[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.

[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.

[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.

[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.

[SPECT-CT of the foot]. / SPECT-CT des Fußes.

UNLABELLED: During the last years SPECT-CT combining the high resolution of CT with high sensitivity of bone SPECT has gained widespread clinical application. Especially in complex anatomic situations, SPECT-CT allows to exactly define the area of the skeleton which is responsible for pain. This holds true especially in patients with foot diseases. CONCLUSION: Bone SPECT-CT gives additional useful information in arthrodesis, infection, accessory bones (sesamoids) as well as tarsal coalition.

[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.

Mid- and long-term results of the joint preserving therapy of hallux rigidus.

BACKGROUND: The hallux rigidus is an over 100-year-known pathology. Yet an overall accepted therapy regime does not exist. The aim of this prospective study was to analyze the long-term clinical outcome and patient satisfaction of joint preserving operative care in patients with symptomatic hallux rigidus. METHODS: We present a prospective study with 60 patients (60 feet) with symptomatic hallux rigidus. In cases with intraoperative dorsiflexion of less than 70 degrees after the cheilectomy, an additional Kessel-Bonney osteotomy was done. The first follow-up after 24 (10-31) months was done on 49 (81.7%) patients and the second after 96 (84-104) months on 46 (76.7%) patients. We recorded the pre- and post-operative Kitaoka score, range of motion, pain and patients satisfaction. The results were related to the operative procedure and the grade of hallux rigidus (according to Regnauld). RESULTS: Twenty patients were graded as I, 35 patients as II and 5 patients as III. At the follow-up, the mean dorsiflexion increased in grade I patients to about 21.7 degrees , in grade II patients about 23.7 degrees and in grade III patients about 26.3 degrees . At the first follow-up [24 (10-31) months], all patients of grade I, 63.3% patients of grade II and 75% of grade III patients had just occasional or no pain. At the second follow-up [96 (84-104) months], 77.8% of grade I and 73.9% of grade II patients had no pain. At the first (second) follow-up 53.3% (61.1%) of grade I, 43.3% (33.3%) of grade II and 50% (25%) of grade III patients were completely satisfied. In order to the operative procedure the patients were completely satisfied or satisfied: first (second) follow-up 52% (85.9%) of patients with cheilectomy and 85% (86.4%) of patients with cheilectomy and Kessel-Bonney osteotomy. In 51.4% of the patients, the Kitaoka Score was higher than 70.4 points. Four patients had a persistent hypaesthesia of the medial side of the great toe and three patients had a delayed wound healing. No revision was necessary. No further operation was done in all the investigated patients. CONCLUSION: The joint preserving operation in patients with grade I and II hallux rigidus shows an increase of dorsiflexion and decrease of daily pain. The long-term follow-up shows a persistent pain reduction and satisfaction of the patients. Our results recommend a joint preserving operation in grade I and II hallux rigidus. An additional osteotomy of the proximal phalanx should be done in cases of dorsiflexion less than 70 degrees after cheilectomy.

Histopathology of cryopreserved bone allo- and isografts: pretreatment with dimethyl sulfoxide.

Partial graft cell survival and enhanced graft revascularization have suggested fast freezing using the cryoprotective substance dimethyl sulfoxide (DMSO) as a promising means to improve the biologic function and immune tolerance of allograft bone. This study determines the presence of osteoblasts (cola(1)(I) mRNA), osteoclasts (TRAP), and cytotoxic T cells (CTLs; GrA mRNA) within pretreated bone grafts 12 days after transplantation. The grafts were transplanted either as isografts, allografts, or allografts in presensitized recipients. In fresh isografts, serving as control, well-formed blood vessels and the highest numbers of viable osteoblasts and osteoclasts were found. In fresh allografts, blood vessels were observed within the marrow cavity and the bone was partially covered by osteoblasts and osteoclasts accompanied by CTLs. In DMSO-pretreated frozen allografts, blood vessels together with osteoblasts were observed in three of five, but in none of five grafts frozen without DMSO. However, infiltration with CTLs was higher in DMSO-pretreated frozen allografts when compared to grafts frozen without DMSO. In presensitized allograft recipients, independent of the pretreatment, in none of the grafts were either blood vessels or osteoblasts found. Thus, fast cryopreservation of bone using DMSO improves vascularization and expression of cola(1)(I) mRNA (osteoblasts) after allografting when compared to cryopreservation alone, potentially improving graft incorporation. As these grafts were still invaded by CTLs, the long-term effect of DMSO pretreatment needs to be defined.

[Animal models of osteomyelitis]. / Tierexperimentelle Osteitismodelle.

Despite new approaches in biochemical testing, radiologic and nuclear medicine and advances in surgical techniques, the problem of diagnosis and therapy of acute and chronic osteitis has not been finally solved. Clinical research on osteitis is problematic as there are many variables influencing the inflammatory process and a wide spectrum in therapeutic options exists, hampering research under defined conditions. Consequently, there was an early need for animal models. In vivo experimental settings were established to gain reproducible and reliable results under standardized conditions on the pathogenesis and therapy of osteitis. In this article, an overview of the hitherto established experimental animal models and the results of osteitis research on these models is given.

[Fracture dislocation of the elbow involving the coronoid process]. / Luxationsfrakturen des Ellenbogens mit Beteiligung des Processus coronoideus.

INTRODUCTION: Elbow dislocations are associated with osseus lesions in 30-50%. Integrity of the coronoid process is essential for stability of the elbow joint. METHODS: A retrospective study of 39 patients out of 51 was conducted to evaluate a result of surgical treatment in fracture dislocation of the elbow involving the coronoid process. The patients were followed for an average of 45 months. RESULTS: Operative results were assessed using the Morrey-Score. 3 patients presented an excellent, 19 a good, 14 a moderate and 3 a non satisfactory result. CONCLUSION: Results of operative treatment of fracture dislocation of the elbow are essentially determined by the extent of associated osseus lesions of the radial head and the olecranon. To achieve acceptable functional results early reconstruction and fixation of the coronoid process as well as early mobilisation of the joint is necessary.

[Pyogenic infection after joint replacement operations: incidence and economic effects]. / Der pyogene Infekt nach Gelenkersatzoperationen: Inzidenz und ökonomische Auswirkungen.

Infection following arthroplasty is a rare but significant and threatening complication. The incidence is about 2%. Treatment of an infected joint replacement may be demanding, time consuming and expensive. For the treating institution there is a risk of substantial financial losses due to inadequate reimbursement. Calculated on the basis of approximately 150,000 implanted joint protheses/a, an infection rate of 2% and treatment costs of approximately 50,000 [symbol: see text]/infected case the economic burden is an estimated 150 million [symbol: see text]/a in Germany. This amount should justify a sound evaluation of costs related to infection in arthroplasty, which should be the effort of the health insurance organisations. Additionally specific research in the field of infection prevention must be sponsored. The system of reimbursement should be adequately adopted and corrected.

[Rate of infection in trauma surgery. An overview based on recent German language literature]. / Infektionsraten in der Unfallchirurgie. Eine Ubersicht anhand der neueren deutschsprachigen Literatur.

Infection rates are important markers for clinical quality assurance. For internal control, they may only be used under the condition of homogeneous data collection and evaluation according to identical standard operating procedures during the entire investigation period. For inter-hospital comparison, they may only be used if additionally the observed patient groups are well defined and comparable. A survey of the infection rates published during the last 6 years in the German traumatological literature (n = 71) indeed shows (concerning series later than 1985) similar infection rates for procedures in less and in more problematic anatomical regions and in clean and contaminated situations of about 2-3%, after open injuries sporadically max. 10%. Finally, it is demonstrated that conclusions concerning a general "risk of infection" based on infection rates for specific surgical procedures are not possible and vice versa. We strongly recommend the future application of a standardized definition of wound infection. The differentiation between deep and superficial infection should be abandoned. For all mentioned "infection rates" it should be indicated whether it is with reference to the risk of infection of a specific procedure or only a general statement.