[Loosening of a Calcaneo-Stop Screw after Trampolining]. / Schraubenlockerung nach Calcaneusstoppschraube bei Trampolinspringen.

Flexible flatfoot is a common malalignment in the paediatric population. Arthroereisis with a calcaneo-stop screw is an effective surgical procedure for treating juvenile flexible flatfoot after conservative measures have been fully exploited. In the present report, we describe the case of a loosening of a calcaneo-stop screw in a 12-year-old youth after excessive trampolining.

[Symptomatic os trigonum with irritation of the flexor hallucis longus tendon - arthroscopic management via a dorsal approach]. / Symptomatisches Os trigonum mit Irritation des M. flexor hallucis longus - Arthroskopische Sanierung über dorsale Zugänge.

Therapy-resistant pain in the region of the medial mallelous in the presence of an os trigonum is suggestive for irritation of the flexor hallucis longus tendon. Two patients were treated by arthroscopy in the prone position via a dorsal approach; the os trigonum was removed and the tendon released. Under the conditions of blunt dissection, dorsal arthroscopy of the os trigonum is a safe and expedient operation in our toolbox. After two weeks of partial load-bearing with 2 crutches, pain-free full load-bearing is already possible and after 3 weeks the patients can return to work.

[Visualization of local cortical defects in Charcot foot using microcomputed tomography]. / Visualisierung lokaler kortikaler Defekte im Charcot-Fuß mittels Mikrocomputertomographie.

BACKGROUND: In the pathogenesis of diabetic neuropathic osteoarthropathy (Charcot's foot) fractures cause chronic destruction of soft tissue and bone structure. To improve an early diagnosis of Charcot foot, modern diagnostic imaging is mainly based on magnetic resonance imaging (MRI), for example in relation to the detection of cortical bone fractures. OBJECTIVES: In this study we investigated the cortical microstructure in cases of Charcot foot with respect to fractures and porosity in order to visualize local cortical defects. This may substantiate recent efforts in a reclassification based on MRI. MATERIAL AND METHODS: Using microcomputed tomography (microCT) we investigated bone parameters, such as cortical thickness and porosity in order to quantify the local metatarsal microstructure in cases of Charcot foot. RESULTS: All bone samples showed a high degree of cortical porosity including pores that perforated the cortical bone. The data suggest that areas with reduced cortical thickness coincide with large cortical pores that may serve as initial points for fractures. Whether the detected microfractures are physiological or artefacts of preparation could not be determined. CONCLUSION: By means of microCT we were able to visualize and quantify the extent of cortical porosity for the first time in high resolution. The data suggest that both cortical fractures and cortical porosity play an important role in the pathogenesis in cases of Charcot foot.

[Diagnostic for Charcot foot]. / Diagnostik des Charcot-Fußes.

BACKGROUND: Early recognition of Charcot foot can save a long period of suffering for the patient, high doctor and hospital costs and ultimately amputation. OBJECTIVES: This article aims to raise awareness of the diagnostics of Charcot foot also known as diabetic neuropathic osteoarthropathy (DNOAP) and the possible differential diagnostic options (e.g. diabetic foot, erysipelas and peripheral arterial occlusive disease). MATERIAL AND METHODS: Clinical diagnostic pathways and classifications are presented and the resulting treatment options are discussed. RESULTS: In recent years new technologies for wound treatment and interventional radiological optimization of vessels have been developed. Many promising surgical options are available for stabilizing and reconstructimg a plantigrade foot. CONCLUSION: Treatment of Charcot foot should be based on a structured diagnosis and classification. In addition to conservative treatment new surgical options are also available.

[Full contact plaster cast for conservative treatment of Charcot foot]. / Konservative Behandlung des Charcot-Fußes mittels Vollkontaktgips.

BACKGROUND: The gold standard for treatment of early stages of Charcot foot are immobilization with a full contact plaster cast, whereby different periods and loading concepts are described in the literature. OBJECTIVES: The etiology, disease course and preparation for an early conservative therapy are described and a key point is a full contact plaster cast. METHODS: An overview of the etiology, pathogenesis and indications for correct evaluation of the wound situation is given. The correct technique for the total cast is described and illustrated step by step with pictures. RESULTS: If treatment of Charcot foot is initiated in the early stages prevention or healing of ulcers can be achieved; therefore, the correct indications and technique are necessary and the cast should be changed periodically which is a key point of the healing process. Healing results in a reduction of redness, temperature and swelling which should be measured and documented. CONCLUSIONS: Treatment of Charcot foot by full contact cast and immobilization should be initiated as soon as possible.

[Diabetic foot syndrome and diabetic neuropathic osteoarthropathy (DNOAP): an update of conservative and surgical therapy methods]. / Diabetisches Fußsyndrom und diabetische neuropathische Osteoarthropathie (DNOAP).

A diabetic foot or Charcot foot diagnosed in time can reduce a lot of problems for the patient, lessen high medical expense, and last but not least prevent an amputation. Good treatment options of the diabetic foot result from new technologies in wound management, angioplastic vessel improvement and optimised orthopaedic aids. Nevertheless it stays a challenging issue for practitioners and medical and health care as well as hospital owners to master this problem which will be even growing in the long run. This article intends to raise the awareness for the diabetic foot and the neuropathic osteoarthropathy, and furthermore illustrate diagnostic steps and offer therapeutic options. After distinguishing the diabetic foot from the Charcot foot a selective therapy for each entity has to be initiated. An interdisciplinary approach of specialists in dermatology, radiology, orthopaedic and internal medicine, plastic surgery and orthopaedic shoemaking is essential for a good therapeutic monitoring in order to avoid the amputation of the lower leg.

Radio-lunate arthrodesis in rheumatoid arthritis: outcome and techniques.

BACKGROUND AND PURPOSE: The wrist is one of the most affected joints in rheumatoid arthritis. The purpose of this retrospective study was to assess clinical, functional and radiographic results of radio-lunate arthrodesis. Two different operation and fixation techniques are compared and detailed outcome after this intervention is presented. METHODS: Twenty-seven patients with long-standing rheumatoid arthritis were operated on, either by stabilisation of the arthrodesis with Shapiro staples (n = 14) or by Herbert screw (n = 13) and followed for a mean of 5.4 years. RESULTS: Radio-lunate arthrodesis resulted in high overall and subjective satisfaction concerning function, grip and return to work. Grip strength was 35 kPa for the dominant and 26 kPa for the non-dominant hand. No revision, pseudoarthrosis or hardware failure was observed; only two conservatively treated wound healing problems were reported. The procedure resulted in a mean flexion of 26° and a mean extension of 24°; a clear improvement was also seen in activities of daily life. No difference between both groups was observed for pain, complication rate or functional outcome. INTERPRETATION: Due to high patient satisfaction and functional outcome, radio-lunate wrist arthrodesis can be recommended independent of fixation method.

[Modified chevron osteotomy with lateral release and screw fixation for treatment of severe hallux deformity]. / Modifizierte Chevron-Osteotomie mit lateralem Release und Schraubenfixation zur Behandlung der schweren Hallux-valgus-Deformität.

BACKGROUND: This prospective study examined the clinical and radiological results of the Chevron osteotomy with screw fixation and distal soft tissue release up to an intermetatarsal angle of 19°. Furthermore, the results are presented for patients over the age of 70 years, and whether or not there is a higher complication rate. MATERIAL AND METHODS: 86 feet of patients between 23 and 81 years were included in the study. Apart from the overall group, a group with an intermetatarsal angle of 16° to 19° and a group of patients over 70 years old were eavaluated. They were evaluated preoperatively and at follow-up after an average of 3.3 years according to the American Orthopaedic Foot and Ankle Society score. RESULTS: The AOFAS score showed a significant improvement from 55 points preoperatively to 90 points at follow-up. The preoperative hallux valgus angle decreased significantly from 32° to 5° and the preoperative intermetatarsal angle decreased from 14° to 6°. Patient satisfaction in the overall group was rated in 92 % as excellent or good. Also, the patient group with 16° to 19° angles and the patients over 70 years showed a significant improvement of clinical and radiological parameters. The complication rate was very low in all groups. CONCLUSION: The results show that the Chevron osteotomy is a very good surgical technique with few complications for the correction of splay foot with hallux valgus deformity. We showed that by using the modified technique with a long plantar arm, an excessive soft tissue release and screw fixation, the indication can be extended up to an intermetatarsal angle of 19° when using screw fixation. Furthermore the patients over 70 years of age showed a significant improvement of clinical and radiological parameters without serious complications such as avascular necrosis or dislocation of the metatarsal head.

Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet. Surgical technique.

BACKGROUND: The modified Ludloff proximal first metatarsal osteotomy is indicated for the surgical correction of moderate-to-severe hallux valgus deformity associated with metatarsus primus varus. We report the intermediate-term results of this procedure. METHODS: Ninety-nine patients (111 feet) with a mean age of fifty-six years underwent a modified Ludloff proximal first metatarsal osteotomy and a distal soft-tissue procedure at two institutions for the treatment of a moderate-to-severe hallux valgus deformity. The American Orthopaedic Foot and Ankle Society score and weight-bearing radiographs of the foot were assessed preoperatively and after a mean duration of follow-up of thirty-four months. Clinical and radiographic outcome was also compared between younger and older patients, with the arbitrarily chosen age of sixty years dividing the two groups. RESULTS: The mean American Orthopaedic Foot and Ankle Society score improved significantly (p < 0.0001) from 53 points preoperatively to 88 points at the time of the most recent follow-up. The mean American Orthopaedic Foot and Ankle Society score for patients who were sixty years of age or less was significantly higher than that for patients who were more than sixty years of age (91 compared with 83 points; p = 0.0057). The mean hallux valgus angle decreased significantly from 35 degrees preoperatively to 9 degrees at the time of the most recent follow-up (p < 0.0001), and the mean intermetatarsal angle decreased significantly from 17 degrees to 8 degrees (p < 0.0001). All osteotomy sites united without dorsiflexion malunion but with a mean first metatarsal shortening of 2.2 mm. CONCLUSIONS: To our knowledge, the present report describes the largest cohort of patients undergoing a modified Ludloff osteotomy for the correction of hallux valgus deformity that has been reported in the literature. Our intermediate-term results demonstrate that the procedure achieves significant correction of moderate-to-severe hallux valgus deformity, significant reduction in forefoot pain, and significant improvement in functional outcome. Patients with an age of sixty years or less appear to have a more favorable outcome.

[Effect of physiotherapy on the functional improvement after hallux valgus surgery - a prospective pedobarographic study]. / Einfluss von Physiotherapie auf die Funktionsverbesserung nach Hallux-valgus-Operationen - eine prospektive pedobarografische Studie.

AIM: Recent pedobarographic analyses have shown that in spite of acceptable clinical and radiological results after hallux valgus surgery, there is decreased function of the big toe and the first ray, respectively. The aim of this prospective study was to evaluate if physiotherapy can help to increase big toe function and to restore physiological gait patterns after hallux valgus surgery. METHODS: 33 patients (31 females, 2 males, 34 feet) with a mild to moderate hallux valgus deformity have been included in this study. 22 patients underwent Austin osteotomy and 11 patients underwent Scarf osteotomy, respectively. Postsurgically, the patients wore the Rathgeber postop shoe for 4 weeks. After this period they received physiotherapy. Pedobarographic examinations were performed with the EMED-at platform 4 weeks, 8 weeks and 6 months after surgery. The AOFAS score and ROM of the first MTP joint were evaluated prior to surgery and 6 months after surgery. Also, patient's satisfaction has been evaluated 6 months after surgery. RESULTS: In the big toe region peak pressure increased from 80.7 kPa 4 weeks after surgery to 171.9 kPa 8 weeks after surgery (p < 0.0001) and 336.1 kPa 6 months after surgery. In the same period maximum force increased from 18.6 N to 47.6 N and 90.9 N, respectively. In the first metatarsal head region peak pressure increased from 141.4 kPa 4 weeks postoperatively to 215.8 kPa 8 weeks postoperatively and 292.7 kPa 6 months after surgery (p < 0.0001). The AOFAS score increased from 60.8 presurgically to 94.0 at 6 months after surgery and ROM of the first MTP joint increased during the same period from 66 degrees to 70 degrees . CONCLUSIONS: The authors conclude that postoperative physiotherapy improves big toe function and pressure distribution in the region of the first metatarsal head. This helps to restore physiological gait patterns after hallux valgus surgery.

Intermediate-term results of the Ludloff osteotomy in one hundred and eleven feet.

BACKGROUND: The modified Ludloff proximal first metatarsal osteotomy is indicated for the surgical correction of moderate-to-severe hallux valgus deformity associated with metatarsus primus varus. We report the intermediate-term results of this procedure. METHODS: Ninety-nine patients (111 feet) with a mean age of fifty-six years underwent a modified Ludloff proximal first metatarsal osteotomy and a distal soft-tissue procedure at two institutions for the treatment of a moderate-to-severe hallux valgus deformity. The American Orthopaedic Foot and Ankle Society score and weight-bearing radiographs of the foot were assessed preoperatively and after a mean duration of follow-up of thirty-four months. Clinical and radiographic outcome was also compared between younger and older patients, with the arbitrarily chosen age of sixty years dividing the two groups. RESULTS: The mean American Orthopaedic Foot and Ankle Society score improved significantly (p < 0.0001) from 53 points preoperatively to 88 points at the time of the most recent follow-up. The mean American Orthopaedic Foot and Ankle Society score for patients who were sixty years of age or less was significantly higher than that for patients who were more than sixty years of age (91 compared with 83 points; p = 0.0057). The mean hallux valgus angle decreased significantly from 35 degrees preoperatively to 9 degrees at the time of the most recent follow-up (p < 0.0001), and the mean intermetatarsal angle decreased significantly from 17 degrees to 8 degrees (p < 0.0001). All osteotomy sites united without dorsiflexion malunion but with a mean first metatarsal shortening of 2.2 mm. CONCLUSIONS: To our knowledge, the present report describes the largest cohort of patients undergoing a modified Ludloff osteotomy for the correction of hallux valgus deformity that has been reported in the literature. Our intermediate-term results demonstrate that the procedure achieves significant correction of moderate-to-severe hallux valgus deformity, significant reduction in forefoot pain, and significant improvement in functional outcome. Patients with an age of sixty years or less appear to have a more favorable outcome.

[The acquired flatfoot: mid-term results of the medial displacement calcaneal-osteotomy with flexor digitorum longus transfer]. / Der erworbene Plattfuss: mittelfristige Ergebnisse der medialisierenden Kalkaneusosteotomie mit Flexor digitorum longus-Sehnentransfer.

AIM: The present retrospective study investigates the mid-term results after medial displacement calcaneal osteotomy combined with flexor digitorum longus transfer for the treatment of acquired flatfoot deformity due to posterior tibial tendon insufficiency at stage II (Johnson and Strom Classification). METHOD: 30 feet in 29 patients (6 male, 23 female) with an average age of 58 years (from 43 to 68 years) had surgery between 1995 and 2001. All feet were examined at an average follow-up of 58.5 months (range 35-97 months) and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score. RESULTS: The average AOFAS-Score was 88.8+/-10.7 points (range 48 to 100) at final follow-up. The AOFAS-pain-subscale score was 34+/-6.2 points. At the latest follow-up were 14 feet (47%) painfree, 14 feet (47%) noted mild pain and 2 feet (6%) had daily pain. One foot (3%) had pain due to subluxation of the musculus flexor digitorum longus tendon, in another one pain was caused by a contract Chopart joint (3%). Further complications were painful prominent hardware (17%) and neuralgia of the sural nerve (7%). CONCLUSION: The authors conclude that the combination of the medial calcaneal displacement osteotomy with flexor digitorum longus transfer may provide optimal results in patients with adult acquired flatfoot deformity and posterior tibialis tendon dysfunction.

[The modified Ludloff osteotomy for correction of severe metatarsus primus varus with hallux valgus deformity]. / Die modifizierte Ludloff-Osteotomie zur Korrektur der schweren Spreizfussdeformität mit Hallux valgus-Fehlstellung.

AIM: The present study investigates the clinical and radiological mid-term results of the modified Ludloff osteotomy, a proximal metatarsal osteotomy for surgical correction of severe metatarsus primus varus with hallux valgus deformity. METHOD: 70 feet in 67 patients from 25 to 78 years (average age 56 years) were included in this prospective study. The patients were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot metatarsophalangeal interphalangeal score, which was used preoperatively and at an average follow-up of 37 +/- 6 months. Weight-bearing foot radiographs were analysed according to AOFAS guidelines and statistical evaluation was made with the Wilcoxon signed-rank test. RESULTS: The average AOFAS score improved significantly (p < 0.0001) from 55.2 +/- 15.2 points preoperatively to 86.6 +/- 15.2 points at follow-up. Preoperatively, all patients complained of pain (20.2 +/- 9.6 points) which had improved significantly (p < 0.0001) at the latest follow-up (37.3 +/- 5.7 points). The average hallux valgus angle (HVA) was 37 +/- 8 degrees preoperatively and improved significantly to 12 +/- 11 degrees at follow-up (p = 0.0001). The intermetatarsal angle (IMA) improved significantly from 18 +/- 2 degrees preoperatively to 8 degrees +/- 4 degrees after 37 +/- 6 months (p = 0.0002). The sesamoid position improved significantly from preoperative to follow-up (p = 0.0003). Radiographic evaluation of the patients indicated that all examined osteotomies had healed after 37 +/- 6 months. CONCLUSION: This prospective investigation at intermediate follow-up using currently available outcome measures suggests that the Ludloff osteotomy is a suitable procedure for the surgical correction of severe metatarsus primus varus (IMA > 15 degrees ) with hallux valgus deformity.

The Weil osteotomy: a seven-year follow-up.

We prospectively evaluated the one- and seven-year results of the Weil osteotomy for the treatment of metatarsalgia with subluxed or dislocated metatarsophalangeal joints in 25 feet of 24 patients. Good to excellent results were achieved in 21 feet (84%) after one year and in 22 (88%) after seven years. The American Orthopaedic Foot and Ankle Society score significantly improved from 48 (SD 15) points before surgery to 75 (SD 24) at one year, and 83 (SD 18) at seven years. The procedure significantly reduced pain, diminished isolated plantar callus formation and increased the patient's capacity for walking. Redislocation of the metatarsophalangeal joint was seen in two feet (8%) after one year and in three (12%) after seven years. Although floating toes and restricted movement of the metatarsophalangeal joint may occur, the Weil osteotomy is safe and effective.