Prospective evaluation of clinical and radiographic 10-year results of Fitmore short-stem total hip arthroplasty

BACKGROUND

Short stems were introduced into total hip arthroplasty (THA) to preserve bone stock, to transmit more load to the proximal femur, and to enable minimal invasive approaches. This study is the first long-term study (with a follow-up of 10 years) of the survival as well as the clinical and radiographic outcomes of the Fitmore hip stem, a short curved uncemented stem.

METHODS

In total, 123 Fitmore hip stems were prospectively evaluated. At the final 10-year follow-up, 80 Fitmore stems (78 patients: 30 female, 48 male) were eligible for evaluation. Clinical parameters were thigh pain, EQ-5D, Harris Hip Score (HHS) and Oxford Hip Score. Radiographic parameters were cortical hypertrophy (CH), bone condensation, cortical thinning, radiolucency, reactive lines, calcar rounding, calcar resorption, subsidence and varus/valgus position.

RESULTS

After 10 years, there was a survival rate of 99% (1 revision because of aseptic stem loosening). HHS had improved from 59 to 94 and Oxford Hip Score from 22 to 43. CH rate after 1 year was 69% and after 10 years 74%. In the first year, radiolucency was found in 58% and in 17.5% after 10 years. Subsidence after 1 year was 1.6 ± 1.6 mm and 5.0 ± 3.1 mm after 10 years.

CONCLUSIONS

The Fitmore hip stem showed a survival rate of 99% as well as good clinical and radiographic outcomes in the long-term follow-up of 10 years.

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

BACKGROUND

Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA.

METHODS

Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint "deterioration" was reached if 2 of the 3 parameters turned worse.

RESULTS

Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain.

CONCLUSIONS

Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

Prospective 5-year study with 96 short curved Fitmore™ hip stems shows a high incidence of cortical hypertrophy with no clinical relevance

Background

An increased occurrence of cortical hypertrophy (CH) was observed 1–2 years after implanting short curved Fitmore hip stems. There are no published data about either the clinical relevance or the progression of CH over the long term.

Methods

Ninety-six primary total hip arthroplasties were performed between 2008 and 2010 using the Fitmore hip stem. Clinical and radiological parameters were recorded preoperatively and at 1, 2, 3, and 5 year follow-up.

Results

CH appeared mainly on antero-posterior radiographs in Gruen Zones 2, 3, 5, and 6. After 1 year, the diameter was 10 ± 2 mm and remained constant thereafter. The CH rate after 1 year was 69% and after 5 years 71%. Subsidence after 1 year was 1.6 ± 1.55 mm and 1.93 ± 1.72 mm after 5 years. Cortical thinning was 46% after 1 year and 56% after 5 years, mainly in Gruen Zones 7 and 8. In the first year radiolucencies were found in 51% in all Gruen Zones, and in 20% after 5 years. Patient, implant, and surgical factors did not correlate with radiological outcomes except that larger stems had more CH. After 5 years, the Harris Hip Score had improved from 59 to 94 and the Oxford Hip Score from 22 to 41. Radiographic parameters, notably CH, were not associated with clinical outcomes except that cortical thinning correlated with lower outcome scores.

Conclusions

CH correlated neither with clinical outcome nor with patient, surgical or implant factors, except for a positive correlation with stem size. The Fitmore hip stems settled within the first year to a stable fixation and then remained almost unchanged. However, cortical thinning is common in Gruen Zone 7 and 8 meaning that there is stress-shielding.

Stiffness and Range of Motion After Minimally Invasive Chevron-Akin and Open Scarf-Akin Procedures

BACKGROUND

Stiffness after open hallux valgus surgery affects 7% to 38% of patients. Minimally invasive surgery (MIS) is thought to decrease this rate by reducing soft tissue trauma. MIS, now in its third generation, is advertised as delivering results superior to open surgery. However, no studies have reported stiffness or range of motion (ROM).

METHODS

Between January 2014 and December 2015, a total of 50 patients received open scarf-Akin surgery and 48 received minimally invasive Chevron Akin (MICA) surgery. The endpoints were American Orthopaedic Foot & Ankle Society (AOFAS) score, range of motion, visual analog scale for pain, scar length, and subjective foot value. The minimal follow-up time was 2 years.

RESULTS

Moderate stiffness occurred in 3 cases in both groups. In MICA, extension increased by 10 degrees while it remained unchanged in scarf. Both groups showed similar improvements in AOFAS score, pain, and subjective foot value. Radiographic evidence of correction was comparable, except for an increased shortening of the first metatarsal by 3 mm in MICA. The scars were smaller in MICA (1.2 cm) than in scarf (5 cm). Wound problems included delayed healing in 10% in scarf and wound infections in 4% in MICA. The rate of recurrence and other complications were comparable, except for reoperations, which were higher in MICA (27% mainly for protruding screws) than in scarf (8% mainly for stiffness). In MICA, 14% were intraoperatively converted to open surgery.

CONCLUSION

MICA showed no advantages over scarf other than a shorter scar. The observed gain in extension could be related to the increased shortening of the first metatarsal because of the size of the burr.

LEVEL OF EVIDENCE

Level II, prospective cohort (nonrandomized, comparative) study.

Minimally Invasive versus Open Hallux Valgus Surgery

Category:

Bunion

Introduction/Purpose:

About 20% of patients suffer from stiffness (arthrofibrosis) after hallux valgus surgery. Minimally Invasive Surgery (MIS) has been invented to reduce the rate of unfavorable result, MIS enjoys increasing popularity with both surgeons and patients and is applied in a growing number of cases. It is being advertised as delivering better results due to reduced soft tissue injury and quicker recovery while effecting a similar amount of deformity correction. However, to date there are no scientific data to support this claim. The aim of the current project is to fill this lacuna by comparing the outcomes of MIS and open hallux valgus surgeries prospectively at our institution.

Methods:

From 01/2014 to 12/2015, 123 patients were operated: 75 open (average age 51 years, 91% female) and 48 MIS (age 47 years, 88% female). Inclusion criteria were either open Chevron/Scarf or MIS-Chevron at our Foot and Ankle Center with 5 different hospitals and three surgeons. Exclusion criteria were radiological signs of osteoarthritis, extension of less than 30°, pain on motion or during the night, and all other hallux valgus surgeries (lapidus, open wedge, Akin and buniektomy only). Radiographs were taken of all patients 6 weeks and 1 year postop. All patient charts were screened by an independent research assistant for complications and reoperations. All radiographs were measured by two independent observers. All patients were examined in a blinded control by an independent study nurse at 24±6 months after surgery for the clinical results (for parameters please see Tab. 1).

Results:

All clinical and radiographic results, as well as all additional surgeries, reoperations and complications are shown in Tab.1. The results show that open and MIS surgery achieved a similar gain in AOFAS-score, flexion, extension, VAS and subjective foot value. The scar was significantly smaller in MIS than open, but the satisfaction with the scar was similar. The radiographic correction was equal. Open surgery was combined with more additional procedures than MIS, especially Weil osteotomies and plantar plate repairs. The rate of CRPS, prolonged pain, and stiffness was equal. The reoperation rate was significantly higher for MIS due to a screw removal rate of 34%.

Conclusion:

MIS is an interesting concept, but it enjoys no advantages over open surgery, at least when carried out with current methods. Calls for open-trained surgeons to switch to MIS are therefore premature. Both surgical techniques have similar clinical and radiological outcomes, while MIS had a higher screw removal rate. Furthermore, complex cases have to be operated with open surgery.

Survival of the Scandinavian Total Ankle Replacement (STAR)

Category:

Ankle Arthritis

Introduction/Purpose:

The purpose of this study was to evaluate survival and clinical outcome of the Scandinavian total ankle replacement (STAR) prosthesis after a minimum of ten years up to a maximum of 19 years.

Methods:

Fifty STAR prostheses in 46 patients with end stage ankle osteoarthritis operated between 1996 and 2006 by the same surgeon (MH) were included. Minimal follow-up was ten years (median 14.6 years, 95% confidence interval [CI] 12.9-16.4). Clinical (Kofoed score) and radiological assessments were taken before the operation and at one, ten (+2), and 16 (±3) years after implantation. The primary endpoint was defined as exchange of the whole prosthesis or conversion to arthrodesis (def. 1), exchange of at least one metallic component (def. 2), or exchange of any component including the inlay (due to breakage or wear) (def. 3). Survival was estimated according to Kaplan-Meier. Further reoperations related to STAR were also recorded.

Results:

The ten year survival rate was (def. 1) 94% (CI 82- 98%), (def. 2) 90% (CI, 77-96%), and (def. 3) 78% (CI 64-87%). The 19-year survival rate was (def. 1) 91% (CI 78-97%), (def. 2) 75% (CI 53-88%), and (def. 3) 55% (CI 34-71%). Considering any re-operations related to STAR, 52% (26/50) of prostheses were affected by re-operations. Mean pre-operative Kofoed score was 49, which improved to 84 after one year (n = 50), to 90 after ten years (n = 46), and to 89 after 16 years (n = 28).

Conclusion:

The survival rate for def. 1 and 2 was high. However, re-operations occurred in 52% of all STAR prosthesis.

Assessment of hindfoot alignment using MRI and standing hindfoot alignment radiographs (Saltzman view)

OBJECTIVE

To compare the hindfoot alignment measured on standing HAV radiographs (Saltzman view) and on non-weight-bearing coronal MR images.

MATERIALS AND METHODS

The apparent moment arm was measured on weight-bearing conventional radiographs (Saltzman views) and on MRIs of the ankle in 50 consecutive patients (mean age, 54 years; age range, 18-77 years). The evaluation was performed independently by three readers using analogous reference points for both methods. Positive values were assigned when the deepest point of the calcaneus was lateral to the tibial axis as valgus, negative values as varus. The intertechnique agreement and correlation for the measurements performed with HAV radiographs and MRI were assessed for each reader using the Bland-Altman method and the Pearson correlation coefficient, respectively. The interobserver agreement was assessed using the intraclass correlation coefficient.

RESULTS

The means of apparent moment arms, with the standard deviation (SD) in parentheses, of three readers were +2.0 (±8.4) mm, +1.5 (±6.6) mm and -1.4 (±8.2) mm on HAV radiographs and +4.6 (±7.4) mm, +6.3 (±5.3) mm and +5.4 (±6.4) mm on MRI. The Bland-Altman analysis found a systematic bias for all three readers, corresponding to an overestimation of measurements with MRI (systematic bias ranging from 2.6 to 4.8 mm). The intertechnique correlation was found moderate to high. The Pearson coefficients for the three readers were 0.75, 0.64 and 0.65. The interobserver agreement among the three readers was 0.72, 0.77 and 0.68 for HAV, MRI and both modalities together, respectively.

CONCLUSION

Hindfoot alignment can be estimated on MRI but the correlation between the values on HAV radiographs and MR images is only moderate with a tendency to increased positive values (valgization) on MR images.

Radiographic Study of Pes Planovarus

BACKGROUND

Depending on the direction of the subtalar joint, a foot deformity generally tends towards pronation (pes planovalgus) or supination (pes cavovarus). However, the combination of hindfoot varus and flat midfoot/forefoot (pes planovarus) is an exception to this rule. Pes planovarus has so far only been referred to in connection with Müller-Weiss disease and congenital disease. We diagnosed pes planovarus in otherwise healthy patients without these diseases.

METHODS

Forty patients with 54 symptomatic feet who were treated between August 2012 and July 2016 were included (mean age, 44.1 ± 15.7 years; 15 male/25 female). They were selected from 1064 consecutive cases (3.8%). Inclusion criteria were hindfoot varus and flat midfoot/forefoot. Their symptoms, radiographs, and therapies within the first 3 months were retrospectively analyzed. The position in the hindfoot alignment view (HAV), talometatarsal-1 angle lateral (TMT1lat) and dorsoplantar (TMT1dp), talocalcaneal angle lateral (TCAlat) and dorsoplantar (TCAdp), and calcaneal pitch angle (CPA) were measured on a DICOM/PACS system.

RESULTS

The mean radiological results (standard values from the literature in brackets) were as follows: the hindfoot was significantly in varus in the HAV (-6.9 ± 3.6 mm [-1.6 ± 7.2 mm]; P < .001), the TMT1lat was significantly flatter (-6.7 ± 5.8 degrees [8.4 ± 5.9 degrees]; P < .001), the TMT1dp was significantly less in abduction (1.5 ± 7.9 degrees [7.7 ± 8.2 degrees]; P = .005), the TCAdp showed no difference (25.9 ± 7.9 degrees [24.1 ± 5.7 degrees]; P = .118), the TCAlat was significantly larger (47.5 ± 6.1 degrees [43.4 ± 7.1 degrees]; P < .001), and the CPA was significantly flatter (17.6 ± 3.9 degrees [24.5 ± 3.0 degrees]; P < .001). The most frequent symptoms were stress-induced foot pain (n = 33), hallux valgus (n = 20), chronic ankle instability (n = 17), metatarsalgia (n = 15), chronic midfoot pain (n = 13), heel pain (n = 12), and lesser toe deformities (n = 8). Thirty-one feet were treated conservatively and 23 operatively.

CONCLUSION

This study showed the existence of pes planovarus without Müller-Weiss disease or congenital disease. This unusual foot form leads to difficulties if standard treatment strategies are applied, which raises the issue of the correct treatment for such patients.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Complications After Resection of Os Trigonum or Posterior Talar Process

Category:

Sports

Introduction/Purpose:

The resection of os trigonum or posterior talar process for posterior ankle impingement is a technically easy and frequent operation. So far, the scientific literature has focused only on the surgical approach and perioperative problems. However, the author has encountered unfavorable followup results (professional athletes had to stop their career), which also other surgeons tell to have encountered. This study aims to describe for the first time this complication rate and possible reasons therefore.

Methods:

From 3/11 to 7/15 29 patients (17male, 12 female, 32+/-14 years) with 30 feet were operated (22 endoscopic, 8 open resections). Average followup was 27+/-13 months. All charts and pre- and postoperative radiographs were retrospectively evaluated. Patients were grouped into “no complications”, “minor temporary (< 3 months)”, “major follow up (end of athletic career)” complications. The following radiographic parameters were measured referenced on the intersection of the talar radius with the calcaneus (Fig. 1): (1) length of posterior talar process/ os trigonum, (2) length of the calcaneus below the posterior process/os trigonum, (3) length of the uncovered subtalar joint after resection.

Results:

The major complication rate was 13.3% (4 of 30 feet, 2 os trigonum, 2 posterior talar process): all 4 had symptomatic talar edema and 3 of 4 had symptomatic subtalar osteoarthritis. 1 minor complication (persistent pain for 3 months) was found. The length of the posterior talar process was preoperatively 9.37 +/- 2.89 mm (os trigonum 8.62+/- 2.62 mm) postoperatively 0.64+/-1.8 mm. The length of the posterior calcaneus preoperatively was 8.35 +/- 4.63 mm, postoperatively 1.97 +/-3.0 mm. The uncovered subtalar joint surface postoperatively was 1.77+/- 2.92 mm. All patients with major complications showed retrospectively what we call the “deadly configuration”: the radius of the talus ends within the subtalar joint. Consequently the free subtalar joint surface was significantly larger (6.4 mm +/- 3.33) in feet with major complications than in feet without (1.06 mm +/- 2.15, P < 0.001). Feet without complications but with this deadly configuration (7/26) had a lower free subtalar surface (3.27 mm +/- 1.81, P=0.09) than feet with major complications.

Conclusion:

The resection of os trigonum or posterior talar process has a high complication rate of 13.3% with symptomatic talar edema and subtalar osteoarthritis at follow up which can be career-ending in professional athletes. The only risk factor found was what we call the “deadly configuration” characterized by the ending of the talar radius into the subtalar joint. In such cases, the resection has to be made sparingly preferably not anterior into the subtalar joint and patients have to be informed about this possible unfavorable course.

Pes Planovarus – The Description of a New Foot Form

Category:

Hindfoot

Introduction/Purpose:

In classic anatomy textbooks probably based on dissections of European executed convicts it is written, that according to the direction of the subtalar joint, a deformity of the foot is generally going either into supination (cavovarus foot) or pronation (planovalgus foot). However today we live in a multiethnic society and the author has encountered feet with hindfoot varus and flat mid- and forefoot, without mueller-weiss-syndrome. This deformity should theoretically not exist and has not been described in the literature yet. Its treatment is unclear.

Methods:

From 8/2012 to 8/2015 984 new patients were seen in the clinic and included in the study if they showed clinically a hindfoot varus and flat mid-/forefoot on exam. 29 patients (2.9%) with 38 feet were identified (44.6+/-16.2 years, 12 male/17 female). Their main complaints and therapy were retrospectively analyzed. Two independent observers (intraobserver variability ICC 0.998) measured on a DICOM/PACS-monitor the following radiographic parameters (Fig. 1): (1) position in the Saltzman- view, (2) talus-metatarsal-1 angle dorso-plantar (dp) and lateral, (3) talus-calcaneus angle dp and lateral, (4) calcaneal pitch angle. Standard values were taken from the literature.

Results:

Main complaints were chronic ankle instability (n=22), pain in sports (n=18), achillestendon-tendinitis (n=14), heel pain (n=14), hallux valgus (n=10), metatarsalgia (n=8), midfoot pain (n=6), posterior tibial tendon tendinitis (n=3), midfoot osteoarthritis (n=3). There was no mueller-weiss disease. 25 feet were treated conservatively, 13 with operation. Radiological results: The hindfoot alignment view was significantly in varus 6.57+/-3.74mm (standard 1.6+/-7.2mm, P < 0.001), the talus-MT1 angel lateral was significantly flat with 5.97+/-8.3° towards a negative arch (standard 8.4+/-5.85° positive arch, P < 0.001), the talus- MT1- angle dp was 2.4+/-8.2° in abduction (standard 7.7+/-8.2°, P=0.2), the calcaneus pitch angle was 18.63+/-6.45° (standard 24.5+/- 3.0, P < 0.001), the talus-calcaneus angle lateral was 48.13+/-6.76° (standard 43.4+/-7.1°, P < 0.001), the talus calcaneus angle dp was 25.35+/-8.22° (standard 24.1+/-5.7+, P=0.38).

Conclusion:

We found in 2.9% of our patients this new foot form, which is significantly different from standard feet characterized by a simultaneous hindfoot varus and flatfoot with negative arch. This seems paradox, as this is not in line with the axis of the subtalar joint. These feet pose a difficulty in treatment as for example a correction of the hindfoot varus in chronic ankle instability would increase the flatfoot and the correction of flatfoot in midfoot pain/metatarsalgia/heel pain would increase the hindfoot varus. Therefore conservative treatment was the primary choice because surgery would include a simultaneous correction of both deformities. Further research is necessary.

Intraoperative positioning of the hindfoot with the hindfoot alignment guide: a pilot study

BACKGROUND

In a previous study, intraoperative positioning of the hindfoot by visual means resulted in the wrong varus/valgus position by 8 degrees and a relatively large standard deviation of 8 degrees. Thus, new intraoperative means are needed to improve the precision of hindfoot surgery. We therefore sought a hindfoot alignment guide that would be as simple as the alignment guides used in total knee arthroplasty.

METHODS

A novel hindfoot alignment guide (HA guide) has been developed that projects the mechanical axis from the tibia down to the heel. The HA guide enables the positioning of the hindfoot in the desired varus/valgus position and in plantigrade position in the lateral plane. The HA guide was used intraoperatively from May through November 2011 in 11 complex patients with simultaneous correction of the supramalleolar, tibiotalar, and inframalleolar alignment. Pre- and postoperative Saltzman views were taken and the position was measured.

RESULTS

The HA guide significantly improved the intraoperative positioning compared with visual means: The accuracy with the HA guide was 4.5 ± 5.1 degrees (mean ± standard deviation) and without the HA guide 9.4 ± 5.5 degrees (P < .05). In 7 of 11 patients, the preoperative plan was changed because of the HA guide (2 avoided osteotomies, 5 additional osteotomies).

CONCLUSIONS

The HA guide helped to position the hindfoot intraoperatively with greater precision than visual means. The HA guide was especially useful for multilevel corrections in which the need for and the amount of a simultaneous osteotomy had to be evaluated intraoperatively.

LEVEL OF EVIDENCE

Level IV, case series.

The midfoot load shows impaired function after ankle arthrodesis

BACKGROUND

A large number of parameters are registered by pedobarography, usually requiring a research setting for interpretation. The purpose of this study was to evaluate which pedobarographic parameters (adjusted for walking speed and body weight) discriminate between healthy volunteers and patients after ankle or tibiotalocalcaneal arthrodesis. Furthermore, we evaluated which parameters are associated with the American Orthopaedic Foot and Ankle Society (AOFAS) score.

METHODS

Thirty-five healthy volunteers, 57 patients with ankle and 42 with tibiotalocalcaneal arthrodesis were assessed by AOFAS scores and dynamic pedobarography. The arthrodesis patients were further investigated with radiographs. Median follow up was 4 years. Eighteen basic parameters were measured each in the hind-, mid-, and forefoot. For dimension reduction, we represented a pre-selected set of 9 parameters by two indices (load, rollover). We used ordinal logistic and multiple linear regression to address the questions.

FINDINGS

The midfoot index of load was the most important pedobarographic predictor (interquartile range odds ratio 100; 95% confidence interval 13, 771) for belonging to the healthy volunteers rather than the ankle or tibiotalocalcaneal arthrodesis groups. Similarly, it was an independent predictor for the AOFAS score (interquartile range effect 5 points; 95% confidence interval 1, 9). Healthy volunteers had a deeper midfoot depression in the force/pressure time graphs compared to patients after arthrodesis.

INTERPRETATION

When evaluating foot function after ankle or tibiotalocalcaneal arthrodesis, the interpretation of a large number of pedobarographic parameters can be reduced to the interpretation of the midfoot index of load and the evaluation of the force/pressure time graphs.

Solid bolt fixation of the medial column in Charcot midfoot arthropathy

Charcot medial column and midfoot deformities are associated with rocker bottom foot, recurrent plantar ulceration, and consequent infection. The primary goal of surgical intervention is to realign and stabilize the plantar arch in a shoe-able, plantigrade alignment. Different fixation devices, including screws, plates, and external fixators, can be used to stabilize the Charcot foot; however, each of these methods has substantial disadvantages. To assess the effectiveness of rigid, minimally invasive fixation of the medial column and midfoot, 8 cases of solid intramedullary bolt fixation for symptomatic Charcot neuroarthropathy were reviewed. The patients included 6 males (75%) and 2 females (25%), with a mean age of 63 (range 46 to 80) years. The Charcot foot deformity was caused by diabetic neuropathy in 7 cases (87.5%) and alcoholic neuropathy in 1 (12.5%). The mean duration of postoperative follow-up period was 27 (range 12 to 44) months. The mean radiographic correction of the lateral talar-first metatarsal angle was 15° (range 3° to 19°), and the mean radiographic correction of the dorsal midfoot dislocation was 9 (range -4 to 23) mm. The mean loss of correction of the lateral talar-first metatarsal angle and midfoot dislocation after surgery was 7° (range 0° to 26°) and 1 (range 0 to 7) mm, respectively. No bolt breakage was observed, and no cases of recurrent or residual ulceration occurred during the observation period. Bolt removal was performed in 3 cases (37.5%), 2 (25%) because of axial migration of the bolt into the ankle joint and 1 (12.5%) because of infection. The results of the present review suggest that a solid intramedullary bolt provides reasonable fixation for realignment of the medial column in cases of Charcot neuroarthropathy.

Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced?

BACKGROUND

We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach.

QUESTIONS/PURPOSES

We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable.

PATIENTS AND METHODS

From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90° for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months).

RESULTS

The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10° to 20° in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5).

CONCLUSIONS

Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Achilles tendon ruptures and tibialis anterior tendon ruptures]

Achilles tendon ruptures (ATR) are becoming the most frequent tendon rupture of the lower extremity, whereas less than 100 cases of tibialis anterior tendon ruptures (TATR) have been reported. Common in both tendons are the degenerative causes of ruptures in a susceptible tendon segment, whereas traumatic transections occur at each level. Triceps surae and tibialis anterior muscles are responsible for the main sagittal ankle range of motion and ruptures lead to a distinctive functional deficit. However, diagnosis is delayed in up to 25% of ATR and even more frequently in TATR. Early primary repair provides the best functional results. With progressive retraction and muscle atrophy delayed tendon reconstruction has less favourable functional results. But not all patients need full capacity, power and endurance of these muscles and non-surgical treatment should not be forgotten. Inactive patients with significant comorbidities and little disability should be informed that surgical treatment of TATR is complicated by high rates of rerupture and surgical treatment of ATR can result in wound healing problems rarely necessitating some kind of transplantation.

Does alignment in the hindfoot radiograph influence dynamic foot-floor pressures in ankle and tibiotalocalcaneal fusion?

BACKGROUND

The Saltzman-el-Khoury hindfoot alignment view (HAV) is considered the gold standard for assessing the axis from hindfoot to tibia. However, it is unclear whether radiographic alignment influences dynamic load distribution during gait.

QUESTIONS/PURPOSES

We evaluated varus-valgus alignment by the HAV and its influence on dynamic load distribution in ankle and tibiotalocalcaneal (TTC) arthrodesis.

PATIENTS AND METHODS

We clinically assessed 98 patients (ankle, 56; TTC, 42) with SF-36 and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual hindfoot alignment, HAV angle, and dynamic pedobarography using a five-step method. For comparison, 70 normal feet were evaluated. Minimum followup was 2 years (average, 4.11 years; range, 2-6 years).

RESULTS

The mean HAV angle was -0.8° ± 7.8° for ankle and -1.2° ± 6.9° for TTC arthrodesis. The HAV angle correlated with pedobarographic load distribution (r = 0.35-0.53). Radiographic alignment did not influence SF-36 or AOFAS scores; however, load distribution correlated to qualities of these scores. Visual alignment only predicted the corresponding HAV angle in 48%. To reproduce the dynamic load of healthy subjects, HAV angles of 5° to 10° valgus were needed.

CONCLUSIONS

Visual positioning is inadequate to determine intraoperative positioning and resulted in a varus position with a relatively large SD. The HAV should be used to assess the hindfoot alignment correctly. HAV angles of 5° to 10° valgus are needed to reproduce a physiologic gait pattern.

Clinical relevance of hindfoot alignment view in total ankle replacement

BACKGROUND

Alignment is instrumental for success and long-term survival of Total Ankle Replacement (TAR). At this point in TAR, only coronal alignment in the region of the tibiotalar joint or above has been assessed because inframalleolar deformity is difficult to visualize radiographically. The Hindfoot Alignment View (HAV) allows visualization of the hindfoot position relative to the tibia. The purpose of this study was to evaluate the clinical relevance of this view in assessing patients with TAR.

MATERIALS AND METHODS

Twenty-eight consecutive patients with a Hintegra-TAR with an average followup of 4.1 ± 1.5 years were followed with (1) AOFAS and SF-36 scores, (2) visual judgment of the hindfoot position, (3) HAV and AP/lateral radiographs, (4) dynamic pedobarography (Novel emed m/E, Munich, Germany).

RESULTS

The HAV position correlated well with different load parameters on heel strike (r = 0.44 to 0.62) but not with the varus-valgus load pattern of the rest of the foot. Visual judgment and TAR joint line did not correlate to radiographic hindfoot alignment or to pedobarographic load distribution. The hindfoot alignment measured by the HAV correlated significantly to the Physical Function and Role Physical of SF-36. No correlation was found to other SF36-qualities or the AOFAS-score.

CONCLUSION

Inframalleolar alignment, as assessed by the HAV, influenced the dynamic pedobarographic load pattern and clinical outcome. Visual judgment and TAR joint line were not accurate enough to estimate the hindfoot alignment or dynamic load pattern. We believe adjusting the hindfoot correctly with HAV might improve long-term outcome and survival of TAR.

Can porous tantalum be used to achieve ankle and subtalar arthrodesis?: a pilot study

A structural graft often is needed to fill gaps during reconstructive procedures of the ankle and hindfoot. Autograft, the current gold standard, is limited in availability and configuration and is associated with donor-site morbidity in as much as 48%, whereas the alternative allograft carries risks of disease transmission and collapse. Trabecular metal (tantalum), with a healing rate similar to that of autograft, high stability, and no donor-site morbidity, has been used in surgery of the hip, knee, and spine. However, its use has not been documented in foot and ankle surgery. We retrospectively reviewed nine patients with complex foot and ankle arthrodeses using a tantalum spacer. Minimum followup was 1.9 years (average, 2 years; range, 1.9-2.4 years). Bone ingrowth into the tantalum was analyzed with micro-CT in three of the nine patients. All arthrodeses were fused clinically and radiographically at the 1- and 2 year followups and no complications occurred. The American Orthopaedic Foot and Ankle Society score increased from 32 to 74. The micro-CT showed bony trabeculae growing onto the tantalum. Our data suggest tantalum may be used as a structural graft option for ankle and subtalar arthrodesis. All nine of our patients achieved fusion and had no complications. Using tantalum obviated the need for harvesting of the iliac spine.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications

BACKGROUND

Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail has been described as a technically easy, minimally invasive operation with few complications and an early return to competitive sports.

HYPOTHESIS

The results reported thus far have been positive. The titanium elastic nail is associated with multiple intraoperative and postoperative problems.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From April 2004 to March 2007, 34 patients at our institution were treated with intramedullary nailing. A standard titanium elastic nail was used in 19 cases and a titanium elastic nail with an end cap in 15 cases. The titanium elastic nail was inserted and advanced under fluoroscopic control. A short incision at the fracture site was made for open reduction if needed. Postoperatively, free range of motion was allowed.

RESULTS

In 62% of patients, open reduction was necessary independent of fracture type, flattening of the titanium elastic nail, or transverse fragments. Operating time was 44 minutes (range, 10-105 minutes) and fluoroscopy time 9 minutes (range, 2-25 minutes). In 70% of patients, problems or complications occurred (7 medial perforations, 7 lateral penetrations, 1 titanium elastic nail breakage, 1 titanium elastic nail dislocation, 7 hardware irritations). The reoperation rate was 36%. Medial migration and pain were significantly reduced by using an end cap.

CONCLUSION

Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail is a technically demanding operation with various complications in the postoperative phase. This study might explain why the implant has not yet achieved widespread application, despite the fact that other authors have reported good results. Amending the operative technique and postoperative treatment might improve the outcome in the future.

The biomechanical influence of tibio-talar containment on stability of the ankle joint

Chronic ankle instability (CAI) is a frequent sport orthopaedic entity. Although many risk factors have been studied extensively, little is known how it is influenced by the osseous joint configuration. Based on lateral X-rays, the radius of the talar surface and the tibial coverage of the talus (sector alpha) were measured on a DICOM/PACS system in 52 patients with CAI and an age- and sex-matched control group. The talar radius was found to be larger in patients with CAI (21.2 +/- 2.4 mm) than in the control group (17.7 +/- 1.9 mm; P < 0.0001). The tibio-talar sector was smaller in patients with CAI (80 degrees +/- 5.1 degrees ) than in the control group (88.4 degrees +/- 7.2 degrees ; P < 0.0001). The aim of this study is to analyse the biomechanical influence of the clinical data on stability of the ankle joint. A two-dimensional model of the tibio-talar joint in the sagittal plane was developed. The joint configuration was described by the tibio-talar sector (alpha) and the radius (r) of the talus. The force (F = F (BW) tan alpha/2) and energy (E = F (BW) r [1 - cos alpha/2]) to dislocate the talus out of the tibial plafond were deduced. Ankle stability is a function of the tibio-talar sector: the force necessary to dislocate the joint is decreasing with a smaller sector. The clinical data show that the force needed to dislocate the ankle of CAI patients was 14% weaker than the one needed in the case of healthy subjects (P < 0.0001). The energy to dislocate the ankle depends both on the sector and the radius. The clinical data do not show a significant difference between the energy needed to dislocate the joint of CAI patients and the one of healthy subjects. This is because there is a correlation of a small sector and a large radius for CAI ankles. CAI is associated with an unstable osseous joint configuration, which is characterized by a larger radius of the talus and a smaller tibio-talar sector. The findings of the biomechanical model explain the clinical observations and demonstrate how stability of the ankle joint is influenced by the osseous configuration. Surgical ankle ligament stabilization might be more recommended in patients with an unstable osseous configuration as such patients have a disposition for recurrent sprains. Removing anterior osteophytes for anterior impingement should be done carefully in CAI patients because this would decrease the tibial coverage of the talus and thus dispose the talus to dislocate anteriorly. People who have an unstable ankle configuration and who nevertheless engage in activities with high risk of ankle sprains could be asked to wear ankle protecting sports equipment.

Chronische Instabilität des oberen Sprunggelenks

Chronic ankle instability represents a typical sports injury. After an acute ankle sprain 20-40% of the injured develop chronic ankle instability. From an orthopaedic point of view chronic ankle instability can be subdivided into lateral and medial instability or a combination of both, the so-called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of neuromuscular control. For the physician chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy often surgical. This review on chronic ankle instability deals with the pathomechanisms, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, such as ligamentous osteoarthritis.

[Chronic ankle instability in sports -- a review for sports physicians]

Chronic ankle instability represents a typical sports injury which can mostly be seen in basketball, soccer, orienteering and other high risk sports. 20 to 40 % of the acute ankle sprains develop into chronic ankle instability. From a sports orthopaedic point of view, chronic ankle instability can be subdivided into a lateral, medial or a combination of both so called rotational ankle instability. From a pathophysiological point of view, chronic ankle instability can be either mechanical with a structural ligament lesion or functional with loss of the neuromuscular control. For the sports physician, the chronic ankle instability is a difficult entity as the diagnosis is usually complex and the therapy usually surgical. This review on chronic ankle instability addresses pathomechanism, diagnostics, indications for conservative and surgical treatments, and possible long-term sequelae, as ligamentous osteoarthritis.

The effect of osseous ankle configuration on chronic ankle instability

BACKGROUND

Chronic ankle instability (CAI) is a common orthopaedic entity in sport. Although other risk factors have been studied extensively, little is known about how it is influenced by the osseous joint configuration.

AIM

To study the effect of osseous ankle configuration on CAI.

DESIGN

Case-control study, level III.

SETTING

Radiological examination with measurement of lateral x rays by an independent radiologist using a digital DICOM/PACS system.

PATIENTS

A group of 52 patients who had had at least three recurrent sprains was compared with an age-matched and sex-matched control group of 52 healthy subjects.

MAIN OUTCOME MEASURES

The radius of the talar surface, the tibial coverage of the talus (tibiotalar sector) and the height of the talar body were measured.

RESULTS

The talar radius was found to be larger in patients with CAI (21.2 (2.4) mm) than in controls (17.7 (1.9) mm; p<0.001, power >95%). The tibiotalar sector, representing the tibial coverage of the talus, was smaller in patients with CAI (80 degrees (5.1 degrees )) than in controls (88.4 degrees (7.2 degrees ); p<0.001, power >95%). No significant difference was observed in the height of the talar body between patients with CAI (28.8 (2.6) mm) and controls (27.5 (4.0) mm; p = 0.055).

CONCLUSION

CAI is associated with an unstable osseous joint configuration characterised by a larger radius of the talus and a smaller tibiotalar sector. There is evidence that a higher talus might also play some part, particularly in women.

Recurrence and prevention of diabetic foot ulcers after total contact casting

BACKGROUND

Total contact casting (TCC) has become established as standard treatment for Wagner grades 1 and 2 diabetic foot ulcers. However, the recurrence rate after TCC is unacceptably high, and a clear concept to prevent recurrences is still lacking. The purpose of this study was to evaluate recurrences and the effectiveness of preventive measures in a group of diabetic patients treated with TCC.

METHODS

From January of 1999, to June of 2004, 28 patients (20 men and 8 women; average age 63 years) with 34 ulcers were treated using TCC. Thereafter, orthopaedic shoes were provided and patients were followed regularly. Recurrences were treated first by TCC, and operative correction was carried out in patients with an underlying foot deformity. Mean followup was 2.8 (1 to 5) years.

RESULTS

Primary TCC treatment lasted 4 (1 to 17) months. Complete healing was achieved in 85% of ulcers; 57% of patients had a total of 26 recurrences, and 18 new ulcers were found in a different area or on the other foot. Sixteen recurrences were treated successfully by TCC, but the rate of new recurrences during followup was 50%. Eight recurrences were treated by operative correction of foot deformities. Most patients stayed ulcer-free thereafter. An unloading shoe was applied twice. No amputations were required.

CONCLUSIONS

The first TCC showed an effective healing rate of 85%. The high recurrence rate of 57% in the presence of optimal instruction, shoes, and followup suggests that these measures are not sufficient. However, because patients who had operative corrections stayed ulcer-free thereafter, it is suggested that foot deformities should be operatively corrected immediately after primary healing rather than waiting until further recurrences occur.

The Swiss Orthopaedic Registry

Following the tradition of the IDES European Hip Registry inaugurated by M. E. Müller in the 1960s, the Institute for Evaluative Research in Orthopaedic Surgery at the University of Bern started a new era of data collection using internet technology (www.memdoc.org). With support of the Swiss Orthopaedic Society, the pilot of the Swiss Orthopaedic Registry was conducted, and in cooperation with different academic and non-academic centers the practicability of integrating the various data collection instruments into the daily clinical workflow was evaluated. Three different sizes of hip and knee questionnaires were compiled, covering the individual demands of the participating hospitals whereby the smaller questionnaires always represent a subset of the next larger one. Different types of data collection instruments are available: the online interface, optical mark reader paper questionnaires, and barcode sheets. Precise implant tracking is implemented by scanning the implant barcodes directly in the operating theaters and linking them to the clinical data set via a central server. In addition, radiographic information can be linked with the clinical data set. The pilot clinics suggested enhancements to the user interface and additional features for data management. Also, recommendations were made to simplify content in some instances and diversify in others. With a new software release and adapted questionnaires the Swiss Orthopaedic Registry was officially launched in Summer 2005.

Reduction in co-morbidities 4 years after laparoscopic adjustable gastric banding

BACKGROUND

We investigated the reduction in co-morbidities following laparoscopic adjustable silicone gastric banding (LAGB).

METHODS

Between December 1996 and October 2002, 295 patients with mean BMI 45 kg/m(2) were operated (79% women, average age 41 years). Mean follow-up was 44 months. Reduction in co-morbidity was scaled relative to the preoperative co-morbidity level as having been cured, improved, unchanged, or worsened. Patients needing reoperations were analyzed separately.

RESULTS

The preoperative frequencies of co-morbidities were as follows: hypertension 52%, diabetes 20%, dyspnea 85%, peripheral edema 63%, sleep apnea 36%, arthralgia 89%, reflux 57%, reduced self-esteem 95%, reduced general physical performance 96%, hyperlipidemia 39%, hyperuricemia 36%, and menstrual problems 22%. Excess weight loss after 1 year was 40%, after 2 years 46%, after 3 years 47%, and after 4 years 54%. After 4 years, the rate of cure/improvement of the co-morbiditites were: hypertension 58% / 42%, diabetes 75% / 8%, dyspnea 85% / 12%, arthralgia 52% / 24%, reflux 79% / 11%, self-esteem 45% / 39%, and general physical performance 58% / 33%. We also found an improvement in stress incontinence, sleep apnea, peripheral edema, and regulation of menstruation. Greater weight loss was associated with greater reduction in dyspnea, arthralgia, self-esteem, and physical performance. Hypertension, diabetes, reflux, and edema improved independent of the amount of weight loss. Reoperated patients undergoing either rebanding or biliopancreatic diversion with duodenal switch had similar weight loss and reduction in co-morbidities as did patients treated with LAGB only.

CONCLUSION

With moderate weight loss following LAGB, co-morbidities were cured in 50-80% or improved in 10-40% of all patients.

Radiologic and endoscopic evaluation for laparoscopic adjustable gastric banding: preoperative and follow-up

BACKGROUND

Laparoscopic adjustable silicone gastric banding (LASGB) has replaced vertical banded gastroplasty (VBG) as the most widespread restrictive bariatric operation in Europe. Although these two procedures are similar in principle, the experience concerning the preoperative examinations and follow-up cannot be arbitrarily transferred from VBG to LASGB. The reasons for and consequences drawn from radiologic and endoscopic examinations are described.

METHODS

From December 1996 to January 2000, 148 patients (84% women, average age 39 years, body weight 127 kg, BMI 45 kg/m2) underwent LASGB. The mean follow-up was 17 months. Upper GI series, abdominal ultrasound, and gastroscopy were done before operation. The postoperative stoma adjustments were performed under radiological observation. All adjustments were analyzed.

RESULTS

Preoperative: Of 147 upper GI series, 74 showed hiatal hernia, 2 motility disorders, and 1 an incomplete malrotation. In 104 gastroscopies, 35 reflux and 53 gastritis with 24 Helicobacter pylori infections were found. Postoperative: On average, 2.7 radiological adjustments were done per patient. Until satisfactory satiety and weight reduction, 78% of the patients needed 0-3 adjustments. Besides routine adjustments, an additional 57 upper GI series were done in 35 patients, 44 times with opening of the stoma-diameter. A total of 14 slippages and 4 pouch enlargements were found. A gastroscopy was required in 12 patients.

CONCLUSION

Radiologic and endoscopic examinations before LASGB revealed pathology needing therapy in 42% of the patients and provided important additional information influencing the operative procedure. At an average follow-up of 17 months, 24% of the 148 patients needed unplanned additional upper GI series.