Spezializing in subfields of Orthopaedics is common in anglo-american countries for more than 20 years. IThe aim of this paper is to demonstrate the necessity of fellowship programms in extremity orientated subfileds of orthopaedics. Analyzing the results of ankle arthrodesis performed by general orthopaedic surgeons campared to ankle arthrodesis performed by spezialized foot and ankle surgeons the difference in results will be demonstrated.

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques.

Background

The adult acquired flat foot is caused by a complete or partial tear of the tibialis posterior tendon. We present the results of flexor digitorum longus transfer and medializing calcaneal osteotomy for recontruction of the deformity.

Introduction

End-stage ankle osteoarthritis is a debilitating condition that results in functional limitations and a poor quality of life. Ankle arthrodesis (AAD) and total ankle replacement (TAR) are the major surgical treatment options for ankle arthritis. The purpose of the present study was to compare preoperative and postoperative participation in sports and recreational activities, assesses levels of habitual physical activity, functional outcome and satisfaction of patients who underwent eighter AAD or TAR.

Background: The chevron osteotomy is a widely accepted method for the correction of mild to moderate hallux valgus deformity that reveals good to excellent results in terms of radiographic correction of hallux valgus deformity as well as functional outcome scores. However, recent pedobarographic studies have shown that there is decreased load of the big toe region and the first metatarsal head region respectively at a short and intermediate-term follow-up Sufficient load of these structures is essential in order to provide physiological gait patterns. The purpose of the present study was to determine if a modification in the postoperative regimen improves the functional outcome of chevron osteotomy for correction of hallux valgus deformity.

Methods: 29 patients with an mean age of 58 years who suffered on mild to moderate Hallux valgus deformity without radiographic signs of osteoarthritis of the first MTP joint who underwent chevron osteotomy were included in this prospective study. Postoperatively patients were placed in a forefoot relief shoe for 4 weeks. After this period they received a multimodal rehabilitation program including kryotherapy, lymphatic drainage, mobilisation, manual therapy, strnthening exercises and gait training. The patients received a mean of 4.2 treatment sessions and the sessions took place one time a week for 3 to 6 weeks. Preoperatively and one year after surgery plantar pressure distribution parameters including maximum force, contact area and force-time integral were evaluated. Additionly the AOFAS score, ROM of the first MTP and plain radiographs were assessed. The results were compared using Student’s t-test and level of significane was set at p< 0.05.

Results: In the big toe region maximum force increased from 72.2 N presurgically to 106.8 N at one year after surgery, contact area increased from 7.6 cm2 preoperatively to 8.9 cm2 one year postsurgically and force-time integral increased from 20.8 N*sec to 30.5 N*sec. All changes were statistically significant.(p< 0.05) For the first metatarsal head region maximum force increased from 122.5 N presurgically to 144.7 N one year after surgery and force-time integral increased from 42.3 N*sec preoperatively to 52.6 N*sec one year postoperatively. However, those changes were not statistically significant. (p=0.068; p=0.055)The mean AOFAS score increased from 61 points preoperatively to 94 points at follow-up (p< 0.001). The average hallux valgus angle decreased from 31° to 9° and the average first intermetatarsal angle decreased from 14° to 6° respectively.(p< 0.001)

Conclusions: The results of the present study indicate that postoperative physical therapy and gait training help to improve weight-bearing of the big toe and first ray respectively. Therefore, there is a restoration of physiological gait patterns in patients who recieve this postoperative regimen.

Introduction: Arthrodesis has been recommended for the treatment of end-stage osteoarthritis of the ankle joint, especially as the results of prosthetic ankle replacement are not comparable with those achieved with total hip or knee replacement. In vitro studies revealed that ankle arthrodesis restricts kinematics more than total ankle replacement in terms of range of motion as well as movment transfer. However, little is known about in vivo gait patterns in patients with arthrodesis of the ankle joint.

Aim of this retropective study was to determine plantar pressure distribution in patients who underwent ankle arthrodesis with a standardized screw fixation technique in a single surgeon population.

Methods: 21 patients (7 male/14 female) who underwent isolated unilateral ankle arthrodesis with 3 crossed 7,3 mm AO screws (Synthes Gmbh, Austria) in a standardized technique by a single surgeon between October 2000 and January 2008 have been included in this study. At a mean follow-up of 25 months (range 12 – 75) pedobarograhy (Novel GmbH., Munich), clinical evaluation using the AOFAS hindfoot score and weight-bearing x-rays of the foot were performed.

Results: Pedobarographic assessment revealed no statistically significant difference between the operated foot and the contralateral foot eighter in terms of peak pressure, maximum force, contact area and contact time or the gait line parameters velocity of center of pressure, lateral-medial force indices or lateral-medial area indices.

The average AOFAS score was 80,5 (range 46 – 92) and mean tibioplantar angle determined on the lateral standing radiograph was 91° (82° – 100°). Non-union didn’t occur in any patient.

Discussion: The results of the present study indicate that ankle arthrodesis restores plantar pressure distribution patterns to those of healthy feet. Therefore, the functional outcome of ankle arthrodesis seems to be good as long as the fusion is in fixed in an appropriate position.

Infection of the rear foot and ankle joint often leads to destruction of the bony structures leaving amputation as the only reasonable choice. New techniques using antibiotic impregnated bone grafts have proven efficient even under extreme circumstances. We report of their first application in apparently hopeless cases of rear foot infection.

Between 2004 and 2006 eight patients were operated because of florid infection of a severely destroyed rearfoot. In all cases the pre-treating surgeons suggested amputation below the knee as the only remaining possibility, which was refused by the patients. There were 3 men and 5 women. All patients had multiple surgery (min. 4, max. 72). The duration of infection was between 2 and 26 years. Diagnoses were: 4 St.p. open fracture, 2 Neuropathy, 1 Immunosuppression (kidney X), and 1 Rheumatoid arthritis.

Preoperative diagnostic measures included MRI and Bone Scans, localising the sites of infection. We performed radical debridement of all infected areas, intensive pulsed lavage, filling of defects with antibiotic bone compound (ABC) and stabilization using screws (4x) or the Ilizarov device (1x), respectively. Wounds could be closed primarily in 7 cases; in one case a fasciocutaneous suralis flap was necessary for closing. All patients were followed prospectively with a minimum period of 3 months and a maximum of 3 years.

Wound healing was completed uneventfully within 3 weeks. Surgery was always followed by a period of more than 6 months without any signs of infection. Re-intervention because of recurrence was necessary in 4 cases, whereas during all operations conditions were markedly improved compared to the foregoing intervention. So far 2 patients required 4 re-revisions of which one is awaiting a fifth revision, 1 patient one re-revision, and 1 patient decided to have the leg amputated. Six cases could be supplied with a custom-made shoe and were fully weight-bearing without pain or sign of infection at the last follow-up.

Reconstruction of the infected rearfoot is feasible even under extremely unfavourable conditions using antibiotic impregnated bone grafts. Fifty percent of cases may expect long-standing salvage with a weight-bearing limb. The other 50% must expect repeated surgery. It may be discussed, whether amputation in such cases could provide for a more favourable situation. However, we do believe that the decision for amputation shall be the sole decision of the patient. As long as the patient wants to keep his limb, being aware of all consequences thereafter, the surgeon is obliged to maintain the function of the foot as well as possible. Reconstruction with ABC seems to offer a promising tool for that purpose. So far 7 out of the 8 patients treated have been satisfied with the result and they would have it repeated in case of recurrence. They are aware that recurrence may occur but they should not show fear of the possibility of another revision since the hospital stays are short, discomfort is tolerable and rehabilitation is quick.

Aims: The aim of this prospective study was to analyse the Ludloff osteotomy for its potential of correcting hallux valgus deformity. Methods: Between September 1998 and October 1999 84 consecutive patients who underwent a Ludloff osteotomy were included in this prospective study. All patients were examined preoper-atively and at a minimum follow up of 2 years according a standardized questionnaire based on the HMIS of the American Foot and Ankle Society. X-rays were taken preoperatively, at 6 weeks and at þnal follow up. Results: 75 patients were available for an average follow up of 33 months (24 to 41). The average preoperative HMIS was 52 points and at follow up 87 points. 78% of the patients rated the outcome as excellent and good. 82% of patients were painfree at follow up. Radiological evaluation revealed a preoperative average hallux valgus angle (HV) of 36û and a preoperative average intermetatarsal angle (IM) of 17û This was corrected by surgery to an average HV of 14û and an average IM of 8û. Preoperatively sesamoidposition Grade III was present I 71%, Garde II in 29%. At follow up Grade 0 was present in 60%m Grade 1 in 37% and Grade2 in 3%. There was no Grade 3 sesamoid position at follow up. Conclusions: The ludloff osteotomy is a good alternative for the correction of severe hallux valgus deformity. In elderly patients and osteoporotic bone early weight-bearing should not be allowed because of poor bone quality.