[Etiology, pathogenesis, clinical features, diagnostics and conservative treatment of adult flatfoot]. / Ätiologie, Pathogenese, Klinik, Diagnostik und konservative Therapie des adulten erworbenen Plattfußes.

BACKGROUND: On average, one in six adults is affected by an acquired flatfoot. This foot deformity is characterized by its progression of stages and in 10% of cases causes complaints that require treatment. Untreated, the loss of walking ability may result in the final stage. Correct staging is crucial to being able to offer a specific course of therapy including a wide spectrum of conservative and operative treatments. MATERIAL AND METHODS: This review is based on pertinent publications retrieved from a selective search in PubMed and Medline and on the authors' clinical experience. DIAGNOSTICS: The loss of function of static (spring ligament complex) and dynamic (tibialis posterior tendon) stabilizers causes the characteristic deformity with loss of the medial arch, hind foot valgus and forefoot abduction. In the late stage, severe secondary osteoarthritis in upper and lower ankle joints occurs and impedes walking ability. The essential physical examination is supplemented by weight-bearing dorsoplantar and lateral radiographs, which provide further information about axial malalignment (Meary's angle, Kite's angle). The long axis hind foot view allows analysis of the hindfoot valgus. MRI provides further information about the integrity of the tibialis posterior tendon, spring ligament complex and cartilage damage. THERAPY: The therapy aims to reduce pain, regain function and avoid development of secondary osteoarthritis and degenerative tendon disorders. Progress of the deformity should be stopped. Therefore, the main aspects of the deformity-loss of medial arch, hindfoot valgus and forefoot abduction should be addressed and corrected. In the acute phase, tendovaginitis of the tibialis posterior tendon can be treated sufficiently by anti-inflammatory measures, relieving mechanical loads on the tendon and muscle and physiotherapy.

[Rupture of the tendon of the tibialis anterior muscle : Etiology, clinical symptoms and treatment]. / Ruptur der Musculus-tibialis-anterior-Sehne : Ätiologie, klinische Symptome und Therapie.

Ruptures of the tendon of the tibialis anterior muscle tend to occur in the context of degenerative impairments. This mainly affects the distal avascular portion of the tendon. Owing to the good compensation through the extensor hallucis longus and extensor digitorum muscles, diagnosis is often delayed. In addition to the clinical examination, magnetic resonance inaging (MRI) diagnostics are of particular importance, although damage or rupture of the tendon can also be demonstrated sonographically. Therapeutic measures include conservative or operative measures, depending on the clinical symptoms. Conservative stabilization of the ankle can be achieved by avoiding plantar flexion using a peroneal orthosis or an ankle-foot orthosis. Subsequent problems, such as metatarsalgia or overloading of the medial foot edge can be addressed by insoles or a corresponding shoe adjustment. An operative procedure is indicated when there is corresponding suffering due to pressure and functional impairment. The direct end-to-end reconstruction of the tendon is only rarely possible in cases of delayed diagnosis due to the degenerative situation and the retraction of the tendon stumps. Depending on the defect size and the tendon quality, various operative techniques, such as rotationplasty, free transplants or tendon transfer can be used.

[Correction of flexible lesser toe deformity : Transfer of the flexor digitorum longus tendon]. / Behandlung flexibler Kleinzehenfehlstellungen : Transfer der Flexor-digitorum-longus-Sehne.

OBJECTIVE: Realignment and pain relief of toes 2-5 by flexor-to-extensor tendon transfer of the flexor digitorum longus (FDL) muscle. INDICATIONS: As an isolated procedure in flexible proximal interphalangeal (PIP) joint flexion and/or flexible metatarsophalangeal (MTP) joint extension (hammer toe). In combination with a metatarsal osteotomy or PIP joint arthrodesis in case of flexible MTP joint extension. CONTRAINDICATIONS: General medical contraindications to surgical interventions. Stiffness of the PIP or MTP joint. SURGICAL TECHNIQUE: Plantar stab incision in the distal interphalangeal (DIP) flexion crease and tenotomy of the FDL tendon. More proximally transverse incision on the plantar aspect of the proximal phalanx and isolation of the FDL tendon. The tendon is split longitudinally along the raphe and the two limbs are transferred from plantar to the dorsal aspect of the proximal phalanx adjacent to the bone. The crossed limbs are sutured to each other under appropriate tension and corrected position of the toe. POSTOPERATIVE MANAGEMENT: Postoperative dressings for 3 weeks in corrected position. Subsequently tape dressing in plantar position for 6-12 weeks. Full weight bearing. RESULTS: A total of 24 toes with flexible PIP and/or MTP joint deformity were treated with a FDL tendon transfer. In 14 toes an isolated procedure was performed, in 10 cases an additional metatarsal osteotomy. Patients with operative treatment of the first ray, revision or reoperation were excluded. Mean follow-up was 8.4 (4-14) months. After 6 weeks 22 toes (92%) showed physiological alignment of the PIP and MTP joint. At the last follow-up, 4 (16%) toes had recurrent or persistent extension deformity of the MTP joint. There were no infections, overcorrections, impaired wound healing or transversal malalignment.

[Soft tissue techniques in hallux valgus surgery]. / Weichteiltechniken in der Hallux-valgus-Chirurgie.

The hallux valgus represents combined bony and soft tissue pathology. In addition to known bony surgical procedures, addressing the soft tissue with regard to the anatomical structures, the surgical technique and the extent of correction are discussed.The goal of the operation is the restoration of the physiological balance between the active and passive stabilizing factors of the MTP-I-joint. The joint capsule, the ligaments and the tendons of the first ray act directly as stabilizing structures, whereas the hind foot and the position of the upper ankle have an indirect influence on the MTP-I-joint.The present work gives an overview of the pathoanatomy of the MTP-I-joint in the hallux valgus pathology. The individual anatomical structures are presented with regard to their physiological and pathological influence and the possible therapeutic options.

[Distal soft-tissue procedure in hallux valgus deformity]. / Distaler Weichteileingriff am Großzehengrundgelenk bei Hallux-valgus-Deformität.

OBJECTIVE: Distal, lateral soft tissue release to restore mediolateral balance of the first metatarsophalangeal (MTP) joint in hallux valgus deformity. Incision of the adductor hallucis tendon from the fibular sesamoid, the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament. INDICATIONS: Hallux valgus deformities or recurrent hallux valgus deformities with an incongruent MTP joint. CONTRAINDICATIONS: General medical contraindications to surgical interventions. Painful stiffness of the MTP joint, osteonecrosis, congruent joint. Relative contraindications: connective tissue diseases (Marfan syndrome, Ehler-Danlos syndrome). SURGICAL TECHNIQUE: Longitudinal, dorsal incision in the first intermetatarsal web space between the first and second MTP joint. Blunt dissection and identification of the adductor hallucis tendon. Release of the adductor tendon from the fibular sesamoid. Incision of the lateral capsule, the lateral collateral ligament, and the lateral metatarsosesamoid ligament. POSTOPERATIVE MANAGEMENT: Postoperative management depends on bony correction. In joint-preserving procedures, dressing for 3 weeks in corrected position. Subsequently hallux valgus orthosis at night and a toe spreader for a further 3 months. Passive mobilization of the first MTP joint. Postoperative weight-bearing according to the osteotomy. RESULTS: A total of 31 patients with isolated hallux valgus deformity underwent surgery with a Chevron and Akin osteotomy and a distal medial and lateral soft tissue balancing. The mean preoperative intermetatarsal (IMA) angle was 12.3° (range 11-15°); the hallux valgus (HV) angle was 28.2° (25-36°). The mean follow-up was 16.4 months (range 12-22 months). The mean postoperative IMA correction ranged between 2 and 7° (mean 5.2°); the mean HV correction was 15.5° (range 9-21°). In all, 29 patients (93%) were satisfied or very satisfied with the postoperative outcome, while 2 patients (7%) were not satisfied due to one delayed wound healing and one recurrent hallux valgus deformity. There were no infections, clinical and radiological signs of avascular necrosis of the metatarsal head, overcorrection with hallux varus deformity, or significant stiffness of the first MTP joint.

[Current treatment strategies for spondylodiscitis in surgical clinics in Germany]. / Aktuelle Behandlungsstrategien der Spondylodiszitis in deutschen Akutkliniken.

BACKGROUND: Spondylodiscitis is a rare disease which is associated with high mortality. No guidelines for treatment exist and the available studies are not homogeneous. Attempts have been made in recent years to structure therapy using algorithms. Early recognition of the disease is above all important for its later outcome. Therapy takes place in not only orthopaedic/trauma surgery clinics but also in neurosurgical clinics. MATERIAL AND METHOD: We sent an online survey on this subject to orthopaedic clinics, trauma surgery and neurosurgery clinics in Germany. The aim was to ascertain current care strategies in Germany. A further objective was to elicit differences between the specialist fields. RESULTS: A total of 164 clinics responded to the survey. The response rate was 16% of the orthopaedic/trauma surgery clinics and 32% of the neurosurgical clinics. Differences between the two specialist fields can be found particularly in the use of systemic and local antibiotics, in the choice of surgical access to the thoracic spine and the lumbar spine and in post-operative imaging. In both specialist fields, patients with neurological dysfunctions are treated primarily in clinics with high case numbers. In terms of surgery, 2/3 of the responding clinics choose a one-stage operative treatment. Minimally invasive procedures and the use of cages are widespread. The participants estimate that, on the whole, a better outcome and higher patient satisfaction tend to exist after operative treatment. CONCLUSIONS: The lack of homogeneity regarding treatment strategies which is indicated here clearly shows the need for therapy guidelines as an aid to orientation. This will be a challenge for the future due to the low incidence and the situation regarding currently available studies.

[The talus stop screw arthroereisis for flexible juvenile pes planovalgus]. / Die Talus-Stopp-Schraubenarthrorise beim flexiblen kindlichen Pes planovalgus.

OBJECTIVE: Pain relief by realignment of the hindfoot and blocking excessive pronation through insertion of a screw into the lateral aspect of the calcaneus in juvenile pes planovalgus. INDICATIONS: Symptomatic juvenile flatfoot (9-13 years). CONTRAINDICATIONS: Congenital, fixed and secondary (neuromuscular disorder) flatfoot deformities. SURGICAL TECHNIQUE: Incision at the lateral aspect of the sinus tarsi. Guide wire insertion into the lowest point of the lateral anterior calcaneus (fluoroscopy). Drilling (3.2 mm) and insertion of a 6.5-7.0 mm cancellous screw. The screw head impinges against the lateral aspect of the talus and prevents excessive eversion. POSTOPERATIVE MANAGEMENT: Compression dressing. Full weight bearing allowed. No sports activity for 4 weeks. RESULTS: Between 2002 and 2011, the technique was used in 35 children (68 feet; mean age 10 years). Complications were peroneal spasms, overcorrections, wound healing problems and local tenderness. Tarsometatarsal and calcaneal pitch angle improved significantly. The procedure is a reliable method for the correction of flexible juvenile flatfeet allowing "growth adjustment" of the subtalar joint.

[Fractures of the proximal humerus in the elderly : Osteosynthesis versus joint replacement]. / Frakturen des proximalen Humerus im hohen Lebensalter : Osteosynthese versus Gelenkersatz.

BACKGROUND: Expected changes in population demographics will have significant implications for society and health care provision for the treatment of proximal humeral fractures in the elderly. OBJECTIVES: This article presents the incidence and clinical characteristics of geriatric fractures of the proximal humerus, a description of therapeutic options and treatment recommendations. METHODS: The published scientific data were reviewed and current opinion available to guide patient care are presented. RESULTS: The majority of fractures of the proximal humerus that require operative treatment are amenable to reconstruction. Primary arthroplasty is usually reserved for comminuted fractures with delayed presentation, head-splitting fractures or those in which the humeral head is devoid of soft tissue attachments. Secondary replacement may be required in cases of fixation failure and symptomatic avascular necrosis. CONCLUSION: Decision-making is dependent on the fracture pattern as well as on patient and surgeon-related factors.

[Diagnostic and therapeutic management of primary and recurrent patellar dislocations - analysis of a nationwide survey and the current literature]. / Aktuelle diagnostische und therapeutische Vorgehensweise bei der primären und rezidivierenden Patellaluxation - Analyse einer bundesweiten Umfrage und der aktuellen Literatur.

AIM: Patellar dislocations are a common injury of the knee joint. During patella dislocations injuries of soft-tissue structures can occur that can destabilise the patella and lead to recurrent dislocations. There are also congenital pathologies that predispose to patella dislocations. In the current literature, diagnostics and treatment of patellar dislocations are frequently discussed. Therefore the aim of our survey was to analyse and summarise actual diagnostic and therapeutic strategies regarding primary and recurrent patella dislocations. METHODS: An online questionnaire form was sent to 735 orthopaedic and/or trauma departments in Germany. The departments were invited to participate in an anonymous survey concerning diagnostics and treatment of primary and recurrent patellar dislocations. The questionnaire consisted of multiple choice questions and was divided into three sections. The first section included questions concerning the department structure. The second part contained questions regarding diagnostics and treatment of primary patella dislocations. The third part involved diagnostic and treatment strategies for recurrent patella dislocations. A systematic review of outcome after treatment of patellar dislocation was performed and discussed with the results of the survey. RESULTS: 245 hospitals (33.3 %) returned the questionnaire. Among the participants were 23 % orthopaedic surgery departments, 32 % trauma surgery departments and 45 % combined departments. 12 % were university hospitals and 53 % academic teaching hospitals. Clinical examination was performed by nearly all participants after primary and recurrent patella dislocations. MRI was used as diagnostic tool in 81 % after primary patella dislocation and in 85 % after recurrent patella dislocation. Conventional X-rays were performed in 58 % (primary) and 51 % (recurrent patella dislocations). Computed tomography scans for measurement of the tuberositas tibiae-trochlea groove distance were used in 35 % after recurrent dislocations and in 20 % after primary patella dislocations. 69 % of the participating departments performed non-operative therapies after primary patella dislocations, especially when no associated injuries and no congenital pathologies were observed. Reconstruction of the medial retinaculum was the most frequent surgical therapy (52 %) followed by the reconstruction of the medial patellofemoral ligament (36 %) after primary patella dislocation. Following recurrent patella dislocations reconstruction of the medial patellofemoral ligament (58.5 %) was the most performed surgery and a tuberositas transfer was done in 58 % of participating departments after recurrent patella dislocation. CONCLUSION: The results of our survey showed diagnostic and therapeutic procedures in the participating departments which are in accordance with recommendations in recent publications. The clinical importance of the MPFL reconstruction was observed for primary and recurrent patella dislocation. In addition, conservative treatment is still the most common treatment after primary dislocation of the patella.

[Vertical talus: current diagnostic and therapy options]. / Talus verticalis: Aktuelle Diagnose- und Therapieoptionen.

Congenital vertical talus is a rare condition which presents as an isolated deformity or in association with neuromuscular and/or genetic disorders. Pathoanatomically the deformity shows a dislocated talonavicular and subtalar joint. The etiology and pathogenesis are still not finally determined although in some cases a genetic basis has been identified. The clinical picture is that of a flat, convex longitudinal arch with abduction and dorsiflexion of the forefoot and an elevated heel. Clinical diagnosis is confirmed by plain radiographic imaging. Congenital vertical talus should not be confused with other deformities of the foot, such as congenital oblique talus, flexible flat feet or pes calcaneus. The object of treatment of congenital vertical talus is to restore a normal anatomical relationship between the talus, navicular and calcaneus to obtain a pain-free foot. Major reconstructive surgery has been reported to be effective but is associated with substantial complications. Good early results of a modified non-operative treatment using serial manipulation, cast treatment and minimally invasive surgery may change therapeutic concepts.

[Competency-based medical education: National Catalogue of Learning Objectives in surgery]. / Kompetenzorientierung in der medizinischen Ausbildung: Nationaler Lernzielkatalog Chirurgie.

Competency-based medical education is a prerequisite to prepare students for the medical profession. A mandatory professional qualification framework is a milestone towards this aim. The National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) of the German Medical Faculty Association (MFT) and the German Medical Association will constitute a basis for a core curriculum of undergraduate medical training. The Surgical Working Group on Medical Education (CAL) of the German Association of Surgeons (DGCH) aims at formulating a competency-based catalogue of learning objectives for surgical undergraduate training to bridge the gap between the NKLM and the learning objectives of individual medical faculties. This is intended to enhance the prominence and visibility of the surgical discipline in the context of medical education. On the basis of different faculty catalogues of learning objectives, the catalogue of learning objectives of the German Association of Orthopedics and Orthopedic Surgery and the Swiss Catalogue of Learning Objectives representatives of all German Surgical Associations cooperated towards a structured selection process of learning objectives and the definition of levels and areas of competencies. After completion the catalogue of learning objectives will be available online on the webpage of the DGCH.

Treatment strategies for severe C1C2 luxation due to congenital os odontoideum causing tetraplegia.

PURPOSE: High-grade C1C2 luxation is a rare pathology. There is no clear evidence as to how to treat this deformity. There is only limited evidence about the different surgical techniques and possible approaches including advantages, disadvantages, and complications. METHODS: This is an uncommon case of a 13-year-old child with progressive, tetraplegia due to congenital os odontoideum with translational instability between C1 and C2, and progressive luxation of C2. An irreducible dislocation of the C0/C1 complex caused significant compression at the cervicomedullary junction and neurologic deficit. In this paper we highlight the different types of os odontoideum, a review of existing evidence of surgical correction. We will discuss the different treatment strategies which could be applied and the current solution will be described. RESULTS: Continuous skeletal traction and translational reduction was achieved by a specially designed halo traction system including continuous skeletal traction in a wheelchair for 6 weeks. The surgical treatment consisted of a posterior only release, translational reduction and posterior instrumentation from C0 to C4 with a Y plate and homologous bone graft. Neurological deficits started to improve during halo traction. After surgery the patient was ambulatory without any assistance and reached a Frankel stage E. Postoperative X-rays and CT scan revealed complete reduction at the C1/C2 level and a decompressed cervicomedullary junction. CONCLUSION: Treatment of severe C1C2 luxation is difficult with limited evidence in the literature. The current case shows a successful treatment strategy to reduce the deformity and lists alternative approaches.

[Options and limits of subtalar arthroereisis in childhood]. / Möglichkeiten und Grenzen der subtalaren Arthrorise im Kindesalter.

The minimally invasive subtalar screw arthroereisis procedure is becoming an increasingly more established option for treating juvenile flexible flatfoot. The procedure is indicated in children who are 9-13 years old and have idiopathic juvenile flexible flatfoot that has progressed to a symptomatic pathology. Minimally invasive subtalar screw arthroereisis functions by a combination of mechanical and proprioceptive effects that allow for growth adjustment of the subtalar joint and with a low complication rate. This surgical intervention is contraindicated for treating fixed and secondary pes plano valgus. The subtalar screw is removed once the pediatric foot has stopped growing and results in permanent correction of the flexible flatfoot.

[Treatment options for brachymetatarsia]. / Therapieoptionen bei Brachymetatarsie.

Brachymetatarsia can be congenital, idiopathic or secondary and describes an abnormal shortening of a metatarsal bone. The indications for treatment are not only due to cosmesis. The shortening of a ray changes the biomechanics of the foot and can lead to metatarsalgia. A frequent clinical feature is dorsal dislocation of a toe causing painful shoe conflict and disturbed proprioception. There are three main options for operative correction: lengthening osteotomy, interposition of a tricortical bone and gradual lengthening by callus distraction. While one stage lengthening procedures such as osteotomy and interposition are more appropriate for correction of moderate length deficiencies, the callus distraction method is more suitable for larger elongation. Common to all procedures is a long-term treatment with a high risk of different complications whereby patient compliance can be problematical.

[Osteochondrosis of the pediatric foot]. / Osteochondrosen des kindlichen Fußes.

Osteochondrosis is a heterogeneous group of self-limiting conditions characterized by disturbance of enchondral ossification caused by a lack of circulation. Foot pain is a relatively common problem in children and adolescents and may be due to osteochondrosis. Osteochondrosis of the growing foot shows painful radiological alterations including increased density, fragmentation and irregularity of the epiphyses, physes and apophyses. Lacking etiologic and pathophysiologic information, ostoechondroses have been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating pediatric foot pain. The most common localizations of osteochondroses of the growing foot include the navicular as Kohler's syndrome, the metatarsal as Freiberg's infraction and calcaneal apophysitis as Sever's disease. Prognosis and final outcome vary considerably between the different localizations. Physicians should therefore be informed about the etiology, clinical presentation and treatment options for osteochondroses of the growing foot.

[Patient safety in orthopaedics: implementation and first experience with CIRS and team time-out]. / Patientensicherheit in der Orthopädie: Implementierung und erste Erfahrungenmit CIRS und Team Time-out.

AIM: The critical incident reporting system (CIRS)and a surgical safety checklist (SSC) are considered to be the most powerful and important means for patient safety and for avoiding surgical errors. Nevertheless, these tools are not yet standard in orthopaedic surgery. We have implemented CIRS and a surgical checklist adapted to the specific conditions in orthopaedic surgery. METHOD: In this article, we provide a guideline to put CIRS and SSC into practice and report on preliminary results one year after implementation in our department. RESULTS: A comprehensive statistical analysis of the reduction in surgical errors cannot yet be given. As a first effect after one year, an improvement in interdisciplinary team building, an increased sense of responsibility of each employee and a positive change in failure culture can be observed. CONCLUSIONS: SSC and reporting near mistakes enables a comprehensive failure analysis helping to avoid future complications and improve medical quality.

Infectious diseases and field water supply and sanitation among migrant farm workers.

An audit for fecal-related symptoms was performed on clinic patient charts of 936 migrant farm workers without access to water and sanitation facilities in the work fields and on an urban poor population of 8,968 patients. Migrants displayed a clinic utilization rate for diarrhea 20 times higher than that of the urban poor; similar findings for other enteric disease symptoms were documented. The data suggest that a water and sanitation standard mandating facilities in the work field for farm workers would reduce the incidence of fecal-related disease.