Reinhard Schuh

Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome

PurposeAnkle arthrodesis (AAD) and total ankle replacement (TAR) are the major surgical treatment options for severe ankle arthritis. There is an ongoing discussion in the orthopaedic community whether ankle arthrodesis or ankle fusion should be the treatment of choice for end stage osteoarthritis. The purpose of this study was to compare the participation in sports and recreational activities in patients who underwent either AAD or TAR for end-stage osteoarthritis of the ankle.MethodsA total of 41 patients (21 ankle arthrodesis /20 TAR) were examined at 34.5 (SD18.0) months after surgery. At follow-up, pre- and postoperative participation in sports and recreational activities has been assessed. Activity levels were determined using the ankle activity score according to Halasi et al. and the University of California at Los Angeles (UCLA) activity scale. Clinical and functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. The percentage of patients participating in sports and recreational activities, UCLA score and AOFAS score were compared between both treatment groups.ResultsIn the AAD group 86% were active in sports preoperatively and in the TAR group this number was 76%. Postoperatively in both groups 76% were active in sports (AAD, p = 0.08). The UCLA score was 7.0 (± 1.9) in the AAD group and 6.8 (± 1.8) in the TAR group (p = 0.78). The AOFAS score reached 75.6 (± 14) in the AAD group and 75.6 (± 16) in the TAR group (p = 0.97). The ankle activity score decrease was statistically significant for both groups (p = 0.047).ConclusionsOur study revealed no significant difference between the groups concerning activity levels, participation in sports activities, UCLA and AOFAS score. After AAD the number of patients participating in sports decreased. However, this change was not statistically significant.

Impact of Implant Developers on Published Outcome and Reproducibility of Cohort-Based Clinical Studies in Arthroplasty

BACKGROUND The reproducibility of the results of cohort-based clinical studies of arthroplasty procedures by the average orthopaedic surgeon is a major issue involving the quality of the scientific literature. We compared the results of a comprehensive literature analysis with data from national arthroplasty registries to examine the influence of arthroplasty implant inventors on the outcomes published in peer-reviewed journals. METHODS A structured review of the literature published in MEDLINE-listed journals was performed. A comparison of the average revision rates in the identified studies (adjusted for the number of arthroplasty cases and the duration of follow-up) with the registry data was then conducted. RESULTS Seventeen of the analyzed arthroplasty implants were developed in the United States. Studies by the developers of these implants often had a substantial influence on the published outcome. For approximately 50% of the implant systems analyzed, the average revision rate derived by combining all published studies showed a statistically significant and clinically relevant deviation from the revision rate derived from the arthroplasty registry data, which reflected the outcome in the average patient. For the majority of implants for which the revision rate calculated from the published clinical studies was very low compared with the rate calculated from the registry data, the developing institution accounted for 39% to 100% of the published outcome data for the implant. In contrast, the published results were usually reproducible in clinical practice if <25% of the published data were reported by the developers. Three of the nine arthroplasty implants developed in Europe showed a significant and clinically relevant difference between the revision rate derived from only the studies published by the developers and the rate calculated from the registry data. However, because of the considerably greater amount of data from independent studies that was typically available for the European implants than for the American implants, studies by the developer that deviated significantly from the registry data could usually also be identified as outliers by a meta-analysis of all published studies. A high proportion of the published data involving three of the European implants was reported by the inventors, but comparison with the registry data revealed that the average published revision rates for two of these three implants were reproducible in clinical practice. CONCLUSIONS The published results of the clinical studies involving many of the arthroplasty implants, especially implants developed in the United States, were highly influenced by reports from the center that developed the implant. This often had a substantial effect on the reproducibility of the outcome data. There appeared to be relevant differences between the medical research systems in Europe and the United States that also affected the reproducibility and applicability of the results for the average surgeon. Registry data can contribute substantial added value to an informed discussion of arthroplasty outcomes.

Gait Abnormalities and Inflammatory Cytokines in an Autologous Nucleus Pulposus Model of Radiculopathy

Study Design. The authors investigated gait abnormalities and mechanical hypersensitivity associated with invertebral disc herniation in a rat model of radiculopathy. Further evaluation involved assessing how nucleus pulposus (NP) injury affected systemic cytokine expression and molecular changes at the dorsal root ganglion (DRG). Objective. The objective of this work was to describe the gait and behavioral changes in an animal model of disc-herniation induced radiculopathy. A second objective included examining how these functional changes correlated with neuroinflammation and autoreactive lymphocyte immune activation. Summary of Background Data. Animal models of radiculopathy describe demyelination, slowed nerve conduction, and heightened pain sensitivity after application of autologous NP to the DRG. The quantitative impact of disc herniation on animal locomotion has not been investigated. Further, while local inflammation occurs at the injury site, the role of autoimmune cytokines reactive against previously immune-sequestered NP requires investigation. Methods. NP-treated animals (n = 16) received autologous tail NP placed onto the L5 DRG exposed by unilateral facetectomy, and control animals (n = 16) underwent exposure only. At weekly time points, animals were evaluated for mechanical allodynia, thermal hyperalgesia, and gait characteristics through digitized video analysis. Serum cytokine content was measured after animal sacrifice, and immunohistochemistry tested DRG tissue for mediators of inflammation and immune activation. Results. Sensory testing revealed mechanical allodynia in the affected limb of NP-treated rats compared with sham animals (P < 0.01) at all time points. Gait analysis reflected functional locomotive consequences of marked asymmetry (P = 0.048) and preference to bear weight on the contralateral limb (duty factor imbalance, P < 0.01) at early time points. Equivalent serum cytokine expression occurred in both groups, confirming the local inflammatory nature of this disease model. Immunohistochemistry of the sectioned DRGs revealed equivalent postsurgical inflammatory activation (interleukin 23, P = 0.47) but substantial early immune activation in the NP-treated group (interleukin 17, P = 0.01). Conclusion. This model of radiculopathy provides evidence of altered gait in a model of noncompressive disc herniation. Systemic inflammation was absent, but mechanical allodynia, local inflammation, and autoreactive immune activation were observed. Future work will involve therapeutic interventions to rescue animals from the phenotype of inflammatory radiculopathy.

Rehabilitation After Hallux Valgus Surgery: Importance of Physical Therapy to Restore Weight Bearing of the First Ray During the Stance Phase

Background: Operative treatment of people with hallux valgus can yield favorable clinical and radiographic results. However, plantar pressure analysis has demonstrated that physiologic gait patterns are not restored after hallux valgus surgery. Objective: The purpose of this study was to illustrate the changes of plantar pressure distribution during the stance phase of gait in patients who underwent hallux valgus surgery and received a multimodal rehabilitation program. Design: This was a prospective descriptive study. Methods: Thirty patients who underwent Austin (n=20) and scarf (n=10) osteotomy for correction of mild to moderate hallux valgus deformity were included in this study. Four weeks postoperatively they received a multimodal rehabilitation program once per week for 4 to 6 weeks. Plantar pressure analysis was performed preoperatively and 4 weeks, 8 weeks, and 6 months postoperatively. In addition, range of motion of the first metatarsophalangeal joint was measured, and the American Orthopaedic Foot and Ankle Society (AOFAS) forefoot questionnaire was administered preoperatively and at 6 months after surgery. Results: The mean AOFAS score significantly increased from 60.7 points (SD=11.9) preoperatively to 94.5 points (SD=4.5) 6 months after surgery. First metatarsophalangeal joint range of motion increased at 6 months postoperatively, with a significant increase in isolated dorsiflexion. In the first metatarsal head region, maximum force increased from 117.8 N to 126.4 N and the force-time integral increased from 37.9 N·s to 55.6 N·s between the preoperative and 6-month assessments. In the great toe region, maximum force increased from 66.1 N to 87.2 N and the force-time integral increased from 18.7 N·s to 24.2 N·s between the preoperative and 6-month assessments. Limitations: A limitation of the study was the absence of a control group due to the descriptive nature of the study. Conclusions: The results suggest that postoperative physical therapy and gait training may lead to improved function and weight bearing of the first ray after hallux valgus surgery.

The Scarf Osteotomy with Minimally Invasive Lateral Release for Treatment of Hallux Valgus Deformity Intermediate and Long-Term Results

BACKGROUND Little is known about the long-term results of surgical correction of hallux valgus deformity, in particular, the recurrence rate and factors leading to recurrence. METHODS Of one hundred and eight patients (115 feet) who underwent a Scarf osteotomy, ninety-three patients (ninety-three feet) were examined at an average duration of follow-up of 124 months. Clinical examination before surgery and at the time of final follow-up included an evaluation of range of motion, pain as measured with a visual analog scale, and American Orthopaedic Foot & Ankle Society (AOFAS) scores. The Foot and Ankle Outcome Score (FAOS) was also assessed postoperatively. Radiographic data were evaluated preoperatively, at six weeks postoperatively, and at the time of final follow-up. Additional radiographic data were available for seventy-nine patients of the same patient cohort at an average of twenty-seven months postoperatively. RESULTS The median overall AOFAS score improved from 57 points preoperatively to 95 points at the time of final follow-up. All radiographic measurements (hallux valgus angle [HVA], intermetatarsal angle [IMA], distal metatarsal articular angle [DMAA], and sesamoid bone position) showed significant (p < 0.05) improvement at the time of final follow-up compared with preoperatively. The rate of recurrence (an HVA of ≥20°) at the time of final follow-up was 30%. We were unable to determine if recurrence resulted in functional impairment or consequences for quality of life. CONCLUSIONS The recurrence rate after ten years was 30%, and a higher final HVA resulted in higher pain levels. The limitations imposed by nonvalidated outcome measures precluded conclusions about the influence of HVA on function or quality of life.

Minimally invasive hallux valgus surgery: a critical review of the evidence.

This systematic review aims to illustrate the published results of “minimally invasive” procedures for correction of hallux valgus. Based on former systematic reviews on that topic, the literature search was organised by two independent investigators. MEDLINE was systematically searched for available studies. The keywords used were “hallux valgus”, “bunion”, “percutaneous surgery”, “minimally invasive surgery”, “arthroscopy”, “Bosch” and “SERI”. Studies were assessed using the level of evidence rating. A total of 21 papers were included in this review. These studies described a total of 1,750 patients with 2,195 instances of percutaneous, minimally invasive or arthroscopic hallux valgus surgery. Clinical reports of results after minimally invasive hallux valgus surgery at meetings are common. Published results in peer-reviewed journals are less common and the majority of papers are level IV studies according to the level of evidence ratings. We found one level II and three level III studies. Reported complications seem to be less than one may see in one’s own clinical practice. This possible bias may be related to the fact that most studies are published by centres performing primarily minimally invasive hallux valgus surgery.

Organisation, data evaluation, interpretation and effect of arthroplasty register data on the outcome in terms of revision rate in total hip arthroplasty.

Originally developed in Scandinavia, national arthroplasty registers have spread worldwide during the last decade. The value of registers for quality improvement in arthroplasty has frequently been documented. However, for the development of a successful register a few key points should be taken into account. Uncontrolled loss of patients from the registry area should be avoided. Registers should form an integral part of a country’s medical system. To realise the potential for improvement, it is crucial that physicians deal with the results in detail. Thus it is absolutely essential to involve the specialty societies in the interpretation and dissemination of results. With respect to revision rates, register data are usually more valid than meta-analyses of clinical studies. For every physician the most valuable data are those coming from a register in his own country; the development of national arthroplasty registers should therefore be continued.

Modular Prosthetic Reconstruction of Major Bone Defects of the Distal End of the Humerus

BACKGROUND Bone defects of the distal end of the humerus require complex reconstructions, for which standard prostheses may be insufficient. We investigated the outcomes of distal humeral reconstruction with use of a modular prosthesis. METHODS Fifty-three elbows in fifty-two patients underwent reconstruction with a modular prosthesis (twelve total humeral replacements and forty-one distal humeral replacements) after tumor resection (thirty-eight elbows) or because of massive joint degeneration (fifteen elbows). In the tumor group, twenty-three patients (twenty-four elbows) had metastatic disease and fourteen had a primary tumor. Degenerative defects of the distal end of the humerus were caused by pseudarthrosis (six elbows), prosthetic failure (five), trauma (two), osteomyelitis (one), and supracondylar fracture (one). The mean duration of follow-up for all patients was twenty-eight months (median, thirteen months; range, one to 219 months). RESULTS The mean Inglis-Pellicci score in the tumor group was 84 points, and the mean Musculoskeletal Tumor Society score was 78%. Patients with total humeral reconstruction had worse scores than those with distal humeral reconstruction. Twenty-four patients died of disease at a mean of thirteen months after surgery. Local tumor control was achieved in all patients. In the revision group, the mean Inglis-Pellicci score was 76 points. The Inglis-Pellicci score was significantly better for patients in the tumor group. Eight patients (15%) had a deep periprosthetic infection, requiring amputation in one patient (2%) and prosthetic removal in two patients (4%). Four patients (8%) had the implants revised for aseptic loosening. CONCLUSIONS Modular prostheses of the distal end of the humerus provide a stable reconstruction of the elbow with satisfactory function and disease control in patients with a tumor, but careful patient selection is required when the prostheses are used for revision surgery in patients without a tumor.

Plantar pressure characteristics in hallux valgus feet

Due to the pathoanatomical changes in hallux valgus feet, the plantar flexion moment of the first metatarsophalangeal joint is reduced. Therefore, load bearing of the hallux is decreased during push‐off. We assessed loading parameters in hallux valgus feet. Based on dorsal‐plantar weight bearing radiographs of 61 feet, the intermetatarsal‐, hallux valgus‐, distal metatarsal articulation‐angle, and sesamoid position were evaluated. Plantar pressure assessment was performed with the emed® system during level walking. We found negative correlations between hallux valgus angle and peak pressure in the great toe (r = −0.301, p < 0.023), the maximum force of the hallux (r = −0.481, p < 0.001), and contact time of the great toe (r = −0.448, p < 0.001), and positive correlations for force time integral (r = 0.348, p < 0.001), contact area (r = 0.307, p < 0.020), maximum force (r = 0.430, p < 0.001), and peak pressure (r = 0.361, p < 0.006) of the fifth metatarsal head. A positive correlation between the sesamoid and the metatarsal subluxation regarding maximum force (r = 0.294, p < 0.034), and a negative correlation between the contact area of the hallux (r = −0.232, p < 0.020) was shown. Depending on the severity, hallux valgus angle, and sesamoid subluxation, load shows significant lateral transmission in hallux valgus feet.

Vascularised or non-vascularised autologous fibular grafting for the reconstruction of a diaphyseal bone defect after resection of a musculoskeletal tumour

Resection of a primary sarcoma of the diaphysis of a long bone creates a large defect. The biological options for reconstruction include the use of a vascularised and non-vascularised fibular autograft. The purpose of the present study was to compare these methods of reconstruction. Between 1985 and 2007, 53 patients (26 male and 27 female) underwent biological reconstruction of a diaphyseal defect after resection of a primary sarcoma. Their mean age was 20.7 years (3.6 to 62.4). Of these, 26 (49 %) had a vascularised and 27 (51 %) a non-vascularised fibular autograft. Either method could have been used for any patient in the study. The mean follow-up was 52 months (12 to 259). Oncological, surgical and functional outcome were evaluated. Kaplan-Meier analysis was performed for graft survival with major complication as the end point. At final follow-up, eight patients had died of disease. Primary union was achieved in 40 patients (75%); 22 (42%) with a vascularised fibular autograft and 18 (34%) a non-vascularised (p = 0.167). A total of 32 patients (60%) required revision surgery. Kaplan-Meier analysis revealed a mean survival without complication of 36 months (0.06 to 107.3, sd 9) for the vascularised group and 88 months (0.33 to 163.9, sd 16) for the non-vascularised group (p = 0.035). Both groups seem to be reliable biological methods of reconstructing a diaphyseal bone defect. Vascularised autografts require more revisions mainly due to problems with wound healing in distal sites of tumour, such as the foot.