Axel Wanivenhaus

First Tarsometatarsal Joint: Anatomical Biomechanical Study:

We studied the function of the first tarsometatarsal joint in 100 specimens of 53 cadavers. The study showed that an adduction and abduction movement described earlier was present only in approximately 10% of the specimens. Moreover, eversion of an average of 6.2° often only occurs as a result of dorsal displacement of the joint surfaces of the first metatarsal in relation to the first cuneiform by an average of 2.6 mm. All other movements in the frontal, horizontal, and sagittal plane can be disregarded or are the result of this movement. New conclusions may be drawn from these results, especially with regard to subcapital osteotomies of the first metatarsal and the adductor transfer according to McBride in metatarsus primus varus. These findings challenge the value of the McBride transfer.

Persistent functional and social benefit 5 years after a multidisciplinary arthritis training program

OBJECTIVE To assess the sustainable benefits of a professional, multidisciplinary training program for patients with rheumatoid arthritis. DESIGN Two studies with different observation periods. Study I was a prospective, randomized trial for 1 year. Study II was a noncontrolled observation over 5 years. SETTING The 9-day program for eight patient groups encompassed a multidisciplinary cooperation between rheumatologists, orthopedists, physicotherapists, psychologists and social workers. PATIENTS Sixty-eight consecutive patients with rheumatoid arthritis participated in an arthritis training program either immediately after enrollment in the program or after 1 year. INTERVENTIONS The program covered the following fields: pathogenesis of rheumatoid arthritis, drug therapy, physicotherapy, practical exercise in remedial gymnastics, use of joint protection devices, orthopedic perspectives, psychological counseling, dietetics, information about unproven cures and social assistance. MAIN OUTCOME MEASURES Clinical outcome was assessed by self-report questionnaires: (1) Stanford Health Assessment Questionnaire, (2) Freiburg Questionnaire of Coping with Illness, (3) Beck Depression Inventory, and (4) a 21-point scale to evaluate cognitive-behavioral and environmental impact. RESULTS A significant and persistent improvement of all investigated parameters was demonstrated in the 1-year controlled trial. Between the end-point of the 1-year study and the 5-year evaluation, this improvement increased even more for functional status and coping with illness, whereas depression returned to baseline values. These effects were seen even without reinforcement of the training. CONCLUSION A professional, multidisciplinary approach to educate patients with rheumatoid arthritis leads to a significant and sustained improvement of the clinical outcome and is an approach that should be established as a part of conventional therapy.

Basal Osteotomy of the First Metatarsal for the Correction of Metatarsus Primus Varus Associated With Hallux Valgus

At the University of Vienna Department of Orthopaedics, 26 feet in 21 patients were treated with a basal osteotomy for hallux valgus associated with metatarsus primus varus. In 85% of the cases, a satisfactory result was achieved. Critical analysis revealed shortening of the first metatarsal and elevation of its head, which resulted in excess lateral straining of the foot and metatarsalgia. In 15 cases, osteoarthritis in the metatarsocuneiform joint was also increased. Given these results, an osteotomy that prevents shortening of the first metatarsal and elevation of the head of the first metatarsal, or one that takes these facts into account, seems ideal.

The Arterial Supply of the Sesamoid Bones of the Hallux: The Course and Source of the Nutrient Arteries as an Anatomical Basis for Surgical Approaches to the Great Toe

The arterial supply of the hallux sesamoids was studied in 29 human feet by anatomical dissection. Eight of them underwent radiographic analysis prior to dissection. The sesamoid arteries branch off from the digital plantar arteries of the hallux, which, in turn, are derived from the medial plantar artery and the plantar arch (type A), the plantar arch (type B), or the medial plantar artery (type C). The respective frequencies of types A, B, and C were 52%, 24%, and 24%. The number of sesamoid arteries varied from one (55%) to three (10%) and the number increased with the size of the sesamoid bones. Anatomical knowledge of the course and distribution of these vessels may be of great help to the orthopedist in the understanding of the pathogenesis of avascular necrosis and may provide insight into several technical aspects regarding surgery of the hallux.

Plantar pressure distribution after resection of the metatarsal heads in rheumatoid arthritis.

Surgical correction of the forefoot in rheumatoid arthritis by resection of all metatarsal heads in combination with a resection arthroplasty of the first metatarsophalangeal joint showed excellent and good results in 20 (77%) of 26 cases and satisfactory and fair results in 6 (23%) of 26 cases. Twenty-six feet in 16 patients were operated on by a plantar approach and examined after a mean follow-up period of 50 months (range, 24–90 months). Seventy-three percent of the patients were free of pain. In 75 (58%) of all 130 investigated toes, complete absence of load distribution was noted. In the remaining 55 (42%) toes, we observed a variable extent of function, depending on the length of resection. Although toe function is better in minimal metatarsal resection, single excessive length or plantar spike formation revealed pressure peaks in the metatarsal area. Metatarsal head resection provided reduction of pain and correction of severe deformities, and permitted the patients to wear ordinary shoes in 24 (93%) of 26 cases.

Long-term outcome of total knee replacement in patients with rheumatoid arthritis.

OBJECTIVES We analysed the long-term clinical and radiological results of 68 consecutive total knee replacements in 50 patients with rheumatoid arthritis. METHODS At a mean follow-up of 11.2+/-1.2 years (range, 9.7-13.7) all revisions were included. Thirty-seven knees in 28 patients still alive were followed retrospectively clinically and radiologically, all other patients who died without revision were censored at time of the last clinical follow-up and no patient was lost to follow-up. Revision was necessary in 13 knees (19%, one revised twice), including an overall deep infection rate of 1.47%. RESULTS The survival rate was 81.6+/-0.05% at 12 years with any revision or removal of the prosthesis as an end point. There was no significant difference in survival between cemented, uncemented or hybrid fixation (log rank, 0.2544). The average Knee Society Scores were 77.2 points clinical (range, 40-95 points) and 75.3 points functional (range, 30-100 points), respectively, at final follow-up. The body mass index (BMI) was 25.9 at surgery and 25.3 at follow-up (n.s.). There was no correlation between BMI, age, side, gender and revision frequency. No arthroplasty was at risk for removal or revision at follow-up. CONCLUSIONS The study shows good 10-12-year clinical and radiological results for the PCA knee replacement in patients with rheumatoid arthritis without preference for the method of fixation or patient weight.

Different cup migration in rheumatoid arthritis and arthrosis : A radiographic analysis of 127 uncemented acetabular cups

We compared retrospectively the radiographic migration profiles of 82 acetabular components in 61 patients having rheumatoid arthritis with those of 45 hips having arthrosis who underwent a standardized technique of cementless arthroplasty with the Zweymüller prosthesis (Alloclassic). We used a modification of Dickobs technique of digital migration analysis that corrects for magnification errors and horizontal pelvic tilt. The rheumatoid patients were stratified as having oligoarticular, polyarticular, or mutilating arthritis. The overall rate of acetabular loosening in rheumatoid hips after mean 88 (26-117) months was 4%. Loosening was seen only in cases with mutilating arthritis and acetabular protrusion, where the direction of cup migration was also clearly different from that detected in the other types of rheumatoid arthritis and in arthrosis. The different patterns of cup migration in cementless hip replacement for rheumatoid arthritis, depending on disease severity, is of importance when comparing outcome of total hip arthroplasty in rheumatoid patients.

Faster integration of human allograft bone than of the bovine substitute Lubboc: non-randomized evaluation of 20 cases with benign tumors or tumor-like conditions.

In 20 patients, we studied healing and time for complete integration of human cancellous bone allografts and the bovine substitute Lubboc plain radiographs. They were all operated on because of benign tumors or tumor-like conditions, and followed until integration of the graft or for at least 1 year after operation. The median follow-up was 10 (2–40) months. Allografts showed a better integration than the bovine substitute. We conclude that allografts are to be preferred for these indications.