[Deformity-associated treatment of the hallux valgus complex]. / Deformitätsassoziierte Behandlung des Hallux-valgus-Komplexes.

Hallux valgus represents a combined deformity with malpositioning of the big toe in the metatarsophalangeal joint and metatarsal splaying due to metatarsus primus varus formation. It is defined on the basis of joint condition of the metatarsophalangeal and tarsometatarsal (TMT) joints, the extent and congruence or incongruence of malposition, mobility of the metatarsophalangeal joint and TMT stability. Basic resection appears to be indicated only in exceptional cases. Depending on the degree of severity, deformities can be corrected by means of distal, diaphyseal or proximal osteotomies and TMT arthrodeses. Any correction requires the use of subtle soft tissue surgery with recentering of the tendon, tightening of the medial capsule and abductor hallucis and releasing the lateral capsule. A check-list-like analysis of hallux valgus deformity helps determine the ideal procedure and avoid over- or under-treatment.

Brachytherapy in early prostate cancer--early experience.

Use of brachytherapy with radioactive seeds in the management of early prostate cancer is commonly used in the United States. The early experience has been reported from the prostate treatment centers in Seattle for the last 10 years. In this manuscript we are reporting our early experience of 150 radioactive seed implantations in early stage prostate cancer using either Iodine 125 or Palladium 103 seeds. The average age of the patient is 66 years and the median Gleason score is 5.4 with a median PSA of 6. A brief description of the evolution of the treatment of prostate cancer as well as the preparation for the seed implantation using the volume study with ultrasound of the prostate, pubic arch study using CT scan of the pelvis and the complete planning using the treatment planning computers are discussed. We also have described the current technique which is used in our experience based on the Seattle guidelines. We plan a follow-up report with the results of the studies with longer follow-up.

Radiographic analysis of metatarsus primus varus. 45 feet followed 15 months after distal metatarsal osteotomy and lateral soft-tissue release.

We analyzed standardized radiographs of 45 feet in 41 patients with symptomatic hallux valgus and an intermetatarsal angle of 17 (15-23) degrees 15 (9-24) months after distal metatarsal osteotomy and lateral soft-tissue releases. A mean reduction in the II-intermetatarsal angle of 12 degrees and hallux valgus angle of 24 degrees was found. On average, the metatarsus primus varus angle improved by 4 degrees, the I-intermetatarsal angle by 3 degrees and the inclination angle of the first cuneiform by 4 degrees. We conclude that this operation corrects the metatarsus primus varus, without substantially altering the alignment of the long axis of the first metatarsal.

[Mobile flatfoot as a sequela of dislocation injury of the Lisfranc joint. A retrospective analysis of 13 patients]. / Der mobile Plattfuss als Spätfolge einer Subluxationsverletzung im Lisfranc-Gelenk. Eine retrospektive Analyse von 13 Patienten.

In this retrospective study, 13 patients with subtle Lisfranc joint injuries were examined after a mean period of 23 months using clinical assessment, radiography and dynamic pedographic gait analysis. The aims were to identify the factors leading to a mobile flatfoot deformity, evaluate the functional and clinical outcome of these injuries, and draw practical conclusions for initial management and subsequent intervention. All patients showed a mobile flatfoot deformity, increased motion in the subtalar joint, increased load on the hindfoot, decreased load on the forefoot, and a prolonged contact phase during the stance phase. Radiographs revealed progressive osteoarthrosis in the joint and a residual displacement of the medial Lisfranc joint. An unstable medial Lisfranc joint results in the development of a mobile flatfoot. Initial treatment of a subtly displaced Lisfranc joint should consist of exact anatomical reduction and additional maintenance of the longitudinal arch of the foot. After failed initial treatment, early arthrodesis of the midfoot is recommended as a salvage procedure for the foot.

Arthrodesis for traumatic flat foot. Tarsometatarsal and medial longitudinal arch fusion by inlay grafting, 11 feet followed for 1.5 years.

We examined 11 feet, 18 (11-30) months after simultaneous tarsometatarsal and medial longitudinal arch fusion to stabilize a residual mobile flat foot resulting from an injury. All had solid fusion and the surgical correction of the flat foot deformity was maintained. At the follow-up, we rated 6 feet as excellent and 5 as good. Mechanically, simultaneous arthrodesis of the tarsometatarsal joint and the longitudinal arch of the foot seem better than isolated arthrodesis of the tarsometatarsal joints.

[Austin's horizontal V-shaped sliding osteotomy of the metatarsal head [Chevron-osteotomy) in the treatment of hallux valgus]. / Die horizontale v-förmige Verschiebeosteotomie des Metatarsalköpfchens nach Austin (Chevron-Osteotomie) zur Behandlung des Hallux valgus.

From 1983 to 1995, 1587 patients suffering from hallux abductovalgus were treated with the Austin bunionectomy. The operation consists of a medial exostosis removal, a V-shaped laterally directed displacement osteotomy of the metatarsal head, lateral release and medial reefing of the capsulo-ligamentous structures. Lateral transposition is facilitated by performing a sufficient lateral release consisting of dissection of the lateral metatarsophalangeal ligament and separation of the adductor tendon from the base of the phalanx and the lateral sesamoid. In the case of intermetatarsal angles greater than 15 degrees, the metatarsal-sesamoid ligament is also severed just above the lateral sesamoid. The periosteum is stripped in a limited fashion dorsally and toward the plantar, leaving its insertion at the metatarsal head intact. After this procedure, reposition of the metatarsal head onto the sesamoids is usually possible and is maintained by reconstruction of the medial metatarsal-sesamoid ligament. In the author's own research material, metatarsophalangeal angles larger than 50 degrees and intermetatarsal angles of over 20 degrees could be corrected. Pronation of the toe is usually corrected by tenotomy of the abductor tendon near the base of the phalanx. Avascular necrosis is extremely rare with a careful operative technique. In our extensive research material, four cases of AVN were recognized. Provided there is free motion of the joint (60-0-20), mild radiological signs of osteoarthritis are no contraindication for the operation. Even in the aged, good results can be achieved provided there are no trophic problems. The Austin bunionectomy has proved to be a versatile method for treating bunion problems. The possibility of transposing the metatarsal head laterally, toward the plantar, proximally and distally by altering the direction of the osteotomy, as well as tilting it medially or laterally, has made this osteotomy an invaluable tool for addressing various problems in bunion surgery.

Treatment of peroneal tendon dislocation by transposition under the calcaneofibular ligament.

Of the many different surgical techniques to treat peroneal tendon dislocations, transposition of the peroneal tendons under the calcaneofibular ligament has been used at the Orthopädisches Spital of Vienna/Austria since 1975. The method was first described by Platzgummer in 1967. After dividing the calcaneofibular ligament and removing the fatty tissue in the space between this ligament, the posterior talofibular ligament, and the lateral capsule of the subtalar joint, the peroneal tendons are placed behind the lateral malleolus and under the calcaneofibular ligament, which is reconstructed by suture to create an efficient retainment. Of 17 feet operated on, 13 were available for follow-up in 12 patients. Dislocation was idiopathic in three and traumatic in 10 feet. Criteria for evaluation were patient's satisfaction, absence of pain and swelling, and stability of tendon retention and of ankle and subtalar joints. Of the 13 operated feet, 11 showed an excellent result and two showed a good result. In the results graded as "good," occasional pain and swelling occurred in both feet of a patient belonging to the idiopathic group.

The Austin bunionectomy: a follow-up study.

The Austin procedure, a distal metaphyseal "V" osteotomy for the management of hallux valgus was evaluated in several distinct patient groups. The results of the procedure were found to be both reproducible and predictable. Medial capsular reefing in an attempt to maintain the intermetatarsal angle reduction or hallux alignment does not appear to enhance the postoperative results.

Extracorporeal shock-wave lithotripsy in transplanted kidney.

Urolithiasis is the least described urologic sequela of renal transplantation. We describe a renal transplant patient who presented with painless gross hematuria. An intravenous pyelogram demonstrated a 4 x 7-mm calculi in the region of the ureteropelvic junction, causing moderate hydronephrosis. The patient was treated successfully with extracorporeal shock-wave lithotripsy (ESWL). Serum creatinine and twenty-four-hour creatinine clearance were unchanged from levels prior to ESWL.

[Long term results of the Keller-Brandes method of hallux rigidus surgery]. / Langzeitergebnisse der Hallux-Rigidus-Operation nach Keller-Brandes.

Between the years 1971 and 1975 a surgical treatment of hallux rigidus according to Keller Brandes was performed on 293 patients. From 100 patients with 137 operated feet a clinical and roentgenological examination was evaluated 12 to 16 years after surgery. The subjective assessment showed in 92% of the feet very good or good results. Important for the success of the operation is the correct amount of bone removal of the proximal phalanx (between 1/3 and 1/2) and the resultant width of the nearthrotic joint space. The analysis of the podographic examination and the amount of retraction of the sesamoids showed no correlation to the incidence of postoperative metatarsalgia, which we found in 31 feet (29%). Nevertheless, X-Ray Evaluation of all patients with metatarsalgia showed a posterior shift of the sesamoids.

Transrectal prostate ultrasonography as a diagnostic and therapeutic aid for ejaculatory duct obstruction.

Preoperative transrectal ultrasonography was used to establish the diagnosis of ejaculatory duct obstruction and also to determine the distal level of extension of the obstructed system within prostatic parenchyma. Transrectal ultrasonography not only established the diagnosis but also enabled precise transurethral resection into the obstructed system. Prostatic ultrasound facilitates evaluation and treatment of azoospermia caused by ejaculatory duct obstruction and may eliminate the need for vasography in such cases.

Treatment of radiation or cyclophosphamide induced hemorrhagic cystitis using conjugated estrogen.

Five patients with severe hemorrhagic cystitis induced by radiation and/or cyclophosphamide were systematically treated with conjugated estrogen. Two patients received conjugated estrogen twice each day (1 mg. per kg.) intravenously, followed on day 3 and thereafter by 5 mg. per day orally. Hematuria decreased markedly 6 to 8 hours after the initial dose and urine color became light yellow within 1 to 3 days. The other 3 patients received 5 mg. conjugated estrogen per day orally and urine color became clear within 4 to 7 days. Hematuria did not recur during 12 to 22 months in 4 patients who received daily conjugated estrogen (1.25 mg.). However, transient episodes of mild hematuria persisted in 1 patient during the 3-month followup despite a higher dose of conjugated estrogen (10 mg. per day). Complications, including thromboembolism and other side effects associated with conjugated estrogen, were not observed in these patients. We postulate that conjugated estrogen controls hematuria in hemorrhagic cystitis by decreasing the fragility of the mucosal microvasculature of the bladder.

Extracorporeal shock-wave lithotripsy in horseshoe kidneys.

Using the Dornier HM-3 lithotriptor, 10 patients (11 renal units) with calculi in horseshoe kidneys were treated with extracorporeal shock-wave lithotripsy (ESWL) and ancillary procedures. Six renal units (55%) underwent pre-ESWL manipulation consisting of a Double J stent, ureteral catheter, or percutaneous nephrostomy. The "blast path" was employed to treat five renal units which could not be positioned at F2. Good initial stone fragmentation was obtained in eight renal units (73%). There were two episodes of post-ESWL obstruction requiring intervention; both occurred in the same patient. A total of seven post-ESWL procedures were performed on two renal units. After all procedures, eight renal units (73%) were rendered stone-free, six (55%) with ESWL alone. The average follow-up interval was twelve months (range 1-28 months). ESWL can be used effectively to treat some patients with calculi in horseshoe kidneys. The ectopic location of these renal units may make it difficult to position calculi at F2, thus necessitating treatment on the blast path or placement of the patient in prone position. Multiple ancillary procedures may be necessary.

Extracorporeal shock-wave lithotripsy of renal calculi.

Extracorporeal shock-wave lithotripsy (ESWL) is a noninvasive technique that utilizes focused shock waves to fragment stones into sand-sized particles, which then pass spontaneously with urination. The clinical use of this technique was introduced in 1980 in Germany by Chaussy and associates and has replaced most open surgery and percutaneous endoscopy for stone removal. The physics of shock waves, equipment, techniques, and patient selection in ESWL are discussed. Results of treatment of renal, upper ureteral, and lower ureteral calculi are reviewed and compared. Complications of treatment, including ureteral obstruction, hemorrhage, and tissue damage, are discussed. The advent of second-generation lithotripters has widened the parameters for patient selection in the treatment of ESWL and has increased the availability of this treatment modality.

Value of cerclage fibreux for the Keller-Brandes procedure.

In the last 15 years Keller-Brandes operations have been performed in the Orthopedic Hospital Vienna-Speising, with and without cerclage fibreux. We were able to compare both methods in a long-term follow-up study and to check the function of the fibrous cerclage reducing the first intermetatarsal angle. The results of the random follow-up study of 100 patients show impressive advantages of the cerclage fibreux, objectively and subjectively, up to high intermetatarsal angles, which formerly were treated by osteotomies.

[The Akin-New method for surgery of hallux valgus. 1-year results of a covered surgical method]. / Operation des Hallux valgus nach Akin-New. Einjahresergebnisse einer gedeckten Operationsmethode.

A new technique of operation on hallux valgus according to the method of Akin (1925) was introduced to us by Dr. Theodore O. New in 1983. From small skin incisions the removal of the bunion and a corrective osteotomy of the phalanx are accomplished. The results of the operation in 72 out of a total of 77 operated feet one year after operation are reviewed. By the patients 40 (55%) of the results were judged as excellent (A), 23 (32%) as good (B) and 9 (13%) as not satisfying (C). The results of objective assessment were less favorable. 11 (15%) excellent (A) and 34 (48%) good (B) were opposed by 27 (37%) non satisfying results. These are attributed to the stringent rules of judgment and the lack of experience in suitable indications. Saving the metatarsophalangeal joint, minimal postoperative pain and early rehabilitation are advantages of this technique.

Austin bunionectomy: transpositional "V" osteotomy of the first metatarsal for hallux valgus.

The authors present results of their experiences with the Austin procedure in a group of patients approximately 24 months postoperatively. The overall patients' satisfaction rate was 96%. The overall clinical rating was 77%. Reasons for poor results were analyzed.

Combination extracorporeal shock wave lithotripsy and percutaneous extraction of calculi in a renal allograft.

Renal calculi are a well documented although uncommon complication of kidney transplantation and may be associated with significant morbidity in this immunosuppressed population with a single functioning kidney. We describe a patient who presented with 2 episodes of staphylococcal bacteremia associated with a ureteral structure and struvite calculi involving the calices, renal pelvis and proximal ureter of a cadaveric renal allograft. The patient was treated successfully with a combination of extracorporeal shock wave lithotripsy, percutaneous extraction and balloon dilation of the ureteral stricture. Renal transplant function was not altered postoperatively. In selected cases shock wave lithotripsy can be used as effective adjunctive therapy in a renal allograft harboring stones.