Andreas Elsner

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation

ObjectiveAn experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint.MethodAnatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically.ResultsHealing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position.ConclusionClinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Insert position in three-component total ankle replacement

Background: Total ankle replacement has become a valuable treatment option for end-stage osteoarthritis. The most recent generation of implants comprises a second interface between the polyethylene insert and the tibial prosthetic component. This may permit a better adaptation of position between the implant components and thereby prevent unphysiological loading of ankle ligaments and reduce polyethylene wear. To date, no available data have evaluated whether the relative position of talar and tibial implant components change over time. Materials and Methods: We assessed the radiographs of 368 ankles that underwent primary arthroplasty with a HINTEGRA® (Newdeal SA, Lyon, France / Integra, Plainsboro, NJ) ankle to determine the spatial relationship between talar and tibial components at the time of surgery and during followup. The mean time to final followup was 51.2 months (range 11 to 98). We analyzed the anteroposterior offset as the distance between the center of the tibiotalar joint and the longitudinal axis of the tibia. Results: The mean anteroposterior offset ratio was 0.0 ± 0.06 (range −0.21 to 0.16), and it remained constant over time. Conclusion: Our data suggest that the latest three-component prosthesis functions similar to the two-component prosthesis, but we believe with an added advantage of allowing an individualized position of the polyethylene insert in response to the individual soft tissue load due to different ankle joint configurations. Level of Evidence: IV, Case Series

Lambrinudi Arthrodesis with Posterior Tibialis Transfer in Adult Drop-Foot

Background: The adult drop-foot is one of the most disabling disorders that affects gait and quality of life. Despite orthoses and orthopaedic shoes, the disability often progresses. We have used the Lambrinudi arthrodesis to correct the bony component of drop-foot in association with a posterior tibial tendon transfer to provide lateral ankle stability and active dorsiflexion. This study presents results obtained in a consecutive series of 19 patients. Materials and Methods: Nineteen patients (mean age, 54.7 years) were treated for drop-foot with an osseous dorsiflexing procedure according to Lambrinudis original technique and a posterior tibial tendon transfer to the lateral cuneiforme bone. Outcome measurements included extended radiographic and clinical investigations, including the AOFAS Hindfoot Score, SF-36, ROM and VAS. The mean followup time was 39 (range, 24 to 62) months. Results: The AOFAS Hindfoot Score improved from 38.9 preoperatively to 73.2 (p < 0.001) at last followup, and the SF-36 scores improved from 38.3 to 70.5 (p < 0.001). All patients were able to wear normal shoes at final followup. Conclusion: In this study of 19 patients, Lambrinudi arthrodesis combined with posterior tibial transfer proved to be a reliable and reproducible treatment for semi-rigid and rigid adult drop-foot caused by several aetiologies. It provided a stable correction of the adult drop-foot and high patient satisfaction in the mid- to long-term. In particular, it enabled the patient to wear normal shoes. Level of Evidence: IV, Prospective Case Series

Die Hautspaltlinien und die Schnittführung bei Fußoperationen

ZusammenfassungHintergrundIm Zuge der immer differenzierter werdenden und an Bedeutung zunehmenden Fußchirurgie ergibt sich die Frage, ob die bisher angewandten Schnittführungen adäquat sind. Die Frage, ob die Langer-Linien bei operativen Eingriffen am Fuß berücksichtigt werden, ist Gegenstand der vorliegenden Untersuchung. Ziel ist es, an Leichenfüßen das Spaltlinienmuster der Haut in allen Fußregionen zu untersuchen und optimale Schnittführung für fußchirurgische Eingriffe zu etablieren.Material und MethodeUntersucht werden 12 Füße von älteren Verstorbenen. Die Präparate sind fixiert. In den einzelnen Hautregionen werden die Spaltlinien dargestellt und ausgewertet. Um die Bedeutung der gewonnenen Erkenntnisse hervorzuheben, werden Spaltlinien und gängige Hautinzisionen der einschlägigen Operationslehren gegenübergestellt.ErgebnisseEs wird gezeigt, dass aktuelle Standardzugänge häufig das Spalthautmuster missachten und somit unkosmetische Narben erklärlich sind. Eine Kartierung idealer Schnittführungen für die einzelnen Operationen wird vorgenommen.SchlussfolgerungDer ideale Schnitt sollte parallel zu den Spaltlinien der Haut erfolgen. Kann dies aus Gründen der optimalen Situseinstellung nicht wahrgenommen werden, so sollten zumindestens große Anteile der Inzision den Linien folgen.AbstractBackgroundIn the constantly evolving, increasingly important field of foot surgery, the question arises as to whether the incision types currently in use are adequate. Whether Langer’s lines should be considered during the operative approach to the foot is examined here. The goal of the current study was to investigate the pattern of skin cleavage lines of cadaveric feet and to establish the optimal incision type for surgical approaches to the foot.Materials and methodsTwelve feet from older deceased subjects were examined. The samples were fixed. The cleavage lines of the individual skin regions were outlined and evaluated. To emphasize the significance of the investigative findings, the cleavage lines and the current, relevant operative approaches were compared.ResultsStandard current approaches often ignore skin cleavage lines, understandably resulting in cosmetically unsatisfactory scars. A chart with ideal incision types for individual operations was created.ConclusionThe ideal incision should run parallel to skin cleavage lines. If this is not completely possible due to operative requirements, then at least a large part of the incision should follow these lines.

The venous pump of the first metatarsophalangeal joint: clinical implications.

Background: Although the anatomy and physiology of the venous circulation of the ankle and midfoot are well documented, the physiologic importance of forefoot mobility has not been reported in the literature. The question of this study was whether the first metatarsophalangeal (MTP) joint may operate, like the ankle, as a “pump” to encourage venous return. Methods: Forty-nine cadaver foot specimens were examined using dissection, plastination, vessel infiltration, and maceration, and radiographic (including venography, MRI, and magnetic resonance angiography) techniques. The anatomy and physiology were described and compared to the ankle joint. Forty patients had biphasic Doppler flow studies. Results: The major finding was the medial drainage of the plantar venous sinus, which is fibrotically bound to the joint capsule. Functional venous valves were evident distally and within fibrous vascular lumens. Mobilization of the first MTP joint led to compression and emptying of the veins. Passive mobilization of the first MTP joint led to an average flow increase of 55% ± 7 (p < 0.0001), while active movement led to an average increase of 78% ± 7 (p < 0.0001). Conclusions: Our described connection between the joint capsule and veins indicates a “toe-ankle pump” with a significant increase of venous blood flow during motion of the MTP joint. Possible clinical applications for an external MTP pump include anti-edema or thromboprophylactic therapy, especially in patients with foot or ankle injuries. A new toe-pump has been designed based on these results.