Renée A. Fuhrmann

First metatarsophalangeal joint replacement: the method of choice for end-stage hallux rigidus?

Replacement of the first metatarsophalangeal (MTP) joint remains critical because of complex biomechanical conditions and implant fixation. After a 3-year follow-up, most patients who experienced an MTP joint replacement were extremely satisfied with the outcome. Plantar pressure distribution revealed a marked improvement. Nevertheless, recovery of MTP dorsiflexion was limited and joint stability worsened. Radiologically, one-third of the prostheses showed radiolucent lines as a sign of implant loosening. MTP replacement offers distinct advantages in the treatment of end-stage hallux rigidus, but requires further research on implant design and osseous fixation.

Intra-articular injections of high-molecular-weight hyaluronic acid have biphasic effects on joint inflammation and destruction in rat antigen-induced arthritis.

To assess the potential use of hyaluronic acid (HA) as adjuvant therapy in rheumatoid arthritis, the anti-inflammatory and chondroprotective effects of HA were analysed in experimental rat antigen-induced arthritis (AIA). Lewis rats with AIA were subjected to short-term (days 1 and 8, n = 10) or long-term (days 1, 8, 15 and 22, n = 10) intra-articular treatment with microbially manufactured, high-molecular-weight HA (molecular weight, 1.7 × 106 Da; 0.5 mg/dose). In both tests, 10 buffer-treated AIA rats served as arthritic controls and six healthy animals served as normal controls. Arthritis was monitored by weekly assessment of joint swelling and histological evaluation in the short-term test (day 8) and in the long-term test (day 29). Safranin O staining was employed to detect proteoglycan loss from the epiphyseal growth plate and the articular cartilage of the arthritic knee joint. Serum levels of IL-6, tumour necrosis factor alpha and glycosaminoglycans were measured by ELISA/kit systems (days 8 and 29). HA treatment did not significantly influence AIA in the short-term test (days 1 and 8) but did suppress early chronic AIA (day 15, P < 0.05); however, HA treatment tended to aggravate chronic AIA in the long-term test (day 29). HA completely prevented proteoglycan loss from the epiphyseal growth plate and articular cartilage on day 8, but induced proteoglycan loss from the epiphyseal growth plate on day 29. Similarly, HA inhibited the histological signs of acute inflammation and cartilage damage in the short-term test, but augmented acute and chronic inflammation as well as cartilage damage in the long-term test. Serum levels of IL-6, tumour necrosis factor alpha, and glycosaminoglycans were not influenced by HA. Local therapeutic effects of HA in AIA are clearly biphasic, with inhibition of inflammation and cartilage damage in the early chronic phase but with promotion of joint swelling, inflammation and cartilage damage in the late chronic phase.

Arthrodesis of the first tarsometatarsal joint for correction of the advanced splayfoot accompanied by a hallux valgus.

ZusammenfassungOperationszielKnöcherne Korrektur des schmerzhaften Spreizfußes zur Wiederherstellung einer regelrechten Belastung des ersten Strahls und Beseitigung der Hallux-valgus-Fehlstellung.IndikationenFortgeschrittene Spreizfußdeformität mit einem vergrößerten ersten intermetatarsalen Winkel (> 18°).Krankhaft gesteigerte Beweglichkeit des ersten Tarsometatarsalgelenks mit mangelnder Lastaufnahme des ersten Mittelfußstrahls und Entwicklung einer sog. Transfer-Metatarsalgie.Schmerzhafte primäre oder sekundäre Arthrose des ersten Tarsometatarsalgelenks.Rezidiv einer Spreizfußdeformität nach operativer Korrektur.Elevation des ersten Mittelfußstrahls, z. B. bei angeborener Klumpfußdeformität.Metatarsus-primus-varus-Deformität mit Hallux-valgus-Fehlstellung bei hypermobilem Plattfuß.KontraindikationenGeringe bis mäßige Spreizfußdeformität mit einem ersten intermetatarsalen Winkel < 17° und klinisch stabilem erstem Tarsometatarsalgelenk.Unbehandelte Rückfußdeformität, z. B. Knick-Platt-Fuß mit Eversion des Rückfußes.Unfähigkeit zur einer postoperativen Teilbelastung des Fußes an Gehstützen.Gestörte Durchblutung des Vorfußes.OperationstechnikDorsomediale Inzision über dem ersten Tarsometatarsalgelenk. Spalten der Extensorenaponeurose medial der Sehne des Musculus extensor hallucis longus. Subperiostale Darstellung des ersten Tarsometatarsalgelenks. Eröffnung der Gelenkkapsel. Sparsame Entknorpelung des Gelenks unter Entnahme eines lateralbasigen Knochenkeils aus dem Os cuneiforme mediale zur Korrektur des limitvergrößerten ersten intermetatarsalen Winkels. Manuelle Reposition des Spreizfußes bei gleichzeitiger plantarer Verschiebung der Metatarsale-Basis. Wahl der passenden winkelstabilen Platte und der Osteosynthese.Distaler Weichteileingriff am Großzehengrundgelenk und ggf. retrokapitale metatarsale Korrekturosteotomie zur Rezentrierung einer krankhaft veränderten Gelenkflächenorientierung am Mittelfußkopf.ErgebnisseDie klinischen und röntgenologischen Ergebnisse mit dem winkelstabilen Implantat („Orthner-Lapidus-Platte“) beziehen sich auf 56 Patienten (64 Füße) mit einer mittleren Nachuntersuchungszeit von 8,2 Monaten. Patienten mit zusätzlichen Osteotomien am fünften Mittelfußstrahl wurden nicht in die Studie einbezogen. An Komplikationen traten neben einem komplexen regionalen Schmerzsyndrom vier Pseudarthrosen (6,2%) des Metatarsocuneiforme-mediale-Gelenks auf. Die röntgenologische Konsolidierung war nach durchschnittlich 9 Wochen erreicht. Der erste intermetatarsale Winkel konnte von durchschnittlich 20,4° auf 11,2° reduziert werden. Die Fußdruckmessung zeigte eine signifikant (p < 0,05) verbesserte Lastaufnahme durch den ersten Strahl. Der Score der American Orthopaedic Foot and Ankle Society verbesserte sich signifikant (p < 0,01) von 51 auf 92 Punkte.AbstractObjectiveArthrodesis of the first tarsometatarsal joint for the treatment of a painful splayfoot with the aim to restore a normal weight bearing on the first ray. Correction of hallux valgus deformity.IndicationsAdvanced splayfoot deformity with a first intermetatarsal angle > 18°.Hypermobility of the first tarsometatarsal joint with reduced weight bearing on the first ray and development of a transfer metatarsalgia.Painful, primary or secondary osteoarthritis of the first tarsometatarsal joint.Recurrence of splayfoot deformity after previous attempt at surgical correction.Elevation of the first ray such as after developmental clubfoot.Metatarsus primus varus deformity accompanied by hallux valgus in the presence of a hypermobile flatfoot.ContraindicationsMinimal or moderate splayfoot deformity with a first intermetatarsal angle < 17° and a clinically stable first tarsometatarsal joint.Untreated hindfoot deformities such as flatfoot combined with heel valgus.Inability to use walking aids for postoperative partial weight bearing.Insufficient circulation of forefoot.Surgical TechniqueDorsomedial incision overlying the first tarsometatarsal joint. Splitting of the extensor aponeurosis medial to the tendon of the extensor hallucis longus. Subperiosteal exposure of the first tarsometatarsal joint. Opening of the joint. Judicious removal of articular cartilage and resection of a laterally based bony wedge from the medial cuneiform for correction of the increased first intermetatarsal angle. Manual correction of the splayfoot with concomitant plantar displacement of the base of the first metatarsal. Selection of properly fitting fixed-angle plate and internal fixation.Soft-tissue correction at the first metatarsophalangeal joint or metatarsal neck osteotomy to realign the articular surface of the first metatarsal head.ResultsClinical and radiologic results based on 56 patients (64 feet) followed up for an average of 8.2 months. Complications: one reflex sympathetic dystrophy, four nonunions of the first tarsometatarsal joint (6.2%). Radiologic evidence of consolidation at a mean of 9 weeks. Improvement of the first intermetatarsal angle from 20.4° to 11.2°. Pressure measurement showed a significantly improved load-carrying capacity of the first ray.The score of the American Orthopaedic Foot and Ankle Society improved significantly (p < 0.01) from 51 to 92 points.

Die Korrekturarthrodese des ersten Tarsometatarsalgelenks zur Behandlung des fortgeschrittenen Spreizfußes mit Halluxvalgus-Fehlstellung

ZusammenfassungOperationszielKnöcherne Korrektur des schmerzhaften Spreizfußes zur Wiederherstellung einer regelrechten Belastung des ersten Strahls und Beseitigung der Hallux-valgus-Fehlstellung.IndikationenFortgeschrittene Spreizfußdeformität mit einem vergrößerten ersten intermetatarsalen Winkel (> 18°).Krankhaft gesteigerte Beweglichkeit des ersten Tarsometatarsalgelenks mit mangelnder Lastaufnahme des ersten Mittelfußstrahls und Entwicklung einer sog. Transfer-Metatarsalgie.Schmerzhafte primäre oder sekundäre Arthrose des ersten Tarsometatarsalgelenks.Rezidiv einer Spreizfußdeformität nach operativer Korrektur.Elevation des ersten Mittelfußstrahls, z. B. bei angeborener Klumpfußdeformität.Metatarsus-primus-varus-Deformität mit Hallux-valgus-Fehlstellung bei hypermobilem Plattfuß.KontraindikationenGeringe bis mäßige Spreizfußdeformität mit einem ersten intermetatarsalen Winkel < 17° und klinisch stabilem erstem Tarsometatarsalgelenk.Unbehandelte Rückfußdeformität, z. B. Knick-Platt-Fuß mit Eversion des Rückfußes.Unfähigkeit zur einer postoperativen Teilbelastung des Fußes an Gehstützen.Gestörte Durchblutung des Vorfußes.OperationstechnikDorsomediale Inzision über dem ersten Tarsometatarsalgelenk. Spalten der Extensorenaponeurose medial der Sehne des Musculus extensor hallucis longus. Subperiostale Darstellung des ersten Tarsometatarsalgelenks. Eröffnung der Gelenkkapsel. Sparsame Entknorpelung des Gelenks unter Entnahme eines lateralbasigen Knochenkeils aus dem Os cuneiforme mediale zur Korrektur des limitvergrößerten ersten intermetatarsalen Winkels. Manuelle Reposition des Spreizfußes bei gleichzeitiger plantarer Verschiebung der Metatarsale-Basis. Wahl der passenden winkelstabilen Platte und der Osteosynthese.Distaler Weichteileingriff am Großzehengrundgelenk und ggf. retrokapitale metatarsale Korrekturosteotomie zur Rezentrierung einer krankhaft veränderten Gelenkflächenorientierung am Mittelfußkopf.ErgebnisseDie klinischen und röntgenologischen Ergebnisse mit dem winkelstabilen Implantat („Orthner-Lapidus-Platte“) beziehen sich auf 56 Patienten (64 Füße) mit einer mittleren Nachuntersuchungszeit von 8,2 Monaten. Patienten mit zusätzlichen Osteotomien am fünften Mittelfußstrahl wurden nicht in die Studie einbezogen. An Komplikationen traten neben einem komplexen regionalen Schmerzsyndrom vier Pseudarthrosen (6,2%) des Metatarsocuneiforme-mediale-Gelenks auf. Die röntgenologische Konsolidierung war nach durchschnittlich 9 Wochen erreicht. Der erste intermetatarsale Winkel konnte von durchschnittlich 20,4° auf 11,2° reduziert werden. Die Fußdruckmessung zeigte eine signifikant (p < 0,05) verbesserte Lastaufnahme durch den ersten Strahl. Der Score der American Orthopaedic Foot and Ankle Society verbesserte sich signifikant (p < 0,01) von 51 auf 92 Punkte.AbstractObjectiveArthrodesis of the first tarsometatarsal joint for the treatment of a painful splayfoot with the aim to restore a normal weight bearing on the first ray. Correction of hallux valgus deformity.IndicationsAdvanced splayfoot deformity with a first intermetatarsal angle > 18°.Hypermobility of the first tarsometatarsal joint with reduced weight bearing on the first ray and development of a transfer metatarsalgia.Painful, primary or secondary osteoarthritis of the first tarsometatarsal joint.Recurrence of splayfoot deformity after previous attempt at surgical correction.Elevation of the first ray such as after developmental clubfoot.Metatarsus primus varus deformity accompanied by hallux valgus in the presence of a hypermobile flatfoot.ContraindicationsMinimal or moderate splayfoot deformity with a first intermetatarsal angle < 17° and a clinically stable first tarsometatarsal joint.Untreated hindfoot deformities such as flatfoot combined with heel valgus.Inability to use walking aids for postoperative partial weight bearing.Insufficient circulation of forefoot.Surgical TechniqueDorsomedial incision overlying the first tarsometatarsal joint. Splitting of the extensor aponeurosis medial to the tendon of the extensor hallucis longus. Subperiosteal exposure of the first tarsometatarsal joint. Opening of the joint. Judicious removal of articular cartilage and resection of a laterally based bony wedge from the medial cuneiform for correction of the increased first intermetatarsal angle. Manual correction of the splayfoot with concomitant plantar displacement of the base of the first metatarsal. Selection of properly fitting fixed-angle plate and internal fixation.Soft-tissue correction at the first metatarsophalangeal joint or metatarsal neck osteotomy to realign the articular surface of the first metatarsal head.ResultsClinical and radiologic results based on 56 patients (64 feet) followed up for an average of 8.2 months. Complications: one reflex sympathetic dystrophy, four nonunions of the first tarsometatarsal joint (6.2%). Radiologic evidence of consolidation at a mean of 9 weeks. Improvement of the first intermetatarsal angle from 20.4° to 11.2°. Pressure measurement showed a significantly improved load-carrying capacity of the first ray.The score of the American Orthopaedic Foot and Ankle Society improved significantly (p < 0.01) from 51 to 92 points.

Predominant activation of MAP kinases and pro-destructive/pro-inflammatory features by TNF α in early-passage synovial fibroblasts via TNF receptor-1: failure of p38 inhibition to suppress matrix metalloproteinase-1 in rheumatoid arthritis

Objective: To examine the relative importance of tumour necrosis factor-receptor 1 (TNF-R1) and TNF-R2 and their signalling pathways for pro-inflammatory and pro-destructive features of early-passage synovial fibroblasts (SFB) from rheumatoid arthritis (RA) and osteoarthritis (OA). Methods: Cells were stimulated with tumour necrosis factor (TNF)α or agonistic anti-TNF-R1/TNF-R2 monoclonal antibodies. Phosphorylation of p38, ERK and JNK kinases was assessed by western blot; proliferation by bromodesoxyuridine incorporation; interleukin (IL)6, IL8, prostaglandin E2 (PGE2) and matrix metalloproteinase (MMP)-1 secretion by ELISA; and MMP-3 secretion by western blot. Functional assays were performed with or without inhibition of p38 (SB203580), ERK (U0126) or JNK (SP600125). Results: In RA- and OA-SFB, TNFα-induced phosphorylation of p38, ERK or JNK was exclusively mediated by TNF-R1. Reduction of proliferation and induction of IL6, IL8 and MMP-1 were solely mediated by TNF-R1, whereas PGE2 and MMP-3 secretion was mediated by both TNF-Rs. In general, inhibition of ERK or JNK did not significantly alter the TNFα influence on these effector molecules. In contrast, inhibition of p38 reversed TNFα effects on proliferation and IL6/PGE2 secretion (but not on IL8 and MMP-3 secretion). The above effects were comparable in RA- and OA-SFB, except that TNFα-induced MMP-1 secretion was reversed by p38 inhibition only in OA-SFB. Conclusion: In early-passage RA/OA-SFB, activation of MAPK cascades and pro-inflammatory/pro-destructive features by TNFα is predominantly mediated by TNF-R1 and, for proliferation and IL6/PGE2 secretion, exclusively regulated by p38. Strikingly, RA-SFB are insensitive to p38 inhibition of MMP-1 secretion. This indicates a resistance of RA-SFB to the inhibition of pro-destructive functions and suggests underlying structural/functional alterations of the p38 pathway, which may contribute to the pathogenesis or therapeutic sensitivity of RA, or both.

Mid-term results of Scarf osteotomy in hallux valgus

We performed a retrospective study on 178 Scarf osteotomies with a mean follow-up of 44.9 months (range 15–83 months). Clinical rating was based on the forefoot score of the American Orthopaedic Foot and Ankle Society (AOFAS). Weight bearing X-rays were used to perform angular measurements and assess the first metatarsophalangeal joint (MTP 1). At follow-up the mean AOFAS score had improved significantly (p < 0.001), but only 55% of the feet showed a perfect realignment of the first ray. Patients with a hallux valgus angle exceeding 30° and pre-existing degenerative changes at the MTP 1 joint displayed inferior clinical results (p < 0.05). Nearly 20% of the patients suffered from pain at the MTP 1 joint. This was clearly attributed to an onset or worsening of distinct radiographic signs of arthritis (p < 0.05) resulting in painfully decreased joint motion. Comparing radiographic appearance three months postoperatively and at follow-up, we found that radiographic criteria (hallux valgus, first intermetatarsal angle, hallux valgus interphalangeus, MTP 1 joint congruency, arthritic lesions at MTP 1) worsened with time.

Autologous chondrocyte transplantation in the ankle joint. Rational or irrational

Ankle sprains are one the most common injuries of the lower limb. Fractures, ligamentous lesions, and cartilaginous damage are often associated. Nevertheless the injury is often misjudged and concomitant chondral lesions are assessed late. In the case of a symptomatic osteocartilaginous lesion of the talus, which can be illustrated by MRI or X-ray, operative intervention is indicated. Methods such as microfracturing, mosaicplasty, and autologous chondrocyte transplantation (ACT) are in clinical use. The latter is well known and being established as the treatment of choice for large cartilage defects in the knee. Due to the good results in the knee and the technological improvements (three-dimensional tissue constructs seeded with autologous chondrocytes) this method is being increasingly applied for cartilage lesions of the talus. In contrast to the mosaicplasty donor site morbidity is low and the size of the defect is not a limiting factor. The current studies about ACT of the talus show a stable repair of the defect with mostly hyaline-like cartilage and high patient satisfaction. Therefore, the procedure can be recommended for lesions>1 cm2. Concomitant treatment of posttraumatic deformities (malalignment), ligamentous instabilities, and especially the reconstruction of bony defects are compulsory.

Die Behandlung der rheumatischen Fußdeformität

ZusammenfassungDie rheumatische Rückfußdeformität ist gekennzeichnet durch einen Knick-Platt-Fuß, der sich aus einer Ferseneversion, einer Abflachung der Längswölbung und einer Abduktion des Mittel- und Vorfußes zusammensetzt. Unabhängig davon oder auch als Folge dieser Fehlstellungen besteht die rheumatische Vorfußdeformität neben einer Abflachung der Querwölbung aus einem Spreizfuß, der mit unterschiedlichen Zehendeformitäten (Krallenzehe,Klauenzehe, Hallux valgus) kombiniert sein kann. Die adäquate Therapie wird stets unter Berücksichtigung der gesamten unteren Extremitäten festgelegt und besteht immer aus einer gezielten Kombination von schuhtechnischen Maßnahmen und operativen Eingriffen.Aufgrund der Multimorbidität des Rheumatikers, des Befalls mehrerer Gelenkebenen und der Maßgabe einer definitiven Versorgung sind die korrigierenden Rückfußarthrodesen mit Verlängerung der lateralen Säule und Wiederherstellung der Achsenausrichtung als “golden standard” anzusehen. Für das Sprunggelenk hingegen kann aufgrund der vorliegenden Langzeitergebnisse die endoprothetische Versorgung empfohlen werden.Wenngleich für den rheumatischen Vorfuß prinzipiell die gleichen Richtlinien wie für den degenerativ veränderten Vorfuß gelten, besteht nur selten die Indikation zur Durchführung gelenkerhaltender Verfahren der Zehengrundgelenke. Abgesehen von der Mittelfußkopfresektion der lateralen Strahlen scheint die Arthrodese des Großzehengrundgelenks einer Resektionsarthroplastik am ersten Strahl überlegen zu sein, da der Bodenkontakt zu einer verbesserten Stand- und Gangsicherheit führt.AbstractRheumatoid hindfoot deformity presents with hindfoot eversion, flattening of the longitudinal arch and abduction of the forefoot. Splayfoot, as the typical rheumatoid forefoot deformity, is mostly associated with various toe malformations, i.e. hallux valgus,hammer toe and claw toe,which may either be attributed to hindfoot malalignment or develop as a separate entity. The algorithm of treatment, comprising clinical assessment of both lower limbs, includes both orthotic shoe devices and surgical treatment.In rheumatoid flatfoot, arthrodesis of the hindfoot with lengthening of the lateral column and reorientation of joint congruency represent the gold standard of treatment. Despite this principle, the ankle joint should be kept mobile to facilitate standing and walking. Therefore, total ankle prosthesis is thought to be superior.Methods involving the preservation of the lesser metatarsophalangeal joints may be of benefit in providing sufficient ground contact with the toes. Nevertheless, resection arthroplasties are frequently required in cases of arthritic joint destruction. Arthrodesis of the first metatarsophalangeal joint may provide an adequate push-off for the big toe which can not be expected from resectional arthroplasties.

Radiographic Changes in Forefoot Geometry with Weightbearing

Quality assessment of forefoot surgery depends mainly on weightbearing radiographs. A prospective study has been performed to compare the influence of weightbearing on forefoot geometry. Dorsoplantar radiographs for weightbearing and non-weightbearing conditions were performed in 99 patients. Hallux valgus angle, the intermetatarsal angles between the first and second and first and fifth metatarsals and intermetatarsal distance were measured using an interactive digitizer connected to a computer. The intermetatarsal angles showed a statistically significant increase during weightbearing. Unrelated to the severity of hallux valgus deformity, hallux valgus angles demonstrated an inverse behavior showing larger values under non-weightbearing conditions. For that reason, radiological evaluation of forefoot geometry strictly requires similar weightbearing conditions and comparable positioning of the foot.

Autologe Chondrozytentransplantation am oberen Sprunggelenk

Ankle sprains are one the most common injuries of the lower limb. Fractures, ligamentous lesions, and cartilaginous damage are often associated. Nevertheless the injury is often misjudged and concomitant chondral lesions are assessed late. In the case of a symptomatic osteocartilaginous lesion of the talus, which can be illustrated by MRI or X-ray, operative intervention is indicated. Methods such as microfracturing, mosaicplasty, and autologous chondrocyte transplantation (ACT) are in clinical use. The latter is well known and being established as the treatment of choice for large cartilage defects in the knee. Due to the good results in the knee and the technological improvements (three-dimensional tissue constructs seeded with autologous chondrocytes) this method is being increasingly applied for cartilage lesions of the talus. In contrast to the mosaicplasty donor site morbidity is low and the size of the defect is not a limiting factor. The current studies about ACT of the talus show a stable repair of the defect with mostly hyaline-like cartilage and high patient satisfaction. Therefore, the procedure can be recommended for lesions>1 cm2. Concomitant treatment of posttraumatic deformities (malalignment), ligamentous instabilities, and especially the reconstruction of bony defects are compulsory.