intraosseous wiring are known to have the best outcomes. Biomechanical effects of reinforcing the arthrodesis using Kirschner wires have been controversially discussed. PURPOSE: This study aims to compare these two procedures with respect to primary stability under physiological stress in vitro. MATERIAL AND METHODS: In total, 72 fingers from 9 pairs of hands of formalin-ethanol fixed body donors were used for the study. To achieve comparability, these were chirally matched. After arthrodesis, primary stability was evaluated during a two-point application of rotational, abducting and extending forces. Peak torque values acting on the arthrodesis were defined as the breaking load and compared by a paired Student t-test. RESULTS AND CONCLUSION: Kirschner-wire reinforced arthrodeses showed significantly higher breaking loads for extension and abduction than those within the control group. Nevertheless, both methods achieved breaking loads above the physiological load level in the area of the proximal interphalangeal joint. Even though sole intraosseous wiring can be considered biomechanically adequate, we suggest reinforcement using a transverse Kirschner wire to enhance the primary stability.

Mid- to Long-term Outcomes After Split-thickness Skin Graft vs. Skin Extension by Multiple Incisions.

BACKGROUND/AIM: Skin extension by multiple incisions (SEMI) may be superior to split-thickness skin graft (STSG) for closure of large soft tissue defects. MATERIALS AND METHODS: Twenty-six patients who had undergone STSG were compared to 29 patients who had undergone SEMI on the extremities. Patient and Observer Scar Assessment Scale (POSAS), Dermatology Life Quality Index, Wound QoL (Quality of Life) and Short Form Health Survey 36 were used. Elasticity, thickness and skin sensation were compared between the treated and contralateral extremity. Range of motion in adjacent joints was measured. Complication rates were compared. RESULTS: A total of 55 patients with a mean follow-up of 5.5 years (range=2-9 years) were examined. Patients with STSG had significantly worse scores in POSAS. The scar was thinner, less elastic and did not provide intact sensibility. Other scores, ROM and complication rates did not differ significantly. CONCLUSION: SEMI was superior to STSG regarding patient satisfaction and scar quality.

Cadaveric Study on Retrograde Calcaneotibial Fixation of Unstable Ankle Fractures.

BACKGROUND/AIM: In extensive soft tissue injury, primary internal fracture fixation is not always possible and external fixation for primary immobilization plays an important role. The aim of this study was to compare the accuracy of freehand technique and of a target device for retrograde calcaneotibial fixation in an uninjured bone and an unstable ankle fracture. MATERIALS AND METHODS: The calcaneotibial fixation was performed randomly by an experienced surgeon utilizing either a freehand drilling technique or a novel targeting device in four human cadavers before and after producing a bimalleolar ankle fracture. The duration of foot positioning, drilling, number of intensifier shots, and drilling attempts were recorded. The final position of the wire was established using IsoC-3D scan. RESULTS: The mean for definitive wire placement with the target device was 247 sec with a mean of 3.4 attempts, and 92 sec and 2.1 attempts in the freehand technique. Mean intraosseous distance of the K-wire was 45.3 mm and 63.6 mm in the tibia and 39.7 mm and 41.5 mm in the calcaneus respectively. CONCLUSION: The novel target device for calcaneotibial fixation achieves similar results to a trained surgeon using the freehand technique.

Skin Extension by Multiple Incisions (SEMI).

BACKGROUND/AIM: There is a need for a simple and atraumatic technique for wound closure in soft tissue defects. The aim of this study was to evaluate the technique of skin extension by multiple incisions in the healing of soft tissue defects following trauma. PATIENTS AND METHODS: This is a retrospective clinical study on soft tissue defects after trauma. The dimensions of the defects were measured intra-operatively. Exclusion criteria were combined techniques of skin extension by multiple incisions with local flaps or free skin grafts, preoperative numbness, and incomplete data. Complications until wound healing were documented. RESULTS: One hundred soft tissue defects were evaluated. Uneventful healing occurred in 81. Minor complications were found in 15, and revision was performed in 4. Sensitivity to touch was normal in all. CONCLUSION: Skin extension by multiple incisions is very easy to learn and can be performed without special instruments. The survival rate of the extended skin is high. Sensitivity to touch and mobility of the skin can be preserved, which results in a very durable nearly normal skin.

Clinical and Radiological Mid-to-Long-term Outcomes Following Ankle Arthrolysis.

BACKGROUND: The aim of this study was to evaluate the clinical and radiographic success of arthrolysis surgery and the risk of progression of osteoarthrosis at the ankle joint. MATERIALS AND METHODS: In a retrospective clinical and radiological study, with a minimum follow-up of 24 months, the pain level and quality of living were evaluated. RESULTS: Following arthrolysis of the ankle joint, 16% of patients required ankle fusion within 2 years. Women had a higher quality-of-life in terms of Foot Function Index. Younger patients scored higher in both quality-of-life and function scores. Radiographic osteoarthrotic changes and the specific follow-up interval did not correlate with clinical outcome. CONCLUSION: Fewer than 20% of patients required ankle fusion. Female gender and young age had a positive impact. Preoperative radiography and the postsurgical interval are poorly predictive for the progression of osteoarthrosis.

Mid- to Long-term Outcomes After Weber B-type Ankle Fractures With and Without Syndesmotic Rupture.

BACKGROUND/AIM: The aim of the present study was to assess the impact of syndesmotic screw fixation on overall clinical outcomes following Weber B-type ankle fractures. MATERIALS AND METHODS: A total of 21 patients with syndesmotic rupture requiring screw fixation were compared to 40 patients with an intact syndesmosis. Olerud-Molander-Ankle-Score, American Orthopedic Foot & Ankle Society ankle hindfoot score, and the Short Form Health Survey-36 were recorded. Weight-bearing plain radiographs were performed to rate post traumatic osteoarthrosis according to the Kellgren-Lawrence score. Pain levels were evaluated with a visual analog scale. RESULTS: A total of 61 patients with a mean follow-up of 6.6 years (range=2-12 years) satisfied the inclusion criteria. Pain level, clinical outcome scores, and radiographs did not reveal significant differences between the groups. Ankle joints with syndesmotic rupture showed a significant restriction in dorsiflexion compared to those with an intact syndesmosis (15 vs. 20°, p=0.028). CONCLUSION: Syndesmotic rupture does not affect clinical and radiological outcome parameters following Weber B-type ankle fractures, but does lead to a significant restriction in dorsiflexion of the ankle joint.

Clinical and Radiological Mid- to Long-term Outcomes Following Ankle Fusion.

BACKGROUND: The aims of this study were to establish the likelihood of additional surgery after ankle fusion, determine the interval for developing osteoarthrosis in the ipsilateral subtalar or Chopart joints, and evaluate its clinical relevance. MATERIAL AND METHODS: A retrospective clinical and radiological study with a minimum follow-up of 24 months was performed. Short-Form 36 Heath Survey, Foot Function Index, American Orthopaedic Foot and Ankle Society Score (AOFAS) and a visual analog scale (VAS) were used to evaluate pain level and quality of life in at least 62 adult patients. RESULTS: A total of 57% of our patients developed osteoarthrosis in at least one of the related joints and 28% of them required additional surgery due to pain. Patients who received workers' compensation had significantly lower AOFAS and higher VAS pain values. CONCLUSION: More than half of the study cohort developed osteoarthrosis in the related joints after ankle fusion, but fewer than one-third required further joint fusion surgery as a consequence.

Comparison of the Grip Strength Using the Martin-Vigorimeter and the JAMAR-Dynamometer: Establishment of Normal Values.

BACKGROUND/AIM: The JAMAR-Dynamometer and the Martin-Vigorimeter are frequently used tools in a hand surgeon's daily routine. This survey is primarily concerned with the establishment of valid conversion factors for measured values of both instruments, as well as the investigation of influence of anatomical characteristics and age and sex on maximal measured grip strength. PATIENTS AND METHODS: We registered anamnestic data and specific anatomical conditions in 339 patients, maximal grip strength was measured using all notches of both instruments. RESULTS: We found moderate to very high correlation comparing all 28 settings in both instruments. The influence of the hand's anatomy on the grip strength was greater using the JAMAR-Dynamometer than it was using the Martin-Vigorimeter. CONCLUSION: The high reproducibility allowed us to calculate multiplying factors for the conversion of measured data for all settings of both tools. Therefore, the amount of data for meta-analyses relating to hand surgical issues can be significantly increased.

[Tibial pilon fractures : Advoidance and therapy of complications]. / Pilon-tibiale-Frakturen : Vermeidung und Behandlung von Komplikationen.

Because of the complex fracture morphology and vulnerable soft tissue coverage, fractures of the tibial pilon are difficult to treat. Complications are more common than in bi- or trimalleolar fractures. The surgeon has to know about the special risks of these injuries to avoid complications. Early complications are soft tissue necrosis, persisting fragment dislocations after surgery, loss of reposition and deep wound infection. The surgeon has to be aware of early signs of compartment-syndrome and chronic regional pain syndrome (CRPS). In late complications such as bony necrosis with or without deviation, non-union and osteoarthrosis of the ankle joint give the surgeon more time for planning the therapy. Intensive monitoring until bone healing is necessary in tibial pilon fractures to detect complications early and start the therapy immediately. This kind of therapy results in the best outcome for these patients.

[Tendinopathies of the foot and ankle : Evidence for the origin, diagnostics and therapy]. / Tendinopathien an Fuß und Sprunggelenk : Evidenz für deren Entstehung, Diagnostik und Therapie.

Tendinopathies of the foot and ankle result in substantial impairment of the mobility of patients and have a high clinical significance. Knowledge of the origin of these diseases has been accumulated over decades from the multitude of intrinsic and extrinsic triggering factors based on biomechanical considerations with an evidence-based medicine (EBM) level 5. A high correlation between tendinopathy and hypervascularization of the Achilles tendon was found in a double-blind randomized prospective study using Doppler ultrasound (EBM level 1) but these results were not reproducible; therefore, the importance of these findings is unclear. Inspection and clinical examination supplemented by ultrasound and magnetic resonance imaging (MRI) are essential to achieve the correct diagnosis. The varying extent of load-dependent irritation of tendons and the surrounding tissues and the individual variation in experience of investigators mean that the results of clinical examinations are difficult to collate or not reproducible and cannot be investigated in studies. The expression of the varying results is difficult to assess even by the use of sonography and magnetic resonance imaging (MRI). Conservative treatment of tendinopathy is based on medical experience (EBM level 5). The effectiveness of physiotherapeutic eccentric loading and extracorporal shock wave treatment (ESWT) for Achilles tendinopathy was demonstrated in several case control studies and series (EBM level 3). Due to the high rate of healing with physiotherapy, surgery should only be performed following a minimum of 6-12 weeks of unsuccessful conservative treatment, because formation of scar tissue on the foot can result in permanent complaints (EBM level 4).

Effectiveness of Bicycle Safety Helmets in Preventing Facial Injuries in Road Accidents.

BACKGROUND: The effectiveness of bicycle safety helmets in preventing head injuries is well- documented. Recent studies differ regarding the effectiveness of bicycle helmets in preventing facial injuries, especially those of the mid-face and the mandible. OBJECTIVES: The present study was conducted to determine the protective effect of a bicycle helmet in preventing mid-face and mandibular fractures. PATIENTS AND METHODS: Data from an accident research unit were analyzed to collect technical collision details (relative collision speed, type of collision, collision partner, and use of a helmet) and clinical data (type of fracture). RESULTS: Between 1999 and 2011, 5,350 bicycle crashes were included in the study. Of these, 175 (3.3%) had fractures of the mid-face or mandible. In total, 228 mid-face or mandibular fractures were identified. A significant correlation was found between age and relative collision speed, and the incidence of a fracture. While no significant correlation was found between the use of a helmet and the incidence of mid-facial fractures, the use of a helmet was correlated with a significantly increased incidence of mandibular fractures. CONCLUSIONS: Higher age of cyclists and increasing speed of the accident opponent significantly increase the likelihood of sustaining facial fractures. The use of bicycle helmets does not significantly reduce the incidence of mid-facial fractures, while being correlated with an even increased incidence of mandibular fractures.