Tibialis posterior tendon transfer corrects the foot drop component of cavovarus foot deformity in Charcot-Marie-Tooth disease.

BACKGROUND: The foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease is commonly treated by tendon transfer to provide substitute foot dorsiflexion or by tenodesis to prevent the foot from dropping. Our goals were to use three-dimensional foot analysis to evaluate the outcome of tibialis posterior tendon transfer to the dorsum of the foot and to investigate whether the transfer works as an active substitution or as a tenodesis. METHODS: We prospectively studied fourteen patients with Charcot-Marie-Tooth disease and cavovarus foot deformity in whom twenty-three feet were treated with tibialis posterior tendon transfer to correct the foot drop component as part of a foot deformity correction procedure. Five patients underwent unilateral treatment and nine underwent bilateral treatment; only one foot was analyzed in each of the latter patients. Standardized clinical examinations and three-dimensional gait analysis with a special foot model (Heidelberg Foot Measurement Method) were performed before and at a mean of 28.8 months after surgery. RESULTS: The three-dimensional gait analysis revealed significant increases in tibiotalar and foot-tibia dorsiflexion during the swing phase after surgery. These increases were accompanied by a significant reduction in maximum plantar flexion at the stance-swing transition but without a reduction in active range of motion. Passive ankle dorsiflexion measured in knee flexion and extension increased significantly without any relevant decrease in passive plantar flexion. The AOFAS (American Orthopaedic Foot & Ankle Society) score improved significantly. CONCLUSIONS: Tibialis posterior tendon transfer was effective at correcting the foot drop component of cavovarus foot deformity in patients with Charcot-Marie-Tooth disease, with the transfer apparently working as an active substitution. Although passive plantar flexion was not limited after surgery, active plantar flexion at push-off was significantly reduced and it is unknown whether this reduction was the result of a tenodesis effect or calf muscle weakness.

Distal Rectus Femoris Tendon Transfer for the Correction of Stiff-Knee Gait in Cerebral Palsy.

INTRODUCTION: Distal rectus femoris tendon transfer is the standard surgical procedure for the treatment of stiff-knee gait in patients with cerebral palsy and is commonly performed during single-event multilevel surgery. STEP 1 POSITIONING AND APPROACH: With the patient supine, make a 3 to 4-cm longitudinal incision 2 to 3 cm above the patellar proximal pole. STEP 2 PREPARATION OF THE RECTUS FEMORIS TENDON: Separate the rectus femoris tendon from the vasti; avoid releasing the entire quadriceps at all cost. STEP 3 PREPARATION OF THE GRACILIS OR SEMITENDINOSUS TENDON FOR TRANSFER: Isolate the gracilis tendon proximally, release it from its muscle belly, and pull it out distally through a small incision at the pes anserinus insertion. STEP 4 TRANSFERRING THE GRACILIS TENDON TO THE RECTUS FEMORIS TENDON: Insert a long tendon passer above the fascia and beneath the sartorius muscle belly from anterior to posterior to the mini-incision in the pes anserinus region to grasp and transfer the gracilis tendon to the anterior approach. STEP 5 TENDON TENSIONING AND SUTURING: Weave the gracilis tendon into the released rectus femoris tendon with the interlacing technique described by Pulvertaft. RESULTS: Various studies have demonstrated good initial results, with an improvement in peak knee flexion in swing phase and knee motion in swing phase, following distal rectus femoris tendon transfer. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

[Tendon transfer in pediatric foot deformities]. / Sehnentransfers bei kindlichen Fussdeformitäten.

Tendon transfer surgery plays a central role in the treatment of pediatric foot deformities. Tendon transfers are essential for balancing in neurogenic deformities but also important for the treatment of congenital or idiopathic deformities. Furthermore tendon transfer represents an important management tool for revision surgery of failed treatment in foot deformities. Complications and pit-falls which can potentially lead to failure may occur during the indications and planning of the transfer as well as during the surgery. The identification and analysis of possible pitfalls and complications as well as their management is the central issue of this article. Knowledge about possible problems and their management are essential for successful treatment of pediatric foot deformities.

[Preserving foot surgery for diabetics]. / Erhaltende Fusschirurgie beim Diabetiker.

The reconstruction of a diabetic foot is still a challenge for the orthopedic surgeon. Untreated fractures, dislocations and foot and ankle deformities with consequent ulcerations may increase the risk of limb amputation. For patients who refuse a major amputation a surgical reconstruction can be started using bone grafts, angle stable locking plates and ankle arthrodesis nails. The goal of reconstruction in all patients is to avoid amputation.

Rupture of an intracranial aneurysm--unusual complication of an electric shock.

Here we report about a 35-year-old electrical engineer who was found dead in his study. Postmortem examination revealed that death resulted because of subarachnoid and intraventricular hemorrhage caused by the rupture of an intracranial aneurysm. Right hand and left cheek revealed electrical marks with metallizations on skin, an electric shock was diagnosed to have preceded death. The close temporal correlation suggests that a sudden rise in blood pressure was caused by the electric current and was thus responsible for the rupture of the aneurysm.

[The sick physician. A patient like every other?]. / Der kranke Arzt. Ein Patient wie jeder andere?

The sick physician is a patient like any other. However, thanks to his particular training and experience, he generally knows more about the difficulties involved in diagnosing and treating an illness, and about its complications and course. He has a right not only to receive intelligently founded information, but also to compassion on the part of the colleague treating him, in particular when this is a specialist. Out of concern for his aura of medical perfection, he is often more social than other patients. On account of his insider knowledge, especially when confronted with organizational deficiencies, he tends to be a more difficult patient, who is also more likely to develop complications. On the other hand, he may have had a patient with the same illness, who may serve him as a model. When he has recovered from his illness, he is more critical towards himself and his medical skills. His empathy with the pain and fears of others increases, and his behavior towards his surroundings, in particular his family and patients, may change markedly. The setting up of special advisory centers for sick physicians, as is the case in London, is to be recommended.

Osteoporosis in patients with paralysis after spinal cord injury. A cross sectional study in 46 male patients with dual-energy X-ray absorptiometry.

In a cross-sectional study, 46 male patients with paralysis after spinal cord injury (average age 32 years; injuries sustained from 1 to 26 years ago; 33 Frankel A, 13 Frankel B, C, D) were examined clinically and by dual-energy X-ray absorptiometry (DEXA). Their bone mineral density (BMD) values were compared with age-related controls and correlated to clinical parameters. BMD was reduced in the proximal femur (p < 0.05) and the distal forearm (p < 0.05), but not in the lumbar spine. Demineralisation was influenced in the proximal femur (Z-score -2.95) by immobilisation after surgical treatment. Patients suffering from complete lesions had significantly lower BMD in the lumbar spine (-1.47) compared with patients with incomplete lesions (+0.02). BMD was not significantly influenced by the level of the lesion and the ambulatory status. Long-term monitoring showed significant demineralisation in the proximal femur (r = -0.36) and the distal forearm (r = -0.4), but not in the lumbar spine (r = -0.21). By correlating BMD with clinical parameters, it can be deduced that, firstly, immobilisation after surgical treatment should be reduced to a minimum; secondly, that every effort must be expended to prevent turning an incomplete into a complete lesion; and finally, that rehabilitation treatment should be lifelong.

Ultrastructural findings after intraarticular application of hyaluronan in a canine model of arthropathy.

We investigated the effect of intraarticularly applied hyaluronic acid (hyaluronan) on the cartilaginous structure of experimentally induced chondromalacia patellae in dogs. For the induction of chondromalacia, we used the Pond-Nuki technique, which involved severance and resection of the anterior cruciate ligament, as a canine model of arthropathy in 27 foxhounds (three groups of nine animals each). In a pilot study, we evaluated the effect of resection of the anterior cruciate ligament with no therapy. Patellar specimens were retrieved at 3, 6, and 12 weeks postoperatively. Subsequently, we compared a treatment group that received intraarticular injections of hyaluronan with a placebo group that received saline solution. The groups were compared at 3, 6, and 12 weeks postoperatively. Three animals from the treatment and placebo groups received five injections of hyaluronan during one of the 4-week intervals (weeks 3-6, 6-9, or 12-15). Specimens were retrieved 5 weeks after the last injection. In both groups, the uninvolved contralateral knee served as a control. The specimens were taken from the medial and lateral patellar poles. Histological analysis included light microscopy and transmission electron microscopy. The structural and ultrastructural changes were assessed qualitatively and were quantified with use of a modified Mankin score. Our results indicate that chondromalacia patellae may be induced with the Pond-Nuki technique. We found a significant reduction (p < 0.01) of cartilaginous lesions in the hyaluronan group compared with the placebo group. Our results suggest that intraarticularly applied hyaluronan is effective in delaying the degenerative process of cartilage degradation. Therefore, we conclude that the use of hyaluronan may be indicated during the early stages of chondromalacia.

A new concept in the treatment of anterior knee pain: patellar hypertension syndrome.

This prospective clinical study evaluated 69 patients (136 knees) presenting with anterior knee pain after failure to respond to conservative treatment. All patients agreed to undergo minimally invasive intraosseous pressure measurements of the patella under local anesthesia. Forty patients (50 knees) demonstrated a positive pain provocation test (the typical pain sensation could be reproduced by raising intrapatellar pressure) and were treated with a new method of intraosseous drilling and decompression. Ninety percent of the patients treated experienced pain relief >3 years postoperatively. Repeated intraosseous pressure measurements in 33 knees 1 year postoperatively confirmed objective intraosseous pressure reduction in 88%. Patients with anterior knee pain and a positive pain provocation test were labeled as hypertension syndrome of the patella. These results indicate simple extra-articular patellar decompression may offer a valuable new form of treatment in select patients with anterior knee pain, ie, hypertension syndrome of the patella.

[Effect of a rasp surface on cement penetration in paired cadaver femurs]. / Einfluss der Raspeloberfläche auf die Zementpenetration an gepaarten Leichenfemora.

AIM: The purpose of this investigation was to study two different broach surface designs with regard to cement penetration into human cancellous bone. METHODS: In a cadaver study 15 paired human cadaver femora were prepared using broaches of identical geometry but different surface characteristics. All left femora were prepared using chipped toothed broaches, all right femora using diamond shaped broaches. Cancellous bone was irrigated with 1 liter pulsed lavage. The specimens were imbedded in specially designed pots. Bone cement was applied in a retrograde manner and subjected to a standard pressure protocol with a constant force of 3000 N. Radiographs were taken and horizontal sections were obtained at predefined levels using a diamond saw. Microradiographs were taken and analyzed using image analysis to assess cement penetration into cancellous bone. RESULTS: Pressure curves recorded during cement pressurisation were comparable. The microradiographic evaluation revealed no significant morphometric differences in the different groups with regard to cement penetration into cancellous bone. These findings were similar in all sections obtained. CONCLUSIONS: A standardized model was developed allowing comparison of cement penetration into cancellous bone depending on bone preparation. In the presence of pulsed lavage there is no significant influence of broach surface characteristics on cement penetration into cancellous bone of the upper end of the femur.

Function after correction of a clawed great toe by a modified Robert Jones transfer.

We carried out a cross-sectional study in 51 patients (81 feet) with a clawed hallux in association with a cavus foot after a modified Robert Jones tendon transfer. The mean follow-up was 42 months (9 to 88). In all feet, concomitant procedures had been undertaken, such as extension osteotomy of the first metatarsal and transfer of the tendon of the peroneus longus to peroneus brevis, to correct the underlying foot deformity. All patients were evaluated clinically and radiologically. The overall rate of patient satisfaction was 86%. The deformity of the hallux was corrected in 80 feet. Catching of the big toe when walking barefoot, transfer lesions and metatarsalgia, hallux flexus, hallux limitus and asymptomatic nonunion of the interphalangeal joint were the most frequent complications. Hallux limitus was more likely when elevation of the first ray occurred (p = 0.012). Additional transfer of the tendon of peroneus longus to peroneus brevis was a significant risk factor for elevation of the first metatarsal (p < 0.0001). The deforming force of extensor hallucis longus is effectively eliminated by the Jones transfer, but the mechanics of the first metatarsophalangeal joint are altered. The muscle balance and stability of the entire first ray should be taken into consideration in the management of clawed hallux.

Orthopaedic rehabilitation in a case of Tay-syndrome.

This paper reports on the orthopaedic rehabilitation of a patient with Tay-syndrome. Tay-syndrome is a rare monogen-inherited ektodermal dysplastic syndrome with ichtyosis, fragility of the hair and physical and mental retardation. The congenital ichtyosis is ubiquitous. Only the skin on the flexion side of the extremity joints are not involved (orthocerathosis combined with paraceratotic strings). In this case, a young boy developed bilateral subluxation of the hips and was not able to stand or walk freely. Contemporary pre- and neonatal care has prolonged the survival of newborns with severe genodermatoses, including this syndrome. In this case, it has provided the necessity for orthopaedic treatment of the problems caused by osteosclerosis and muscular spasticity.

[Rectus transfer in spastic diplegia]. / Die Verpflanzung der Sehne des Musculus rectus femoris bei Patienten mit spastischer Diparese.

OBJECTIVES: Change of function of the rectus femoris through medial transfer of its distal tendon. This procedure transforms a hip flexor and knee extensor into a hip and knee flexor. Thus the muscle acts as a hip flexor during the terminal stance phase and swing phase and as a knee flexor during the swing phase. This permits the foot to clear the ground and to improve the spastic gait. INDICATIONS: Functional sequelae of a simultaneous spasticity of knee flexors and extensors causing a stiff gait. Isolated spasticity of rectus muscle with continuous muscle activity during stance and swing phase, recurvatum of the knee during the stance phase, limited flexion (<15(o)) of the knee during the swing phase and lack of clearance of the foot. CONTRAINDICATIONS: Pattern of global flexor spasticity. Loss of power of hip flexors. Paresis of quadriceps. SURGICAL TECHNIQUE: Isolation and detachment of the distal tendon of the rectus femoris. The tendon can be transferred either medially or laterally. For a medial transfer the tendon is sutured to the gracilis tendon which is detached as proximal as possible. This permits to displace the direction of pull behind the center of rotation of the knee. For a lateral transfer the tendon is sutured to the iliotibial tract. RESULTS: In 94,8% of patients (n=137; 274 limbs) followed for a mean of 21 months (7 to 39 months) the results were good to satisfactory using the score of Gage. The Duncan-Ely test was negative in these patients. The gait was markedly improved. Important complications did not occur.

Rehabilitation and orthotic management of congenital and acquired meromelia in the lower limbs of children.

Children with limb deficiencies or amputations of the lower extremities should be enabled to stand or walk according to their state of development, because standing and walking are among the most important preconditions for the best possible integration. Supplying them with a prosthesis, orthosis and orthoprosthesis is therefore indispensable for rehabilitation. While a prosthesis replaces parts of the extremities, an orthosis stabilizes the existing extremity. Orthoprostheses compensate longitudinal malformations, have a supporting effect, allow growth to be controlled and compensate for shortening. Just as important as the remedy is early medical treatment. The medical team taking care of the patient works out a treatment plan where responsible cooperation with the parents is of utmost importance. The focus of all efforts is, of course, the handicapped child. Examples are used to demonstrate the course of successful rehabilitation of children and adolescents with damaged limbs. Equally the psychological situation of the parents and child is taken into consideration.

[Effectiveness of intra-articular application of hyaluronic acid on early forms of femoropatellar arthrosis--an experimental study in dogs]. / Wirksamkeit von intraartikulär applizierter Hyaluronsäure auf Frühformen der Femoropatellararthrose--Eine experimentelle Untersuchung an Hunden.

PURPOSE: We investigated the effects of intraarticularly applied hyaluronic acid on the cartilage-integrity with early-forms of retropatellar cartilage degeneration (chondromalacia patellae) in dogs. METHODS: We used the Pond-Nuki model (tenotomy and resection of the anterior cruciate ligament = ACL) in 27 dogs (foxhounds) (3 groups of 9 animals) PILOT STUDY: ACL-tenotomy and resection, no therapy, specimens retrieval after 3, 6, 12 weeks (3 animals each period). VERUM: ACL-tenotomy and resection, hyaluronic acid (start after 3, 6, 12 weeks), 5 injections in 4 weeks, specimens retrieval after 5 weeks following final injection (12, 15, 21 weeks postoperatively, 3 dogs each period). PLACEBO: same procedure as verum, but saline-injections. Specimens were taken from the medial/lateral patellar pole from both, the operated and the normal knee and examined histologically using various staining methods (HE, Azan, Toluidin, Masson-Goldner, Safranin-O). A modified Mankin score was used to grade cartilage degeneration. RESULTS: Our results demonstrate that the Pond-Nuki model is suitable to experimentally induce chondromalacia patellae. There were significantly less degenerative cartilage changes in the knees treated with hyaluronic acid compared to the placebo-group. CONCLUSION: Our results let assume that hyaluronic acid could be indicated i.e. after arthroscopically diagnosed early cartilage-degeneration, the final conclusions concerning the actual mechanisms and therapeutical effectiveness need however further prospective clinical and experimental investigations.

[Rehabilitation program for children and adolescents with limb defects or amputations of the lower extremity]. / Das Rehabilitationsprogramm bei Kindern und Jugendlichen mit Gliedmassenfehlbildungen oder Amputationen der unteren Extremität.

In rehabilitation of children and adolescents with lower limb deficiencies it is very important that the medical team taking care of the patient works out a treatment plan. Responsible cooperation with the parents is of utmost importance, the focus of all efforts is, of course, the handicapped child. The aims of rehabilitation are illustrated by examples demonstrating the course of successful rehabilitation of children and adolescents with damaged limbs. Equally, the psychological situation of the parents and child is taken into consideration. Children with limb deficiencies or amputation of the lower extremities should be enabled to stand and walk according to their state of development, because standing and walking in particular are among the most important preconditions for the best possible integration. Provision with a prosthesis, orthosis and orthoprosthesis is therefore indispensable for rehabilitation. While a prosthesis replaces parts of an extremity, an orthosis stabilizes the existing extremity. Orthoprostheses compensate longitudinal malformations, have a supporting effect, allow growth to be controlled, and compensate for shortening. Just as important as these technical aids is early medical treatment. The sooner the treatment starts, the better the results.

[The Holt-Oram syndrome. Review of the literature and current orthopedic treatment concepts]. / Das Holt-Oram Syndrom (HOS). Literaturüberblick und aktuelle orthopädische Behandlungskonzepte.

PROBLEM: The clinical manifestation of the Holt-Oram-syndrome (HOS) shows congenital heart-disease and anomalies of the upper limb. The inheritance of this syndrome is autosomal dominant. The question arise, as to whether a contemporary orthopedic concept of treatment could developed based on own experiences and data from the literature. METHODS: We revised data from five patients with HOS treated at the Clinic for Orthopaedics of the University of Heidelberg. The review of the literature revealed a comprehensive and detailed picture of the clinical syndrome and, furthermore, information in respect to a comparative analysis of methods of treatments. RESULTS: Our patients showed characteristic cardiac anomalies, i.e. atrio and ventricular septal defects, and persisting Botall's duct (three cases). The types of malformation of the upper limb corresponded with those found in the literature. Furthermore the indication for amputation of rudimentary or hypoplastic fingers in the Heidelberg clinic was in accordance with the clinical treatments described worldwide. CONCLUSION: The type of treatment of the clubhand in cases with HOS depends on (1) the age and (2) the pattern and degree of accompanying malformations of the upper limb. For patients with aplasia of the thumb or amputation of a rudimental one we recommend pollicisation of the index finger to improve its function.