[Fractures of the lateral process of the talus-snowboarder's ankle]. / Frakturen des Processus lateralis tali ­ "snowboarder's ankle".

Fractures of the lateral tubercle of the talus (PLT) are rare. With the increasing popularity of the trend sport snowboarding, the incidence of PLT fractures has increased. The most common classification of PLT fractures is the Hawkins classification. The aim of this review was to raise awareness for the injury and discuss the current evidence. A literature search revealed eight studies, each including at least seven patients. Six out of the eight studies were descriptive, retrospective case series without predefined treatment concepts. These resulted in only moderate treatment outcomes. Due to the low number of patients, the lack of computed tomography (CT) or magnetic resonance imaging (MRI) and inconsistent treatment approaches, these studies do not allow to draw conclusions on a treatment concept for PLT fractures. The other two studies validated existing treatment regimens. Overall, surgical treatment of dislocated fractures and conservative treatment of non-dislocated fractures was carried out with satisfactory results. The outcome of conservative treatment of dislocated factures remains unclear. A reason for the inconsistent treatment results could be the observed concomitant injuries, including dislocation of the tendons of the peroneus muscles (46%), calcaneal chondral injuries (48%) and subluxation of the subtalar joint (7%). Based on the limited evidence available, the authors recommend the application of CT and MRI for PLT fractures to assess concomitant injuries, which are the primary indication for surgery. Dislocated type I and II fractures (>2 mm) should be treated operatively, type III and non-dislocated type I and II fractures can be treated conservatively by immobilization and partial weight-bearing for 6 weeks.

[Minimally invasive cheilectomy]. / Minimalinvasive Cheilektomie.

OBJECTIVES: Treatment of hallux rigidus by minimally invasive resection of the dorsal osteophytes, synovectomy and resection of the dorsal part of the metatarsal head. INDICATIONS: Hallux rigidus grades II and III CONTRAINDICATIONS: End-stage osteoarthritis of the first metatarsophalangeal joint with beginning ankylosis. SURGICAL TECHNIQUE: Osteophytes around the metatarsophalangeal joint are removed using a 1 cm incision dorsomedial, approximately 3 cm proximal of the joint space. The dorsal third of the metatarsal head is resected with a burr to improve dorsiflexion. The extent of bone resection is checked with an image intensifier. Loose bone fragments removed with a rangeur. An arthroscopy can be performed to check the completeness of bone resection, the irrigation of the joint and, if needed, to extend the synovectomy. POSTOPERATIVE MANAGEMENT: Removal of the sutures after 2 weeks. Depending on pain, the patient can change from the postoperative shoe to a normal soft, comfortable and wide shoe after 1-2 weeks. Nonsteroidal drugs can be prescribed as needed. Active and passive mobilization of the metatarsophalangeal joint is also recommended. RESULTS: The technique allows a soft-tissue-preserving resection of the osteophytes and a partial resection of the metatarsal head. The main advantages are limited soft-tissue trauma and rapid rehabilitation. In all, 21 women and 17 men with hallux rigidus stages II and III (Vanore) underwent surgery. Minimum follow-up was 12 months. In 1 patient, injury of the extensor hallucis longus tendon was observed. Two patients underwent revision surgery. One patient was converted to a metatarsophalangeal fusion, while another patient received a resection arthroplasty. At the latest follow-up, the AOFAS (American Orthopaedic Foot & Ankle Society) score averaged 88.7 points.

[Percutaneous calcaneal sliding osteotomy]. / Die perkutane Kalkaneusverschiebeosteotomie.

OBJECTIVES: Correction of calcaneal malalignment as part of a hindfoot correction procedure. INDICATIONS: Varus and valgus malalignment of the calcaneus, increased calcaneal pitch. CONTRAINDICATIONS: Osteoarthritis of the subtalar joint. Fixed and symptomatic deformities of the subtalar joint. SURGICAL TECHNIQUE: After having identified and marked the desired planes of the osteotomy under image intensifier, a percutaneous v­shaped calcaneal osteotomy is performed. The osteotomy allows 3­dimensional correction of the calcaneus by defining the planes of the osteotomy. The procedure allows correction of varus and valgus deformities, as well as a change of the calcaneal pitch. The osteotomy is fixed by percutaneous screws. POSTOPERATIVE MANAGEMENT: Postoperative care includes a 6-week period of partial weight bearing with 10 kg. The ankle joint should be mobilized. After x­ray control of sufficient bone healing, weight bearing can be increased stepwise over another 4­week period up to full body weight. A full length orthotic is recommended for at least 12 months with heel cup and good medial support. RESULTS: The procedure allows correction of calcaneal deformities with preservation of soft tissue, normally as part of a hindfoot correction, e. g., in posterior tibial tendon insufficiency, varus deformities or total ankle replacement. In the literature and in our patients, the rate of injuries of the neurovascular bundle was not increased compared to open surgery. The average calcaneal shift was 1 cm, when necessary an additional correction was realized by rotation of the tuber calcanei.

[Tendoscopy of the Achilles tendon. Indications, technique and results]. / Tendoskopie der Achillessehne. Indikation, Technik und Ergebnisse.

BACKGROUND: Endoscopic surgical techniques are nowadays standard procedures in medicine. The advantages of these minimally invasive techniques compared to open techniques are a smaller access route with reduced tissue damage, reduced scarring and often faster postoperative mobilization. Tendoscopy can be used to treat pathologies of tendons as well as of the surrounding tissues. OBJECTIVES: This article presents the advantages of endoscopic treatment of the Achilles tendon compared to open procedures as well as the chances and limitations of tendoscopy. MATERIAL AND METHODS: Surgical instructions for endoscopy of the Achilles tendon are presented and a review of the literature is given. RESULTS: The literature review showed excellent results for pathologies of the paratenon and Achilles tendinitis. Compared to open surgery there was a significantly lower rate of wound healing problems. All articles reported a high reduction of pain level with an early return to sports activities. Limitations of the procedure are extensive intratendinous pathologies and alterations of tendon insertion sites. CONCLUSION: Tendoscopy of the Achilles tendon is a safe but sometimes challenging minimally invasive technique for the treatment of paratendinopathy.

Therapeutic effect of methotrexate encapsulated in cationic liposomes (EndoMTX) in comparison to free methotrexate in an antigen-induced arthritis study in vivo.

OBJECTIVES: Cationic lipid complexes bind to angiogenic endothelial cells of solid tumours and microvessels of chronic inflammatory tissue. Methotrexate (MTX) is one of the drugs used in the therapy of rheumatoid arthritis (RA); it is applied systemically but can have serious side-effects. The aim of this study was to investigate the impact of MTX encapsulated in cationic liposomes (EndoMTX) in comparison to treatment with free MTX. METHOD: We used an antigen-induced arthritis (AiA) model and investigated the leucocyte- and platelet-endothelial cell interaction in arthritic female C57/Bl6 mice and in healthy controls. The arthritic animals were divided into four different groups receiving either trehalose, free MTX, EndoMTX placebo, or EndoMTX. These parameters and functional capillary density (FCD) were measured and assessed by intravital microscopy (IVM). We controlled clinical parameters such as the knee joint diameter (KJD) throughout the observation period. RESULTS: Animals treated with EndoMTX showed a significant and superior reduction in leucocyte- and platelet-endothelial cell interaction, FCD, and KJD. Free MTX or empty liposomes also showed a reduction in these parameters but not to a significant level. FCD decreased in the EndoMTX group in comparison to using free drugs or empty carrier-like liposomes. CONCLUSIONS: This study demonstrates the advantage of using MTX encapsulated in cationic liposomes in contrast to free and generic MTX, with a higher efficacy in anti-inflammatory and anti-angiogenic abilities. Targeting with cationic liposomes may be a promising treatment option and should be elucidated in further experiments regarding dose reduction and side-effects due to MTX usage.

[Management of midfoot instability in Charcot foot with the ring fixator : Use of a hybrid technique with internal and external stabilization]. / Behandlung von Fußwurzelinstabilitäten bei Charcot-Fuß mit dem Ringfixateur : Anwendung der Hybridtechnik mit interner und externer Stabilisierung.

OBJECTIVE: Combination of external and internal fixation for improvement of stabilization in midfoot arthrodesis. INDICATIONS: Charcot foot of the midfoot with/without (infection-free) ulceration. CONTRAINDICATIONS: Severe anesthesiological risks in multimorbid patients; untreated symptomatic peripheral arterial occlusive disease; severe soft tissue infection and defect with the necessity of amputation. SURGICAL TECHNIQUE: Performing subtractive resection arthrodesis of the midfoot with locking plates and screws combined with an external ring fixator of the foot and lower leg. POSTOPERATIVE MANAGEMENT: Postoperative partial weight bearing with sole contact and walking frame for 3 months. Then removal of external fixator, CT scan and based on the result, staged increasing of stress load with short-leg cast over a period of 4-6 weeks. Podomechanotherapy with full weight bearing. RESULTS: With this surgical procedure, sufficient stabilization with fully load bearing, plantigrade foot with podomechanotherapy with the help of a combined internal and external fixation is possible. Complications (pin-tract infection or dislocation) exist, but they can be controlled. High healing rate of ulceration was achieved by bony position correction and stabilization.

Reconstruction of focal cartilage defects in the talus with miniarthrotomy and collagen matrix.

SURGICAL PRINCIPAL AND OBJECTIVE: Treatment of focal cartilage defects (traumatic or osteochondrosis dissecans) of the talus using a collagen matrix. The goal is to stabilize the superclot formed after microfracturing to accommodate cartilage repair. The procedure can be carried out via miniarthrotomy, without medial malleolus osteotomy. INDICATIONS: International Cartilage Repair Society (ICRS) grade III and IV focal cartilage defects of the talus > 1.5 cm(2). CONTRAINDICATIONS: Generalized osteoarthritis, inflammatory joint disease, gout, neuroarthropathy. SURGICAL TECHNIQUE: Miniarthrotomy to open the ankle joint. Debridement of unstable cartilage and necrotic bone, curettage of cysts. Filling of the bone defects with autologous cancellous bone. Sealing of reconstructed bone with fibrin glue and attachment of a collagen matrix shaped to precisely fit the defect. POSTOPERATIVE REGIMEN: Immobilization for 48 h. Partial weight bearing of 10 kg for 6 weeks, with continuous passive motion. Increasing weight bearing from 7 weeks onwards. RESULTS: Follow-up of at least 30 months in 14 patients showed improvement in the Score of the American Orthopedic Foot and Ankle Society (AOFAS) from 50 to 89 points, with equal mobility on both sides of the upper ankle joint.

[Lateral ligament injuries of the ankle joint]. / Die Verletzung des lateralen Kapsel-Band-Apparats des Sprunggelenks.

Lateral ligament injuries are the most common sports injury and have a high incidence even in non-sportive activities. Although lateral ligament injuries are very common there is still a controversial debate on the best management. The diagnosis is based on clinical examination and X-ray images help to rule out fractures. Further imaging, especially magnetic resonance imaging (MRI) is used to diagnose associated injuries. According to the recommendations of the various scientific societies the primary therapy of lateral ligament injuries is conservative. Chronic ankle instability develops in 10-20 % of patients and the instability can be a result of sensomotoric deficits or insufficient healing of the lateral ligament complex. If the patient does not respond to an intensive rehabilitation program an operative reconstruction of the lateral ligaments has to be considered. Most of the procedures currently performed are anatomical reconstructions due to better long-term results compared to tenodesis procedures.

[Problems in complex hindfoot corrections]. / Probleme bei Komplexen Rückfusskorrekturen.

This article discusses the intraoperative and postoperative problems seen in the treatment of posterior tibial tendon dysfunction. Problems associated with tendon transposition procedures, osteotomy and arthrodesis are discussed. The preoperative, intraoperative and postoperative problems and complications and how to avoid or treat them will be addressed. The individual procedures are often part of other complex hindfoot reconstructions. For this reason the general and special aspects of treating posterior tibial dysfunction can often be transferred to avoiding and resolving problems in hindfoot surgery.