Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference?

BACKGROUND: Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically. OBJECTIVE: The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction. METHODS: A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted. RESULTS: A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary. CONCLUSION: The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.

Fractures to the anterior process of the calcaneus - Clinical results following functional treatment.

BACKGROUND: Fractures to the anterior process of the calcaneus (APC) have long been considered rare injuries. Although recent studies have reported a higher incidence, these injuries have yet received little attention in clinical research. Only few case reports/series, all suffering multiple methodical shortcomings, exist. The aim of this study was to objectively evaluate the outcome after fractures to the APC treated by full weight bearing and to investigate the influence of fracture characteristics. METHODS: Retrospective register study with prospective follow-up. Adults with acute unilateral fractures to the APC and concomitant injuries limited to the Chopart joint line, treated by full weight-bearing, with a follow-up of ≥ 12 months were included. Fracture characteristics (Degan classification, displacement, intra-articular involvement, comminution) were assessed in CT scans. Return to work (RTW) / sports (RTS), Visual Analogue Scale Foot and Ankle (VAS-FA), Karlsson Score and the 12-Item Short-Form Health Survey (SF-12) were assessed. The influence of age, sex, fracture type/characteristics, and concomitant injuries on the outcome parameters was analyzed. RESULTS: 27 patients (38 years, IQR 29-58), 74% female with a median follow up of 24 months (IQR 16-41) were included. 56% of the fractures were non-displaced and 82% comminuted. 48% were type I, 33% type II and 19% type III according to Degan. 78% of the patients suffered concomitant injuries of the Chopart joint line. Median RTW was 14 days (IQR 10-42), and RTS 90 days (IQR 30-180). The clinical outcome resulted in a median overall VAS-FA of 95 (IQR 89-98), Karlsson Score of 90 (IQR 82-100) and SF-12 PCS of 56 (IQR 53-58) / SF-12 MCS 55 (48-58). CONCLUSION: Functional treatment of fractures to the anterior process of the calcaneus yielded good to excellent results and a fast return to work in the vast majority of patients. Yet, a prolonged return to sports was noted. No significant differences regarding the outcome were observed when comparing the different fracture types or any other fracture characteristic assessed.

[Arthroscopic repair of chronic lateral ankle instability]. / Arthroskopische Außenbandstabilisierung bei chronischer Instabilität des Sprunggelenks.

OBJECTIVE: Repair of the lateral ligament complex of the ankle joint; identification and treatment of intra-articular pathologies. INDICATIONS: Symptomatic chronic lateral ankle instability. Treatment of osteochondral lesions associated with lateral ankle instability. CONTRAINDICATIONS: Osteoarthritis of the ankle joint, risk factors such as peripheral occlusive disease, diabetic foot syndrome, complex regional pain syndrome. SURGICAL TECHNIQUE: Diagnostic arthroscopy of the ankle joint utilizing anterolateral and -medial portals; identification and treatment of intra-articular pathologies; identification and preparation of the distal fibula; insertion of two suture anchors; the sutures are passed inside-out through the joint capsule, the scarred lateral ligaments, the extensor retinaculum using a suture lasso; by tying down the sutures the tissue grasped is then pulled against the distal fibula; this will stabilize the lateral ligament complex. POSTOPERATIVE MANAGEMENT: Partial weight-bearing and short leg cast for 2 weeks, then 4 weeks ankle brace and range of motion exercises, thereafter functional physical therapy, ankle brace only during exercises; no sports for at least 3 months. RESULTS: Currently, one randomized controlled trial is available comparing open to arthroscopic lateral ankle ligament repair. Open repair was always combined with arthroscopy to treat intra-articular pathologies. In all patients, surgery led to a significant increase of the American Orthopaedic Foot and Ankle Score (AOFAS), Karlsson Score and visual analog score (VAS), but no significant differences between the open and arthroscopic procedure after one year with similar complications (arthroscopy group: 3 temporary nerve irritations and 2 patients with pain over the knot; open treated group: 2 temporary nerve irritations and one abscess). Intra-articular pathologies were treated in 68% of the arthroscopically treated patients and 70% of the patients treated by open surgery. One out of two retrospective comparative studies reported a significantly shorter operation time and time to return to daily activity and significantly lower VAS three days postoperatively for arthroscopically treated patients, while the other parameters assessed were comparable.

Minimally invasive versus open calcaneal osteotomies - Comparing the intraoperative parameters.

BACKGROUND: The calcaneal osteotomies is often performed to correct asymptomatic hindfoot deformities. More recently minimally invasive techniques have been described with promising clinical outcomes. In a prospective study we compared the intraoperative parameters of the open and minimalinvasive (MICO) techniques, which has not previously been reported. METHODS: 60 consecutive with calcaneal osteotomy (33 open and 27 MICO) and a minimum follow up of 12 weeks were included. We recorded the following intraoperative parameters: operation time for the osteotomy [min], the fluoroscopy time, the fluoroscopy dose and the skin incision. The clinical (FAOS) and radiological outcome were examined 6 and 12 weeks postoperatively. The Wilcoxon test and the continuity correction were used with alpha=5% value for the statistical significance. RESULTS: The minimally invasive group showed a significantly shorter operation time. There was no significant difference between the radiation time and dose in the two groups. The length of the incision in the minimally invasive group was significantly shorter. We found no difference in clinical outcome and radiological follow up. CONCLUSIONS: This study reports a significantly shorter operating time and a shorter incision in the MICO group. The radiation exposition was not significantly different between the two groups. A clinical difference could not be shown in our study. However, we see the shorter operating time of the minimally invasive calcaneal osteotomy being beneficial.

[Lateral ligament injuries]. / Außenbandverletzungen.

Due to the frequency and potentially complicated course distortion of the upper angle joint represents an important entity in the orthopedic patient clientele. The initial diagnosis includes a detailed anamnesis of the injury mechanism and an accurate clinical examination. To exclude bony, ligamentous and chondral lesions, besides basic diagnostics consisting of X­rays and ultrasound, magnetic resonance imaging (MRI) is considered the most important tool. Lateral ankle ligament injuries are generally treated conservatively. After a short period consisting of immobilization of the affected ankle, early functional therapy with semi-rigid orthoses and proprioceptive exercises should be performed. If conservative therapy fails and thus chronic instability develops the indications for operative treatment are given. Meanwhile, surgical techniques have been established with satisfactory results. Inadequate rehabilitation could be identified as a major risk factor for re-injury, therefore phase-adapted aftercare has gained significant importance.

[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.

[Osteoarthritis of the upper ankle joint]. / Arthrose des oberen Sprunggelenks.

The majority of cases of upper ankle joint (UAJ) osteoarthritis are due to secondary causes. Clinically, osteoarthritis is usually characterized by an increasing limitation in dorsal extension of the UAJ with often relatively mild symptoms. In the course of time the full scale of the typical symptoms and the progressive restriction of the global function of the joint develop. Conservative therapy is often able to provide long-term improvement of the symptoms for the majority of patients by means of intermittent analgesics and orthoses as well as shoe modifications. Operative treatment strategies for initial stages are based on joint-sparing methods. The most frequently used therapy for progressive destruction of the UAJ is still arthrodesis. Total ankle replacement is becoming an increasingly more competitive procedure. Total ankle replacement provides a valuable extension of therapeutic possibilities for UAJ osteoarthritis.

[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.

[Lateral instability of the upper ankle joint]. / Laterale Instabilität des oberen Sprunggelenks.

Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.

[Arthodesis of the proximal and distal interphalangeal joint]. / Arthrodese der Mittel- und Endgelenke der Kleinzehen.

OBJECTIVE: Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively). INDICATIONS: Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe. CONTRAINDICATIONS: General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint. SURGICAL TECHNIQUES: PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. POSTOPERATIVE MANAGEMENT: Postoperative full weight bearing for 3-6 weeks, depending on the arthrodesis technique used. RESULTS: Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.

Translation and validation of the German version of the foot and ankle outcome score.

PURPOSE: Outcome assessment is critical in evaluating the efficacy of orthopaedic procedures. The Foot and Ankle Outcome Score (FAOS) is a 42-item questionnaire divided into five subscales, which has been validated in several languages. Germany has no validated outcome score for general foot and ankle pathology. The aim of this study was to develop a German version of the FAOS and to investigate its psychometric properties. MATERIALS AND METHODS: Forward and backward translation was executed according to official guidelines. The final version of the FAOS was investigated in 150 patients with various foot and ankle disorders. All patients completed the FAOS, Short Form-36, numeric rating scales for pain and disability, and the Hannover questionnaire. The FAOS was re-administered after 1 week. Test-retest reliability, internal consistency, minimal detectable change, construct validity, and floor and ceiling effects were analyzed. RESULTS: Test-retest reliability and internal consistency of each subscale were excellent (intraclass correlation coefficient, 0.88-0.95; Cronbach's α, 0.94-0.98). The minimal detectable changes of each subscale were 17.1-20.8 at the individual level and 2.0-2.4 at group level. There were moderate to strong correlations between FAOS subscales and physical outcomes and low to moderate correlations between FAOS subscales and mental outcomes. Floor and ceiling effects were not present. CONCLUSION: The German version of the FAOS is a reliable and valid instrument for use in foot and ankle patients.

Magnesium-based bone implants: immunohistochemical analysis of peri-implant osteogenesis by evaluation of osteopontin and osteocalcin expression.

The functions of some bone proteins, as osteopontin (OPN) and osteocalcin (OC), have been discovered by the latest studies. This fact suggests the possibility of their immunodetection to characterize peri-implant osteogenesis and implant impact on it. Cylindrical pins of Mg alloys (MgCa0.8, LAE442, ZEK100, LANd442) and titanium alloy (TiAl6V4) were implanted into the tibial medullae of 46 rabbits. Each group was divided regarding to implant duration (3 and 6 months). Bone samples adjacent to the implants were decalcified and treated with routine histological and immunohistochemical protocols using OC and OPN-antibodies. OC was detected in matrix of compact bone, but very rarely in osteoid and bone cells. OPN was detected intracellularly and in osteoid. After 3 months, the highest level of both markers was found in titanium group, followed by LAE442-group. In contrast to LAE442 and TiAl6V4, the other Mg alloys showed increasing levels of OC after 6 months. Lower levels of OP and OC compared to the control group are related to the continuous implant degradation and instability of bone-implant interface in early post-surgical period. Reduced marker's expression in LAE442 and TiAl6V4 groups after 6 months may indicate stabilization of bone-implant interface and completion of peri-implant neo-osteogenesis. Declining characters of OC and OPN expression over the implantation time, as well as their lowest levels in late post-surgical term, suggest a more appropriate biocompatibility of LAE442, which therefore seems to be the most preferable of the tested materials for the use in orthopaedic applications.

[Extra-articular arthroereisis according to Grice/Green versus calcaneal lengthening according to Evans: retrospective comparison for therapy of neurogenic pes planovalgus]. / Extraartikuläre Arthrorise nach Grice/Green vs. Kalkaneusverlängerungsosteotomie nach Evans: Retrospektiver Vergleich zur Therapie des neurogenen Pes planovalgus.

BACKGROUND: Common reasons for juvenile neurogenic pes planovalgus are hypoxic brain damage, birth defects of the spinal canal, trauma and cerebral cancer. When symptoms persist despite conservative treatment of symptomatic pes planovalgus, surgery is indicated. Objectives of the operation are improved gait and mobilization as well as an improved basis for wearing shoes. Joint preserving and ankylosing procedures as well as combinations of both are available. The aim of this study was a retrospective comparison of the Grice/Green extra-articular arthroreisis versus the Evans calcaneal lengthening operation. MATERIAL AND METHODS: Between October 2001 and October 2009 a total of 75 arthroereisis operations were performed according to Grice/Green and in the period from April 2006 to February 2010 a total of 83 calcaneal lengthening operations according to Evans. The focus of the study was on patients with an underlying neurogenic disease which resulted in 72 cases in the Grice/Green group and 70 cases in the Evans group. The average age was 14.6 ± 5.0 years in the Evans group and 10.1 ± 3.4 years in the Grice/Green group. Of the patients in the Grice/Green group 17 had infantile cerebral palsy (ICP) and 25 had other neuromuscular diseases and in the Evans group 14 patients had ICP and 28 patients had other neuromuscular diseases. The medical records, preoperative and postoperative radiographs were analyzed. In addition information was obtained on the quality of life (EQ-5D), mobility and the supply of mobility aids using a specially designed questionnaire. The radiological evaluation was based on preoperative and postoperative lateral and dorso-plantar radiographs. The follow-up time for the questionnaire was on average 54 months (range 12-109 months) for the Grice/Green group and 22 months (range 9-53 months) for the Evans group. The postoperative treatment was similar in both groups. RESULTS: The talometatarsal (TMT) index could be improved by surgery according to Grice/Green from - 50.2° to - 28.1° and in the Evans group a correction from - 49.6° to - 31.8° was possible. Considering the cases with severe preoperative deformities (TMT index < -50°) there was a significantly greater correction of the lateral talocalcaneal (TC) angle by the method of Grice/Green. In 67 % of patients in the Grice/Green group and 57 % in the Evans group a significant improvement in terms of pain was possible. A significant improvement in gait and possible walking distance was found in 33 % of the Grice/Green group and 43 % of the Evans group and an average improvement was possible in 40 % and 43 %, respectively. The operation was considered to be very successful by 67 % of patients in the Grice/Green group and in 57 % of patients in the Evans group but the difference was not significant. In the Grice/Green group no revisions were necessary and revision was performed in two cases after surgery in the Evans group due to wound infections. CONCLUSIONS: Both of the processes investigated in this study are suitable for treatment of pes planovalgus. In cases of neurogenic pes planovalgus and also in extreme cases (TMT index < -50°) the procedure according to Grice/Green has radiological advantages for reconstruction of the lateral TC angle.

[Preoperative perfusion analysis before total ankle arthroplasty]. / Präoperative Perfusionsuntersuchung vor Sprunggelenksersatzoperationen.

PURPOSE: Soft tissue management is of paramount importance in ankle surgery. As such, full thickness necrosis of the soft tissue envelope represents a severe complication following total ankle joint arthroplasty (TAA) potentially leading to implant exposure, infection and thus, substantially compromised patient outcomes. One of the main factors leading to soft tissue complications is an undetermined arterial perfusion of the lower leg or ankle joint. We report on clinical cases suffering soft tissue complications following TAA with the respective plastic surgical therapy regimen and present a simple algorithm for preoperative perfusion evaluation. METHODS: The medical records of 30 consecutive primary TAA patients were retrospectively reviewed after observing a higher than expected rate of severe soft tissue defects which have been referred to our plastic surgery department. RESULTS: 3 patients (10%, all females, age 63 ± 5 years; BMI 27 ± 3 kg/m2) presented with a soft tissue defect leading to angiography revealing one case of severe arterial obstruction. Wound closure could be reached in one case by conservative therapy consisting of regular dressing changes. In the further patients definite soft tissue reconstruction could only be performed by surgical intervention. One could be covered by split-thickness skin grafting and one by a microsurgical transplantation of a free latissimus dorsi flap. On the basis of these complications we established an easy algorithm for the preoperative evaluation of the arterial perfusion in the ankle region. First, (I) the pulses of the dorsal foot artery and posterior tibial artery should be examined. In the case of not palpable pulses (II) the ankle-brachial index should be performed. Values of <0.9 or >1.2 recommend (III) to perform angiography. In the case of stenosis or complete obstruction (IV) the arterial blood flow should be reconstituted by interventional radiological stenting or vascular surgical procedures. CONCLUSION: The identification of the arterial perfusion status of patients undergoing TAA using a straightforward clinical algorithm might overcome TAA-related soft tissue complications and improve patient-related outcome measures.

[A special soft tissue procedure for treatment of hallux valgus]. / Eine spezielle Weichteilplastik am Großzehengrundgelenk bei Hallux-valgus-Operationen.

OBJECTIVE: Maintaining the corrected position of the first metatasophalangeal axis. Reducing postoperative stiffness by forgoing a medial capsular shift. INDICATIONS: Hallux valgus deformities or recurrent hallux valgus deformities. CONTRAINDICATIONS: Existing osteoarthritis, joint stiffness, large bone defects, osteonecrosis. General medical contraindications to surgical interventions and anesthesiological procedures. SURGICAL TECHNIQUE: Operation under regional anesthesia (foot block) or general anesthesia. Tourniquet. Longitudinal skin incision medial over the pseudexostosis of the first metatarsal bone. Preparing the tendon of the Musculus abductor hallucis. Detaching the tendon from the capsule. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle in an L-wise manner. Osteotomy of the first metatarsal bone. Lax sutures of the capsule in correct position and reattachment of the Musculus abductor hallucis tendon shifted toward distal and dorsal, regarding the rotation of the hallux. POSTOPERATIVE MANAGEMENT: Postoperative elevation of the operated foot. Analgesia with nonsteroidal antiinflammatory drugs. Postoperative weight-bearing according to the osteotomy. Passive mobilization of the metatarsophalangeal joint. Dressing for 4 weeks postoperatively in the corrected position. Radiologic control after 6 weeks. Hallux valgus orthosis at night and a toe spreader for a further 6 weeks. RESULTS: A total of 30 isolated hallux valgus deformities with a mean preoperative intermetatarsal (IMA) angle of 12.9° (range 11-15°) were operated with a chevron osteotomy. The mean follow-up was 14.4 (range 8-17) months. The mean dorsiflexion at the last follow-up was 44° (range 20-60°). Only 2 patients had a dorsiflexion <40°. The mean reduction of the IM angle was 5.6° (range 3-7°). One patient required wound revision. There was no infection or avascular necrosis of the metatarsal head observed in the patients. At follow-up, 20 (67%) patients were completely satisfied, 9 (30%) satisfied, and 1 (3%) was not satisfied.

[Tendinopathy of the tibialis anterior tendon : surgical management]. / Ansatznahe Tendinopathie des M. tibialis anterior : Operative Therapie.

A tendinopathy of the tibialis anterior tendon is a rare clinical problem. MRI is the diagnostic tool of choice. The first-line therapy should be conservative. We report about five patients who underwent operative therapy after failed conservative treatment. The operation included débridement and augmentation of the tendon. The follow-up was at least 6 months. The mean preoperative Kitaoka score was 63 (50-68) points. After 3 months follow-up the mean Kitaoka score was up to 84 (80-90) points and at the 6-month follow-up up to 96 (94-100) points. The results showed a significant reduction of pain. Operative therapy should be considered in cases of failed conservative therapy.