Peter Ritschl

The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up.

AbstractBackground:The chevron osteotomy, an accepted method for the correction of mild and moderate hallux valgus, is generally advocated for patients younger than the age of fifty years. The purposes of this prospective study were to compare the short-term (two-year) and intermediate-term (five-ye

Comparison of the Results of the Weil and Helal Osteotomies for the Treatment of Metatarsalgia Secondary to Dislocation of the Lesser Metatarsophalangeal Joints

We retrospectively reviewed the outcome of 30 patients who were treated surgically for metatarsalgia resulting from dislocation of one or more lesser metatarsophalangeal (MTP) joints. We used two treatments, including an osteotomy of the metatarsal head (Weil osteotomy, N = 15) or an osteotomy of the metatarsal shaft (Helal osteotomy, N = 15). Before surgery, all patients had been treated with various nonoperative modalities for a minimum of 6 months. Between 1991 and 1993,15 consecutive patients underwent a Helal osteotomy (22 metatarsals), and 15 consecutive patients were subsequently treated between 1994 and 1995 with a Weil osteotomy (25 metatarsals). All patients were evaluated clinically and radiographically at a mean follow-up period of 22 months (range, 12–39 months), noting especially persistent subluxation or dislocation, recurrent metatarsalgia, and transfer lesions. Patients managed with a Weil osteotomy had significantly higher satisfaction (P = 0.049), lower incidence of recurrent metatarsalgia (0 vs 27%, P = 0.107), and fewer transfer lesions (0 vs 41%, P = <0.001) than those managed with a Helal osteotomy. Furthermore, those managed with the Weil procedure had a higher percentage of radiographic reduction and maintenance of the MTP joint dislocation (21 of 25, 84% vs 8 of 22,36% P = 0.002) than those managed with the Helal procedure. In the Weil group, there was also no malunion or pseudoarthrosis; in the Helal group there were five malunions and three pseudoarthroses. Although the follow-up period for the Weil osteotomy (15 months) was shorter than that for the Helal osteotomy (26 months), the former group had higher American Orthopaedic Foot and Ankle Society forefoot scores, which were significantly different from the results attained with the Helal osteotomy. A telephone update was performed on the Weil osteotomy group at an average of 27 months postsurgery, and no patient had experienced changes since the clinical follow-up. We concluded that the Weil procedure is a satisfactory method for correcting metatarsalgia caused by dislocation of the MTP joint and that, because of the high complication rate, the Helal osteotomy is not an acceptable procedure for correcting this condition.

Embolization of Bone Metastases

PURPOSE To assess the effectiveness and clinical usefulness of transcatheter embolization of bone metastases. PATIENTS AND METHODS The procedures and outcome of 61 transcatheter embolization procedures performed in 51 patients with hypervascular skeletal metastases were retrospectively evaluated. Results from computed tomography, magnetic resonance imaging, and diagnostic angiography, performed before and after embolization, were reviewed. RESULTS All embolizations were technically and clinically successful. Major blood loss during surgery was prevented in 32 cases; the size of viable tumor tissue in large, unresectable bone metastases was reduced before radiation or chemotherapy in 17 cases; and otherwise untreatable skeletal pain was decreased in 11 cases. Heavy bleeding from a metastasis was controlled in one case. The complications were temporary paresis of a lower extremity in three patients, cardiac arrest in one patients, and unintentional embolization of synthetic tissue adhesive in one patient. Median survival time was 28 months (range, 3-59 months). CONCLUSION Transcatheter embolization is effective and reliable in the treatment of bone metastases.

The Weil osteotomy: A SEVEN-YEAR FOLLOW-UP

We prospectively evaluated the one- and seven-year results of the Weil osteotomy for the treatment of metatarsalgia with subluxed or dislocated metatarsophalangeal joints in 25 feet of 24 patients. Good to excellent results were achieved in 21 feet (84%) after one year and in 22 (88%) after seven years. The American Orthopaedic Foot and Ankle Society score significantly improved from 48 (SD 15) points before surgery to 75 (SD 24) at one year, and 83 (SD 18) at seven years. The procedure significantly reduced pain, diminished isolated plantar callus formation and increased the patients capacity for walking. Redislocation of the metatarsophalangeal joint was seen in two feet (8%) after one year and in three (12%) after seven years. Although floating toes and restricted movement of the metatarsophalangeal joint may occur, the Weil osteotomy is safe and effective.

Basal Closing Wedge Osteotomy for Correction of Hallux Valgus and Metatarsus Primus Varus: 10- to 22-Year Follow-up

Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144–266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9° (range, 0–40°) and 6.7° (range, 0–18°), respectively. The sesam-oid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.

Intensified Adjuvant IFADIC Chemotherapy for Adult Soft Tissue Sarcoma: A Prospective Randomized Feasibility Trial

Purpose. The present prospective randomized adjuvant trial was carried out to compare the toxicity, feasibility and efficacy of augmented chemotherapy added to hyperfractionated accelerated radiotherapy after wide or marginal resection of grade 2 and grade 3 soft tissue sarcoma (STS).Patients and methods. Fifty-nine patients underwent primary surgery by wide or marginal excision and were subsequently randomized to receive radiotherapy alone or under the addition of six courses of ifosfamide (1500 mg/m(2) , days 1-4), dacarbazine (DTIC) (200 mg/m(2) , days 1-4) and doxorubicin (25 mg/m(2) , days 1-2) administered in 14-day-intervals supported by granulocyte-colony stimulating factor (30 x 10(6) IU/day, s.c.) on days 5-13. According to the randomization protocol, 28 patients received radiotherapy only, whereas 31 patients were treated with additional chemotherapy.Results. The relative ifosfamide-doxorubicin-DTIC (IFADIC) dose intensity achieved was 93%. After a mean observation period of 41+/-19.7 months (range, 8.1-84 months), 16 patients (57%) in the control group versus 24 patients (77%) in the chemotherapy group were free of disease (p>0.05).Within the control group, tumor relapses occurred in 12 patients (43%;six patients with distant metastases, two with local relapse, four with both) versus seven patients (23%; five patients with distant metastases, one with local recurrence, one with both) from the chemotherapy group. Relapse-free survival (RFS) (p=0.1), time to local failure (TLF) (p=0.09), time to distant failure (TDF) (p=0.17) as well as overall survival (OS) (p=0.4) did not differ significantly between the two treatment groups. Treatment-related toxicity was generally mild in both treatment arms.Conclusion. We conclude that the safety profile of intensified IFADIC added to radiotherapy was manageable and tolerable in the current setting. Inclusion of intensified IFADIC was not translated into a significant benefit concerning OS, RFS, TLF andTDF as compared with radiotherapy only, although a potential benefit of chemotherapy for grade 3 STS patients needs to be validated in prospective randomized trials including larger patient numbers.

The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: Good outcome in 21 patients with 42 osteotomies

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.

Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release

Abstract Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15°, or hallux valgus (HV) angle > 30°]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1° preoperatively and 14.6° postoperatively. The respective values for the IM angle were 17.8° and 7.8°. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15° or HV angle > 30 °).

Rotationplasty for limb salvage in the treatment of malignant tumors at the knee. A follow-up study of seventy patients.

Seventy patients who had a rotationplasty for treatment of a malignant tumor in the region of the knee (the femur or the tibia) between 1974 and 1987 were followed for two to thirteen years (mean duration of follow-up, four years). Forty-seven patients had a stage-IIB osteosarcoma; the remaining twenty-three patients had a malignant fibrous histiocytoma, a chondrosarcoma, a Ewing sarcoma, or a giant-cell tumor. The most severe postoperative complication was occlusion of the reanastomosed vessels (seven patients), leading to amputation proximal to the knee in three patients. Other complications were problems with wound-healing (eight patients), transient nerve palsy (five patients), irreversible nerve palsy (two patients), pseudarthrosis (four patients), and rotational malalignment (one patient). Late complications included eight fractures, two infections, two delayed unions, and one lymphatic fistula. More than half of the patients were free of complications related to the operative procedure. Forty-four of the patients who had a stage-IIB osteosarcoma could be followed, and their data were analyzed for survival statistics. These patients had a 58 percent rate of disease-free survival and a 70 per cent rate of over-all survival. One patient had a local recurrence five years after the operation.

Modified Austin Procedure for Correction of Hallux Valgus

The Austin osteotomy is a widely accepted method for correction of mild and moderate hallux valgus. In view of publications by Kitaoka et al. in 1991 and by Mann and colleagues, a more radical lateral soft tissue procedure was added to the originally described procedure. From September 1992 to January 1994, 85 patients underwent an Austin osteotomy combined with a lateral soft tissue procedure to correct their hallux valgus deformities. Seventy-nine patients (94 feet) were available for follow-up. The average patient age at the time of the operation was 47.1 years, and the average follow-up was 16.2 months. The average preoperative intermetatarsal angle was 13.9°, and the average hallux valgus angle was 29.7°. After surgery, the feet were corrected to an average intermetatarsal angle of 5.8° and an average hallux valgus angle of 11.9°. Sesamoid position was corrected from 2.1 before surgery to 0.5 after surgery. The results were also graded according to the Hallux Metatarsophalangeal Interphalangeal Score, and the functional and cosmetic outcomes were graded by the patient. Dissection of the plantar transverse ligament and release of the lateral capsule repositioned the tibial sesamoid and restored the biomechanics around the first metatarsophalangeal joint. There was no increased incidence of avascular necrosis of the first metatarsal head compared with the original technique.