[Deformity-associated treatment of the hallux valgus complex]. / Deformitätsassoziierte Behandlung des Hallux-valgus-Komplexes.

Hallux valgus represents a combined deformity with malpositioning of the big toe in the metatarsophalangeal joint and metatarsal splaying due to metatarsus primus varus formation. It is defined on the basis of joint condition of the metatarsophalangeal and tarsometatarsal (TMT) joints, the extent and congruence or incongruence of malposition, mobility of the metatarsophalangeal joint and TMT stability. Basic resection appears to be indicated only in exceptional cases. Depending on the degree of severity, deformities can be corrected by means of distal, diaphyseal or proximal osteotomies and TMT arthrodeses. Any correction requires the use of subtle soft tissue surgery with recentering of the tendon, tightening of the medial capsule and abductor hallucis and releasing the lateral capsule. A check-list-like analysis of hallux valgus deformity helps determine the ideal procedure and avoid over- or under-treatment.

Driving in Parkinson's disease - a health hazard?

BACKGROUND: The driving safety of Parkinson's disease (PD) patients has lately been questioned after several authors reported road accidents caused by sleep attacks in PD patients on dopaminergic medication. OBJECTIVES: To determine 1) whether PD patients in general and those on dopaminergic medication in particular are especially prone to cause severe road accidents and 2) whether there are PD symptoms or dopaminergic side effects with the potential to compromise driving safety. DATA SOURCE: Relevant articles were identified by electronic search of biomedical databases (1966-2002: MEDLINE, EMBASE, PASCAL, PUBMED), the Cochrane Controlled Trials Register, and reference lists of located articles. RESULTS: Despite frequent occurrence of potentially hazardous dopaminergic side effects (2-57 %) and disabling parkinsonian non-motor and motor disabilities (16-63 %), the two existing studies on accident rates suggest that PD patients are not more prone to cause road accidents than the rest of the population. Five further reports including 1346 patients and focusing on dopaminergically induced sleep attacks provided comparably low accident figures (yearly incidence: 0%-2%). Because of low figures meta-analysis was intended but finally deemed inappropriate as the methodology of included studies varied greatly and was frequently flawed. CONCLUSION: Further prospective community-based well designed studies on accident risk in PD patients are needed to provide evidence based driving recommendations.

Arthrography of the foot and ankle. Ankle and subtalar joint.

Arthrography is the intra-articular injection of contrast media. This article reviews the normal and pathologic findings of standard arthrography and MR imaging arthrography of the ankle and subtalar joint. Standard arthrography is used primarily after acute ankle sprains, whereas MR imaging arthrography is used for staging and detecting osteochondritis dissecans of the talus, anterolateral soft tissue impingement, and chronic lateral ankle instability.

[Airlimb. Initial experiences with a new immediate early management prosthesis with individually adjustable air chambers]. / Airlimb. Erste Erfahrungen mit einer neuen Sofort-Frühversorgungsprothese mit einzeln ansteuerbaren Luftkammern.

Amputations of the lower extremity are still a common problem in diabetic feet and peripheral vasculopathies. The presented paper introduces a new device for an easier and faster mobilization of below-the-knee amputees. It is based on a new modular prostheses with individual inflatable air bladders. The compliance rate is higher with this device and it could be used from the day of surgery until the definitive prostheses is made. A biomechanical cadaver study with the prostheses will also be presented.

[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.

[Intermittent compression devices for swelling reduction and thrombosis prophylaxis--a pilot study after total hip replacement. Is the 2 hour daily minimum application sufficient?]. / Die intermittierende Impulskompression zur Abschwellung und Thromboseprophylaxe--Pilotstudie nach Hüft-TEP. Ist die Minimalanwendungsdauer von 2 h täglich ausreichend?

BACKGROUND: The use of intermittent compression devices for thrombosis prophylaxis and the reduction of postoperative swelling are widely accepted. The recommended minimum application of 2 h daily has never been statistically verified. Without evidence based data, the benefit of this costly equipment cannot be maximized. PATIENTS AND METHODS: A randomized clinical trial on 41 patients after total hip replacement was performed. The A-V Impulse System was applied for 2 h a day during the first 5 postoperative days to observe whether this time was sufficiently effective. RESULTS: In the control group, two deep vein thromboses occurred postoperatively, but there were none in the treatment group. Even though two patients from the treatment group had to be excluded from the study because of severe pain, all other parameters including visual analogue pain scale results and limb circumferences were comparable in both groups. CONCLUSION: These preliminary results suggest that pump systems can prevent deep venous thrombosis after hip surgery even when applied for only short intervals over a short period of time. However, large scale confirmatory studies are needed.

[Post-traumatic metatarsalgia. Early results of treatment with a new insole]. / Die posttraumatische Metatarsalgie. Erste Behandlungserfahrungen mit einer neuen Einlage.

Injuries of the forefoot are a challenge for orthopaedic surgeons. After healing of bone and soft tissue damage, posttraumatic metatarsalgia can persist. The paper presents a therapy algorithm with newly designed insoles, which consist of the common orthopaedic adaptations like a rocker bottom and a stiffening of the sole. The therapy is shown on two cases. With these orthotics adequate is possible and pain relief realistic.

[Vascular lesions in surgery of the hip joint]. / Gefässläsionen in der Hüftgelenkchirurgie.

The vascular anatomy in the acetabular region involves a certain risk of arterial and venous injuries complicating orthopaedic surgery. These complications have been grouped into four categories: lacerations, thrombosis, pseudoaneurysms and arteriovenous fistula. In a period of 5 years, three injuries of the external iliac artery and four lesions of the femoral artery associated with total hip arthroplasty were treated surgically at the Department of Vascular Surgery of the University Hospital in Graz. In one case a concomitant lesion of the pelvic vein was observed. The incidence of iatrogenic vascular injuries in total hip surgery is 0.3%. Combined injury of the external iliac artery and vein led to a life-threatening bleeding complication. The vascular lesion became manifest as acute ischaemia of the lower extremity or as an acute haemorrhage 30 min to 2 h after primary surgery. The late complication of a false aneurysm of the femoral artery occurred in one patient 3 weeks after total hip replacement. Reconstruction of the vascular lesions was performed by direct suture, except that two arterial lesions required the use of polytetrafluoroethylene (PTFE) vascular grafts. Vessels in the pelvic region are at high risk if screw fixation acetabular components are used. Perforation of the iliac artery by protruded methylmethacrylate polymer components of cement has been documented. The obturator vessels are in a vulnerable position if the acetabular floor has been broached by operative instruments or eroded by loosening of the prosthesis facilitated by osteoporosis, steroids or sepsis. Femoral vessels are endangered by Hohmann retractors that are not placed directly on bone. Though vascular injury during hip operations is rare, recognition of such complications is important as safe and satisfactory treatment can be achieved. Rapid identification and immediate surgical repair of these lacerations are essential for their management.

[Stress fractures of the tarsal navicular bone. Causality, diagnosis, therapy, prophylaxis]. / Die Stressfraktur des tarsalen Os naviculare. Ursache - Diagnostik - Therapie - Prophylaxe.

Stress fractures of the tarsal navicular bone are a challenge in diagnosis and therapy. First and foremost you have to think about this fracture. The origin of the injury can be detected in a wrong or too heavy strain of the bone especially in long distance runners and recruits. The MRI is the diagnostic tool of first choice. Therapy of displaced or comminuted fractures as well as pseudarthrosis is best done with surgical procedures like direct screw fixation or interposition of autologous bone depending on the circumstances and the age of injury. Conservative treatment with a plaster of Paris is useful in non-displaced and non-comminuted fractures. Prophylaxis with technical aids and a changing habits is recommended.

The post-discectomy syndrome. Aetiology, diagnosis, treatment, prevention.

The post-discectomy syndrome (PDS) is a common diagnosis in patients with problems following a disc operation. The different causes of PDS make the establishment of the correct diagnosis and its corresponding efficient treatment difficult. A general overview published in the bibliographical data covering the entity of PDS is rare. The following paper aims to specify PDS according to its aetiology, diagnosis, treatment and prevention. The diagnosis should be made efficiently, so that the patient can receive prompt adequate therapy.

[Prevention of epidural fibrosis. Initial experiences with non-resorbable membrane]. / Prävention der epiduralen Fibrose. Erste Erfahrungen mit einer nicht resorbierbaren Membran.

Scars around the neural structures after opening the spinal canal are common and severe problems in spine surgery. This paper presents the use of a special membrane to avoid epidural scarring in two cases.

The Bradykinesia Akinesia Incoordination Test (BRAIN TEST), an objective and user-friendly means to evaluate patients with parkinsonism.

The BRAIN TEST, a computerized alternating finger tapping test, was performed on 154 patients with parkinsonism to assess whether the test could be used as an objective tool to evaluate reliably the severity of Parkinson's disease (PD). Patients were instructed to tap two marked computer keyboard keys as fast and as accurately as possible for 60 seconds. The test generates the following variables: (1) kinesia score (KS)--number of keystrokes/min, (2) akinesia time (AT)--cumulative time that keys are depressed, (3) dysmetria score (DS)--a weighted score generated from incorrectly hit keys and corrected for speed, and (4) arrhythmia score (AS)--variance of the time interval between individual keystrokes. Among parkinsonian patients, we found a significant correlation between the four test parameters and PD rating scores of the Hoehn & Yahr, Schwab & England, and Unified PD Rating Scales (KS, AS, and AT p <0.001 and DS p <0.05). When compared with 73 parkinsonian patients 73 age- and sex-matched control subjects showed significantly higher KS and lower AT (p <0.001) as well as lower DS and AS (p = 0.05). The BRAIN TEST is a reliable and practical tool for evaluating the severity of parkinsonism and for distinguishing subjects with parkinsonism from normal control subjects. A version of the BRAIN TEST is available by FTP on the worldwide web (http://www.anaesthetist.com/software/brain.htm).

[Botulinum toxin--the dose controls the poison. A historical sketch]. / Botulinumtoxin--Die Dosis macht das Gift. Ein historischer Abriss.

Botulism, a potentially lethal form of paralytic food poisoning, was described as early as 1793. Basic research, especially in the late nineteenth and early twentieth centuries, revealed that botulism is caused by exotoxins. Further biochemical work around and after the Second World War gave insight into the molecular structure of seven different serotypes of botulinum toxin (BT/A-G) as well as into its acetylcholine blocking mode of action. In 1977, Scott treated patients with strabism by injecting minute amounts of purified BT/A. In short sequence, BT proved effective in blepharospasm, cervical dystonia, and various off-label indications. In the near future, registration of these new indications, marketing of new serotypes (BT/B), and availability of more practical antibody tests can be expected. The first applications of BT were performed by Roggenkaemper, Dressler, and Benecke in Germany and by Poewe and Auff in Austria. According to a worldwide trend, a rapid expansion regarding BT users and indications followed. Formation of BT competence centers in both countries aims at maintaining high standards in BT research and education.

Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons.

Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.

East-west differences in the organization of botulinum toxin use in nine Central European countries.

Availability and quality of expensive treatment modalities such as botulinum toxin (BTX) largely depend on organizational aspects such as costs, reimbursement by insurance companies, expertise and facilities for expert training, and the propagation of research. To investigate which determinants influence the organization of BTX' use throughout nine Central European countries (Austria, Croatia, Czech Republic, Germany, Hungary, Italy, Slovakia, Slovenia and Switzerland) we sent out questionnaires to leading BTX experts and consulted data banks of manufacturers and bulletins of international organizations. In Western European countries, there is a tendency for users to organize themselves in formal groups and to concentrate on research whereas the way how BTX is provided is diverse regarding qualifications of specialists and institutions. In the post-communist Eastern European countries, we found a tendency towards a centralized system of reimbursement and BTX treatment seems to be more in the hands of neurologists than any other specialists. Strong correlations were observed between the number of BTX centres, degree of organization of user groups and number of scientific publications, on the one hand, and parameters of healthcare performance and socioeconomic determinants, on the other. Our study suggests that in the nine countries surveyed, organizational aspects of BTX use vary considerably, whilst similarities are based mainly on socioeconomic rather than socio-demographic determinants.

Influence of age, gender, education and dexterity on upper limb motor performance in Parkinsonian patients and healthy controls.

Finger tapping, the most widely used test for evaluating motor dysfunction in Parkinson's disease (PD), was found to react sensitively to disease specific factors like disease severity and changes in medication. A possible interference caused by disease unrelated demographic factors--age, gender, education and dexterity--however has not yet been studied systematically. Various components of tapping performance of 187 healthy subjects and 200 PD patients were assessed by means of the BRAIN TEST, a digitalized test battery. The effects of demographic factors--above all education and age--were found to be significant. These influences generally affect different aspects of movement to a different extent, with speed and akinesia being affected more severely than dysmetria and arrhythmokinesis. Our study suggests that whenever precise assement of upper limb motor performance is needed, specific corrections for these demographic factors in both healthy controls and PD patients are necessary.