Carsten Wingenfeld

Treatment of Isolated Peroneus Longus Tears and a Review of the Literature

Background. Isolated peroneus longus tendon tears are rare and represent a frequently overlooked source of lateral ankle pain and dysfunction. Only few cases of isolated peroneus longus tendon tears have been reported and a common treatment algorithm does not exist. The purpose of this study was to give an overview of the literature and to present our experience of 6 consecutive cases that have been treated successfully by operation and immobilizing cast. Methods. A comprehensive chart review was performed to compile each patient’s age, sex, onset of symptoms, time between first symptoms and diagnosis, surgical findings, surgical treatment, length of follow-up, and outcome. The average patient age was 48 years (range 20-63 years). Results. Acute tears occurred in 4 cases, and 2 patients reported about a chronic onset of symptoms. The cause for acute tears was an acute inversion ankle sprain in all cases. Diagnosis was made after an average of 11 months (range 0.75-24 months). There were 2 complete tears, and other 4 were incomplete. An os peroneum was present in 2 cases. In 5 of 6 cases, the results after surgical treatment were excellent or good after a mean follow-up of 28.6 months (range 12-78 months). Conclusion. This study indicates that lateral ankle pain may be due to isolated acute or chronic peroneus longus tendon tears. Thorough clinical and radiological diagnosis is necessary to detect this uncommon injury in time. Patients with acute onset of symptoms and short time between symptoms and diagnosis tend to fare better than the chronic tears and delayed diagnosis. Surgical intervention yields successful and predictable results. Level of Evidence: Level III: Retrospective comparative study

Patientensicherheit in der Orthopädie: Implementierung und erste Erfahrungen mit 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.

Die Cheilektomie und Operation nach Kessel-Bonney zur Behandlung des initialen Hallux rigidus

OBJECTIVE Joint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait. INDICATIONS Hallux rigidus stage I and II according to Regnaulds classification. CONTRAINDICATIONS Hallux rigidus Regnauld stage III. General medical contraindications to surgical interventions and anesthesiological procedures. SURGICAL TECHNIQUE Operation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2-3 mm. Osteosynthesis with mini-plate or transosseous suture. POSTOPERATIVE MANAGEMENT Postoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3-4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks. RESULTS 53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10-51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3 degrees for dorsal extension and 17.1 degrees for plantar flexion. Function had increased to a dorsiflexion of 34.2 degrees and a plantar flexion of 32.8 degrees. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: +/- 16) increased postoperatively to a mean value of 78.9 (SD: +/- 12).ZusammenfassungOperationszielGelenkerhaltender Eingriff bei initialer Arthrose des Metatarsophalangealgelenks I zur Schmerzlinderung sowie Wiederherstellung der eingeschränkten Beweglichkeit, insbesondere der Dorsalextension, und eines harmonischen Abrollvorgangs im Bereich des ersten Strahls.IndikationenHallux rigidus der Stadien I und II nach Regnauld.KontraindikationenHallux rigidus des Stadiums III nach Regnauld.Allgemeine Operations- und Narkoserisiken.OperationstechnikOperation in Allgemein-, Spinal- oder Regionalanästhesie (z.B. Fussblock) möglich. Blutsperre am Ober- oder Unterschenkel. Längs verlaufende Inzision über der Streckseite des Metatarsophalangealgelenks I. Unter Schonung der Sehne des Musculus extensor hallucis longus und des dorsalen Gefäss-Nerven-Bündels Längsinzision der dorsalen Kapsel. Cheilektomie: Entfernung von gelenknahen Osteophyten am Grosszehengrundglied und ersten Mittelfusskopf. Resektion des dorsalen Drittels des Metatarsale-I-Kopfs mit der oszillierenden Säge in Plantarflexion des Grundglieds. Lösung der plantaren Adhäsionen. Operation nach Kessel-Bonney: Präparation der proximalen Phalanx. Inkomplette Osteotomie mit der oszillierenden Säge im metaphysären Bereich der Grundphalanx unter Entnahme eines Keils mit einer dorsalen Basis von 2–3 mm. Belastungsstabile Osteosynthese (z.B. Miniplatte oder transossäre Naht).WeiterbehandlungPostoperative Hochlagerung des Fusses. Analgesie mit nichtsteroidalen Antiphlogistika. Verbandsschuh für 3–4 Wochen. Ab dem 1. postoperativen Tag schmerzorientierte Vollbelastung. Mobilisation des Grosszehengrundgelenks mit Hilfe eines Deuser-Bands. Anlage eines redressierenden Tapeverbands, der die Grosszehe in korrigierender, dorsalextendierender Stellung hält, für insgesamt 3 Wochen. Klinische und radiologische Kontrolluntersuchungen 6 und 12 Wochen postoperativ.ErgebnisseEs wurden 53 Operationen an 45 Patienten durchgeführt. 39 Patienten (86%; 28 Frauen, elf Männer, Durchschnittsalter 43,6 Jahre) konnten klinisch, radiologisch und mittels eines eigenen, von Kitaoka et al. abgeleiteten Fragebogens retrospektiv untersucht werden. Neben Schmerz, Funktion, Tätigkeitseinschränkung, evtl. erforderlicher Schuhzurichtung und Beweglichkeit berücksichtigt dieser Fragebogen auch subjektive Kriterien wie Patientenzufriedenheit, die Dauer der Arbeitsunfähigkeit und die Wiedererlangung der Sportfähigkeit.Nach durchschnittlich 26 Monaten (10–51 Monate) waren 32 von 39 Patienten (82%) subjektiv sehr zufrieden oder zufrieden. Das präoperative Bewegungsausmass betrug im Mittel 12,3° für die Dorsalextension und 17,1° für die Plantarflexion und konnte postoperativ deutlich gesteigert werden (Dorsalextension 34,2° und Plantarflexion 32,8°). Die normale Gehfähigkeit wurde nach durchschnittlich 3,7 Wochen von allen Patienten erreicht. Als revisionspflichtige Komplikation trat eine Wundheilungsstörung auf, die folgenlos ausheilte.In Anlehnung an den Vorfussscore von Kitaoka et al. lag präoperativ ein mittlerer Punktwert von 44,3 (Standardabweichung [SD]: ± 16) vor, welcher postoperativ zum Zeitpunkt der Nachuntersuchung auf 78,9 (SD: ± 12) gestiegen war.AbstractObjectiveJoint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait.IndicationsHallux rigidus stage I and II according to Regnaulds classification.ContraindicationsHallux rigidus Regnauld stage III.General medical contraindications to surgical interventions and anesthesiological procedures.Surgical TechniqueOperation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2–3 mm. Osteosynthesis with mini-plate or transosseous suture.Postoperative ManagementPostoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3–4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks.Results53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10–51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3° for dorsal extension and 17.1° for plantar flexion. Function had increased to a dorsiflexion of 34.2° and a plantar flexion of 32.8°. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: ± 16) increased postoperatively to a mean value of 78.9 (SD: ± 12).

[Cheilectomy and Kessel-Bonney procedure for treatment of initial hallux rigidus].

OBJECTIVE Joint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait. INDICATIONS Hallux rigidus stage I and II according to Regnaulds classification. CONTRAINDICATIONS Hallux rigidus Regnauld stage III. General medical contraindications to surgical interventions and anesthesiological procedures. SURGICAL TECHNIQUE Operation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2-3 mm. Osteosynthesis with mini-plate or transosseous suture. POSTOPERATIVE MANAGEMENT Postoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3-4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks. RESULTS 53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10-51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3 degrees for dorsal extension and 17.1 degrees for plantar flexion. Function had increased to a dorsiflexion of 34.2 degrees and a plantar flexion of 32.8 degrees. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: +/- 16) increased postoperatively to a mean value of 78.9 (SD: +/- 12).ZusammenfassungOperationszielGelenkerhaltender Eingriff bei initialer Arthrose des Metatarsophalangealgelenks I zur Schmerzlinderung sowie Wiederherstellung der eingeschränkten Beweglichkeit, insbesondere der Dorsalextension, und eines harmonischen Abrollvorgangs im Bereich des ersten Strahls.IndikationenHallux rigidus der Stadien I und II nach Regnauld.KontraindikationenHallux rigidus des Stadiums III nach Regnauld.Allgemeine Operations- und Narkoserisiken.OperationstechnikOperation in Allgemein-, Spinal- oder Regionalanästhesie (z.B. Fussblock) möglich. Blutsperre am Ober- oder Unterschenkel. Längs verlaufende Inzision über der Streckseite des Metatarsophalangealgelenks I. Unter Schonung der Sehne des Musculus extensor hallucis longus und des dorsalen Gefäss-Nerven-Bündels Längsinzision der dorsalen Kapsel. Cheilektomie: Entfernung von gelenknahen Osteophyten am Grosszehengrundglied und ersten Mittelfusskopf. Resektion des dorsalen Drittels des Metatarsale-I-Kopfs mit der oszillierenden Säge in Plantarflexion des Grundglieds. Lösung der plantaren Adhäsionen. Operation nach Kessel-Bonney: Präparation der proximalen Phalanx. Inkomplette Osteotomie mit der oszillierenden Säge im metaphysären Bereich der Grundphalanx unter Entnahme eines Keils mit einer dorsalen Basis von 2–3 mm. Belastungsstabile Osteosynthese (z.B. Miniplatte oder transossäre Naht).WeiterbehandlungPostoperative Hochlagerung des Fusses. Analgesie mit nichtsteroidalen Antiphlogistika. Verbandsschuh für 3–4 Wochen. Ab dem 1. postoperativen Tag schmerzorientierte Vollbelastung. Mobilisation des Grosszehengrundgelenks mit Hilfe eines Deuser-Bands. Anlage eines redressierenden Tapeverbands, der die Grosszehe in korrigierender, dorsalextendierender Stellung hält, für insgesamt 3 Wochen. Klinische und radiologische Kontrolluntersuchungen 6 und 12 Wochen postoperativ.ErgebnisseEs wurden 53 Operationen an 45 Patienten durchgeführt. 39 Patienten (86%; 28 Frauen, elf Männer, Durchschnittsalter 43,6 Jahre) konnten klinisch, radiologisch und mittels eines eigenen, von Kitaoka et al. abgeleiteten Fragebogens retrospektiv untersucht werden. Neben Schmerz, Funktion, Tätigkeitseinschränkung, evtl. erforderlicher Schuhzurichtung und Beweglichkeit berücksichtigt dieser Fragebogen auch subjektive Kriterien wie Patientenzufriedenheit, die Dauer der Arbeitsunfähigkeit und die Wiedererlangung der Sportfähigkeit.Nach durchschnittlich 26 Monaten (10–51 Monate) waren 32 von 39 Patienten (82%) subjektiv sehr zufrieden oder zufrieden. Das präoperative Bewegungsausmass betrug im Mittel 12,3° für die Dorsalextension und 17,1° für die Plantarflexion und konnte postoperativ deutlich gesteigert werden (Dorsalextension 34,2° und Plantarflexion 32,8°). Die normale Gehfähigkeit wurde nach durchschnittlich 3,7 Wochen von allen Patienten erreicht. Als revisionspflichtige Komplikation trat eine Wundheilungsstörung auf, die folgenlos ausheilte.In Anlehnung an den Vorfussscore von Kitaoka et al. lag präoperativ ein mittlerer Punktwert von 44,3 (Standardabweichung [SD]: ± 16) vor, welcher postoperativ zum Zeitpunkt der Nachuntersuchung auf 78,9 (SD: ± 12) gestiegen war.AbstractObjectiveJoint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait.IndicationsHallux rigidus stage I and II according to Regnaulds classification.ContraindicationsHallux rigidus Regnauld stage III.General medical contraindications to surgical interventions and anesthesiological procedures.Surgical TechniqueOperation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2–3 mm. Osteosynthesis with mini-plate or transosseous suture.Postoperative ManagementPostoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3–4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks.Results53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10–51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3° for dorsal extension and 17.1° for plantar flexion. Function had increased to a dorsiflexion of 34.2° and a plantar flexion of 32.8°. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: ± 16) increased postoperatively to a mean value of 78.9 (SD: ± 12).

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.

[Distal soft-tissue procedure in hallux valgus deformity].

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.

Distaler Weichteileingriff am Großzehengrundgelenk bei Hallux-valgus-Deformität@@@Distal soft-tissue procedure in hallux valgus deformity

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.

Die Cheilektomie und Operation nach Kessel-Bonney zur Behandlung des initialen Hallux rigidus@@@Cheilectomy and Kessel-Bonney Procedure for Treatment of Initial Hallux Rigidus

OBJECTIVE Joint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait. INDICATIONS Hallux rigidus stage I and II according to Regnaulds classification. CONTRAINDICATIONS Hallux rigidus Regnauld stage III. General medical contraindications to surgical interventions and anesthesiological procedures. SURGICAL TECHNIQUE Operation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2-3 mm. Osteosynthesis with mini-plate or transosseous suture. POSTOPERATIVE MANAGEMENT Postoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3-4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks. RESULTS 53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10-51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3 degrees for dorsal extension and 17.1 degrees for plantar flexion. Function had increased to a dorsiflexion of 34.2 degrees and a plantar flexion of 32.8 degrees. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: +/- 16) increased postoperatively to a mean value of 78.9 (SD: +/- 12).ZusammenfassungOperationszielGelenkerhaltender Eingriff bei initialer Arthrose des Metatarsophalangealgelenks I zur Schmerzlinderung sowie Wiederherstellung der eingeschränkten Beweglichkeit, insbesondere der Dorsalextension, und eines harmonischen Abrollvorgangs im Bereich des ersten Strahls.IndikationenHallux rigidus der Stadien I und II nach Regnauld.KontraindikationenHallux rigidus des Stadiums III nach Regnauld.Allgemeine Operations- und Narkoserisiken.OperationstechnikOperation in Allgemein-, Spinal- oder Regionalanästhesie (z.B. Fussblock) möglich. Blutsperre am Ober- oder Unterschenkel. Längs verlaufende Inzision über der Streckseite des Metatarsophalangealgelenks I. Unter Schonung der Sehne des Musculus extensor hallucis longus und des dorsalen Gefäss-Nerven-Bündels Längsinzision der dorsalen Kapsel. Cheilektomie: Entfernung von gelenknahen Osteophyten am Grosszehengrundglied und ersten Mittelfusskopf. Resektion des dorsalen Drittels des Metatarsale-I-Kopfs mit der oszillierenden Säge in Plantarflexion des Grundglieds. Lösung der plantaren Adhäsionen. Operation nach Kessel-Bonney: Präparation der proximalen Phalanx. Inkomplette Osteotomie mit der oszillierenden Säge im metaphysären Bereich der Grundphalanx unter Entnahme eines Keils mit einer dorsalen Basis von 2–3 mm. Belastungsstabile Osteosynthese (z.B. Miniplatte oder transossäre Naht).WeiterbehandlungPostoperative Hochlagerung des Fusses. Analgesie mit nichtsteroidalen Antiphlogistika. Verbandsschuh für 3–4 Wochen. Ab dem 1. postoperativen Tag schmerzorientierte Vollbelastung. Mobilisation des Grosszehengrundgelenks mit Hilfe eines Deuser-Bands. Anlage eines redressierenden Tapeverbands, der die Grosszehe in korrigierender, dorsalextendierender Stellung hält, für insgesamt 3 Wochen. Klinische und radiologische Kontrolluntersuchungen 6 und 12 Wochen postoperativ.ErgebnisseEs wurden 53 Operationen an 45 Patienten durchgeführt. 39 Patienten (86%; 28 Frauen, elf Männer, Durchschnittsalter 43,6 Jahre) konnten klinisch, radiologisch und mittels eines eigenen, von Kitaoka et al. abgeleiteten Fragebogens retrospektiv untersucht werden. Neben Schmerz, Funktion, Tätigkeitseinschränkung, evtl. erforderlicher Schuhzurichtung und Beweglichkeit berücksichtigt dieser Fragebogen auch subjektive Kriterien wie Patientenzufriedenheit, die Dauer der Arbeitsunfähigkeit und die Wiedererlangung der Sportfähigkeit.Nach durchschnittlich 26 Monaten (10–51 Monate) waren 32 von 39 Patienten (82%) subjektiv sehr zufrieden oder zufrieden. Das präoperative Bewegungsausmass betrug im Mittel 12,3° für die Dorsalextension und 17,1° für die Plantarflexion und konnte postoperativ deutlich gesteigert werden (Dorsalextension 34,2° und Plantarflexion 32,8°). Die normale Gehfähigkeit wurde nach durchschnittlich 3,7 Wochen von allen Patienten erreicht. Als revisionspflichtige Komplikation trat eine Wundheilungsstörung auf, die folgenlos ausheilte.In Anlehnung an den Vorfussscore von Kitaoka et al. lag präoperativ ein mittlerer Punktwert von 44,3 (Standardabweichung [SD]: ± 16) vor, welcher postoperativ zum Zeitpunkt der Nachuntersuchung auf 78,9 (SD: ± 12) gestiegen war.AbstractObjectiveJoint-preserving procedure for initial osteoarthritis of the first metatarsophalangeal joint for improvement of restricted joint motion and achievement of a harmonic gait.IndicationsHallux rigidus stage I and II according to Regnaulds classification.ContraindicationsHallux rigidus Regnauld stage III.General medical contraindications to surgical interventions and anesthesiological procedures.Surgical TechniqueOperation in regional anesthesia (foot block). Tourniquet. Longitudinal skin incision over the dorsal aspect of the first metatarsophalangeal joint. Incision of the joint capsule with protection of the extensor hallucis longus tendon and the dorsal neurovascular bundle. Cheilectomy: removal of osteophytes at the metatarsal head and the base of the proximal phalanx. Resection of the dorsal third of the metatarsal head with an oscillating saw in plantar flexion of the proximal phalanx. Kessel-Bonney procedure: dissection of the proximal phalanx. Incomplete dorsal osteotomy with an oscillating saw at the metaphysis of the proximal phalanx and removal of a dorsal wedge with a base of 2–3 mm. Osteosynthesis with mini-plate or transosseous suture.Postoperative ManagementPostoperative elevation of the operated foot. Analgesia with nonsteroidal anti-inflammatory drugs. Postoperative shoe for 3–4 weeks. Immediate weight bearing. Mobilization of the metatarsophalangeal joint with an elastic bandage. Taping in extension and elastic forefoot dressing for 3 weeks postoperatively. Clinical and radiologic controls after 6 and 12 weeks.Results53 operations on 45 patients were performed. 39 patients (86%; 28 female, eleven male, mean age 43.6 years) were followed up. After a period of 26 months (range: 10–51 months), 32 of 39 patients (82%) were satisfied or very satisfied. The median preoperative range of motion was 12.3° for dorsal extension and 17.1° for plantar flexion. Function had increased to a dorsiflexion of 34.2° and a plantar flexion of 32.8°. All patients returned to a normal walking ability after a mean period of 3.7 weeks. Due to delayed wound healing, one revision was necessary. According to Kitaokas Forefoot Score, the mean preoperative value of 44.3 (standard deviation [SD]: ± 16) increased postoperatively to a mean value of 78.9 (SD: ± 12).