Fabian Krause

Limited open reduction and internal fixation of displaced intra-articular fractures of the calcaneum

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

Treatment of slipped capital femoral epiphysis with a modified Dunn procedure.

BACKGROUND Surgical procedures with use of traditional techniques to reposition the proximal femoral epiphysis in the treatment of slipped capital femoral epiphysis are associated with a high rate of femoral head osteonecrosis. Therefore, most surgeons advocate in situ fixation of the slipped epiphysis with acceptance of any persistent deformity in the proximal part of the femur. This residual deformity can lead to secondary osteoarthritis resulting from femoroacetabular cam impingement. METHODS We retrospectively assessed the cases of twenty-three patients with slipped capital femoral epiphysis after surgical correction with a modified Dunn procedure, an approach that included surgical hip dislocation. The study reviewed the clinical status and radiographs made at the time of surgery, as well as the intraoperative findings. At a minimum follow-up of twenty-four months after surgery, the motion of the treated hip was compared with the motion of the contralateral hip, and the radiographic findings related to the anatomy of the femoral head-neck junction, as well as signs of early osteoarthritis or osteonecrosis, were evaluated. RESULTS Twenty-one patients had excellent clinical and radiographic outcomes with respect to hip function and radiographic parameters. Two patients who developed severe osteoarthritis and osteonecrosis had a poor outcome. The mean slip angle of the femoral head of 47.6° preoperatively was corrected to a normal value of 4.6° (p < 0.0001). The mean flexion and internal rotation postoperatively were 107.3° and 37.8°, respectively. The mean range of motion of the treated hips was not significantly different (p > 0.05) from that of the normal, contralateral hips. Of the eight hips that were considered unstable in the intraoperative clinical assessment, six had been considered stable preoperatively. CONCLUSIONS The treatment of slipped capital femoral epiphysis with the modified Dunn procedure allows the restoration of more normal proximal femoral anatomy by complete correction of the slip angle, such that probability of secondary osteoarthritis and femoroacetabular cam impingement may be minimized. The complication rate from this procedure in our series was low, even in the treatment of unstable slipped capital femoral epiphysis, compared with alternative procedures described in the literature for fixation of slipped capital femoral epiphysis.

Impact of Complications in Total Ankle Replacement and Ankle Arthrodesis Analyzed with a Validated Outcome Measurement

BACKGROUND Major modifications in the design and techniques of total ankle replacement have challenged the perception that ankle arthrodesis is the treatment of choice for end-stage ankle arthritis. High complication and revision rates have been reported after both procedures. METHODS We performed radiographic evaluations at a mean of thirty-nine months following 114 total ankle replacements done with use of commonly used implants and at a mean of thirty-seven months following forty-seven ankle arthrodeses. The mean age was sixty-four years for the patients (fifty-one female and sixty-three male) who underwent total ankle replacement and fifty-nine years in the patients (fifteen female and thirty-two male) who underwent ankle arthrodesis. The impact of complications was analyzed with use of the Ankle Osteoarthritis Scale (AOS), a validated outcome instrument. RESULTS Both groups had significant improvement in the mean AOS score (p < 0.001). There was no significant difference in the mean improvement between the two groups (p = 0.96). The complication rate was 54% following total ankle replacement and 26% following ankle arthrodesis, which was a significant difference (p = 0.003). The impact of major complications on the AOS outcome score was significant in both the total ankle replacement group (p = 0.031) and the ankle arthrodesis group (p = 0.02). CONCLUSIONS At the time of follow-up, at a minimum of two years postoperatively, the outcomes of total ankle replacement and ankle arthrodesis, with regard to pain relief and function, were comparable. While the rate of complications was significantly higher following total ankle replacement, the impact of complications on outcome was clinically relevant in both groups.

Arthroscopic Versus Open Ankle Arthrodesis: A Multicenter Comparative Case Series

BACKGROUND Ankle arthrodesis results in measurable improvements in terms of pain and function in patients with end-stage ankle arthritis. Arthroscopic ankle arthrodesis has gained increasing popularity, with reports of shorter hospital stays, shorter time to solid fusion, and equivalent union rates when compared with open arthrodesis. However, there remains a lack of high-quality prospective data. METHODS We evaluated the results of open and arthroscopic ankle arthrodesis in a comparative case series of patients who were managed at two institutions and followed for two years. The primary outcome was the Ankle Osteoarthritis Scale score, and secondary outcomes included the Short Form-36 physical and mental component scores, the length of hospital stay, and radiographic alignment. There were thirty patients in each group. RESULTS Both groups showed significant improvement in the Ankle Osteoarthritis Scale score and the Short Form-36 physical component score at one and two years. There was significantly greater improvement in the Ankle Osteoarthritis Scale score at one year and two years and shorter hospital stay in the arthroscopic arthrodesis group. Complications, surgical time, and radiographic alignment were similar between the two groups. CONCLUSIONS Open and arthroscopic ankle arthrodesis were associated with significant improvement in terms of pain and function as measured with the Ankle Osteoarthritis Scale score. Arthroscopic arthrodesis resulted in a shorter hospital stay and showed better outcomes at one and two years.

Peroneal Tendon Lesions Caused by Antiglide Plates Used for Fixation of Lateral Malleolar Fractures: The Effect of Plate and Screw Position

Background: Posterolateral antiglide plating of unstable AO-type B lateral malleolar fractures is biomechanically stronger than lateral plating and causes less wound healing problems and less frequent hardware removal. However, the distal end of the plate or the screws may cause peroneal tendinitis. The limits of safe hardware placement have not been established. Method: A retrospective analysis of 70 patients was done to determine hardware position and identify peroneal tendon lesions. An adjunct study involved dissection of the retromalleolar region in 10 embalmed cadaver specimens to study the anatomy of the osteosynovial peroneal groove. Results: Thirty of 70 (43%) patients had the plate removed because of discomfort or signs of peroneal tendinitis. Peroneal tendon lesions were identified intraoperatively in nine of the 30 (30%) patients. Only two of these nine patients had felt symptoms preoperatively. Placement of the distal end of the plate distal to the proximal third of the lateral malleolus did not correlate with a peroneal tendon lesion. However, this placement combined with a screw in the most distal hole of the plate and a prominent screw head was strongly correlated with peroneal tendon lesions. In the anatomic specimens the shape of the osteosynovial part of the peroneal groove was uniform, but its length showed greater variation than the length of the foot. Conclusions: Antiglide plating of lateral malleolar fractures led to high rates of hardware removal and peroneal tendon lesions. Correlations were found to low placement of the plate together with a protruding screw head in the most distal hole of the plate. Distal screw placement should therefore be avoided or the hardware should be removed early. Absence of subjective signs of peroneal tendon irritation does not exclude even a major tendon lesion.

Supramalleolar Lateral Closing Wedge Osteotomy for the Treatment of Varus Ankle Arthrosis

Background: Medial ankle joint pain with localized cartilage degeneration due to medial joint overload in varus malalignment of the hindfoot lends itself to treatment by lateral closing wedge supramalleolar osteotomy. Methods: From 1998 to 2003, nine patients between the ages of 21 to 59 years were operated. The etiology of the malalignment and degeneration was posttraumatic in eight and childhood osteomyelitis in one. Preoperative and postoperative standing radiographs were analyzed to determine the correction of the deformity and the grade of degeneration. Function and pain were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. The average followup was 56 (range 15 to 88) months. Results: The average time to osseous union was 10 ± 3.31 weeks. There were no operative or postoperative complications. The average AOFAS score improved from 48 ± 16.0 preoperatively to 74 ± 11.7 postoperatively (p < 0.004). The average pain subscore improved from 16 ± 8.8 to 30 ± 7.1 (p < 0.008). The average tibial-ankle surface angle improved from 6.9 ± 3.8 degrees of varus preoperatively to 0.6 ± 1.9 degrees of valgus postoperatively (p < 0.004). In the sagittal plane, the tibial-lateral-surface angle remained unchanged. At the final followup, two patients showed progression of radiographic ankle arthrosis grades. In one patient, it rose from grade 0 to I. In the other patient it advanced from grade II to III, with subsequent ankle arthrodesis required 16 months after the index procedure. Seven patients returned to their previous work. Conclusions: Lateral supramalleolar closing wedge osteotomy was an easy and safe procedure, effectively correcting hindfoot malalignment, relieving pain, restoring function, and halting progression of the degeneration in the short-term to mid-term in seven of nine patients.

Reattachment of the tuberosities with cable wires and bone graft in hemiarthroplasties done for proximal humeral fractures with cable wire and bone graft: 58 patients with a 22-month minimum follow-up

Objective: The stability of 2 fixation techniques for the tuberosities in patients with 3- or 4-part proximal humerus fractures treated with hemiarthroplasties was compared. Design: Retrospective review of a nonrandomized sequential series of patients. Setting: Level I university orthopaedic surgery department. Patients: A consecutive series of 58 patients (average age, 64 years) from 1990 to 1999 with 3- and 4-part fractures of the proximal humerus. Intervention: In group 1, 31 patients were treated with either a Neer or Aequalis shoulder prosthesis using nonabsorbable sutures and no bone graft for the reattachment of the tuberosities. In group 2, 27 patients were treated with either an Aequalis or Epoca shoulder prosthesis and a combination of cable fixation and bone grafting. Main Outcome Measurements: At follow-up (average, 32 months), radiographs were taken to confirm tuberosity fixation or degree of displacement or resorption. Functional outcome was assessed by the Constant-Murley Score. Results: Significantly more dislocated tuberosities were found radiographically in group 1 (10 of 13 in total, P = 0.011), and significantly more tuberosities were resorbed in group 1 (9 of 12 in total, P = 0.012). Significant differences in functional results among healed versus failed tuberosity fixation were observed for activity of daily living (P = 0.05), range of motion (P = 0.002), strength (P = 0.01), the total score (P = 0.008), and the passive rotation amplitude (P = 0.04). Conclusion: In hemiarthroplasties for proximal humeral fractures, the reattachment of the tuberosities with cable wire and bone grafting gives consistently better radiographic and functional results than with suture fixation alone.

Ankle joint pressure in pes cavovarus

A cavovarus foot deformity was simulated in cadaver specimens by inserting metallic wedges of 15 degrees and 30 degrees dorsally into the first tarsometatarsal joint. Sensors in the ankle joint recorded static tibiotalar pressure distribution at physiological load. The peak pressure increased significantly from neutral alignment to the 30 degrees cavus deformity, and the centre of force migrated medially. The anterior migration of the centre of force was significant for both the 15 degrees (repeated measures analysis of variance (ANOVA), p = 0.021) and the 30 degrees (repeated measures ANOVA, p = 0.007) cavus deformity. Differences in ligament laxity did not influence the peak pressure. These findings support the hypothesis that the cavovarus foot deformity causes an increase in anteromedial ankle joint pressure leading to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.

Tibial Nerve Palsy Associated with Lateralizing Calcaneal Osteotomy: Case Reviews and Technical Tip:

Level of Evidence: V, Expert Opinion

Ankle joint pressure changes in a pes cavovarus model after lateralizing calcaneal osteotomies.

Background: Tendon transfers and calcaneal osteotomies are commonly used to treat symptoms related to medial ankle arthrosis in fixed pes cavovarus. However, the relative effect of these osteotomies in terms of lateralizing the ground contact point of the hindfoot and redistributing ankle joint contact stresses are unknown. Materials and Methods: Pes cavovarus with fixed hindfoot varus was simulated in eight cadaver specimens. The effect of three types of calcaneal osteotomies on the migration of the center of force and tibiotalar peak pressure at 300 N axial static load (half-body weight) were recorded using pressure sensors. Results: A significant lateral shift of the center of force was observed: 4.9 mm for the laterally closing Z-shaped osteotomy with additional lateralization of the tuberosity, 3.4 mm for the lateral sliding osteotomy of the calcaneal tuberosity, and 2.7 mm for the laterally closing Z-shaped osteotomy (all p < 0.001). A significant peak pressure reduction was recorded: −0.53 MPa for the Z-shaped osteotomy with lateralization, −0.58 MPa for the lateral sliding osteotomy of the calcaneal tuberosity, and −0.41 MPa for the Z-shaped osteotomy (all p < 0.01). Conclusion: This cadaver study supports the hypothesis that lateralizing calcaneal osteotomies substantially help to normalize ankle contact stresses in pes cavovarus.