T. Hüfner

Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results

Etiology and outcome of 155 patients with midfoot fractures between 1972 and 1997 were analyzed to create a basis for treatment optimization. Cause of injuries were traffic accidents (72.2%), falls (11.6%), blunt injuries (7.7%) and others (5.8%). Isolated midfoot fractures (I) were found in 55 (35.5%) cases, Lisfranc fracture dislocations (L) in 49 (31.2%), Chopart-Lisfranc fracture dislocations (CL) in 26 (16.8%) and Chopart fracture dislocations (C) in 25 (16%). One hundred and forty eight (95%) of the midfoot fractures were treated operatively; 30 with closed reduction, 115 with open reduction, 3 patients had a primary amputation. Seven (5%) patients were treated non-operatively. Ninety seven (63%) patients had follow-up at an average of 9 (1.3–25, median 8.5) years. The average scores of the entire follow-up group were as follows: AOFAS – sum of all four sections (AOFAS-ET): 296, AOFAS-Midfoot (AOFAS-M): 71, Hannover Scoring System (HSS): 65, and Hannover Questionnaire (Q): 63. Regarding age, gender, cause, time from injury to treatment and method of treatment no score differences were noted (t-test: p > 0.05). L, C or I showed similar scores and CL significantly lower scores (AOFAS-ET, AOFAS-M, HSS, Q). The highest scores in all groups were achieved in those fractures treated with early open reduction and operative fixation. Midfoot fractures, particularly fracture dislocation injuries, effect the function of the entire foot in the long-term outcome. But even in these complex injuries, an early anatomic (open) reduction and stable (internal) fixation can minimize the percentage of long-term impairment.

Achilles Tendon and Paratendon Microcirculation in Midportion and Insertional Tendinopathy in Athletes

Background Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. Purpose To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. Study Design Cohort study; Level of evidence, 2. Methods In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 ± 8 years), 14 patients had insertional pain (7 men, 29 ± 8 years), and 11 patients had midportion tendinopathy (7 men, 38 ± 13 years, not significant). Results Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 ± 79 vs 132 ± 42, P<. 05) as well as in midportion tendinopathy (150 ± 74 vs 119 ± 34, P<. 05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 ± 42 insertional asymptomatic vs 119 ± 34 mid-portion vs 120 ± 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. Conclusion Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.

New indications for computer-assisted surgery: tumor resection in the pelvis.

The resection of recurrent malignant pelvic tumors was supported by a commercially available navigation system in three patients. Preoperatively three-dimensional images from the pelvis were obtained by computed tomography or magnetic resonance imaging to identify the tumor extension. During surgery navigated tools oriented the surgeon to excise the tumor with adequate virtual margins. Navigation was helpful for tumor identification in one patient with a recurrent presacral mesenchymal chondrosarcoma. In the other two patients the tumor resection in the bone was done with three-dimensional observation of the osteotomies in the sacrum. In all three patients the histopathologic analysis confirmed that the neoplasms were excised accurately within their margins. We think that computer-assisted surgery is a potential method to increase the accuracy of tumor resections.

Intraoperative 3D imaging in calcaneal fracture care-clinical implications and decision making.

BACKGROUND In operative calcaneal fracture care malposition of screws and joint line incongruity frequently remain unrecognized using fluoroscopy intraoperatively, and are frequently only recognized on postoperative computed tomography scans. The purpose of this study was to analyze the feasibility and utility of a new C-arm-based three-dimensional imaging technology for calcaneal trauma care. METHODS The C-arm-based three- dimensional imaging device (ISO-C-3D) was used in 32 patients during a 2-year period. Patients were indicated for open reduction and internal fixation using standard techniques and fluoroscopy. After reduction and implant placement was determined to be correct, the ISO-C-3D procedure was performed. The time for setup and use, and the consequences were recorded. An assessment was obtained from the surgeon regarding the feasibility and the adequacy and quality of the data provided, using a Visual Analog Scale. RESULTS The average total time required for ISO-C-3D use was 610 seconds. The information obtained from the scan led the surgeon to alter the reduction or screw placement during the procedure in 41% of the patients. Surgeons rating according to a Visual Analog Scale: feasibility 9.5, accuracy and quality 9.2, clinical benefit 8.2. CONCLUSION Intraoperative three- dimensional visualization with the ISO-C-3D provides important information in the operative treatment of calcaneal fractures which cannot always be obtained from plain films or standard fluoroscopy alone. The use of the device adds minimal time to the overall procedure, and was found to be extremely useful in evaluating reduction and implant position intraoperatively in calcaneal fractures.

Intraoperative 3D imaging: value and consequences in 248 cases.

BACKGROUND Intraoperative visualization of articular surfaces is technically demanding, and standard two-dimensional fluoroscopic imaging frequently does not provide adequate detail of nonplanar joints. New imaging modalities allow for intraoperative 3D visualization, which are useful in articular fractures. Purpose of this study was to evaluate the utility of 3D imaging in articular fracture reconstruction. METHODS In a prospective cohort study, we evaluated 248 consecutive patients with intra-articular fractures. After fracture fixation using standard fluoroscopy, 3D imaging was performed intraoperatively using the Iso-C3D system for all patients. Surgeons filled out questionnaires regarding the utility and perceived accuracy of the 3D system. Postoperative CT scans were performed on approximately half of the patients. Main outcome measurements were based on the surgeons decision to immediately revise the articular reduction or implant position. The setup time for the system was recorded. For patients with postoperative CT scans, articular surface gaps of 2 mm or intra-articular hardware placement was again evaluated. RESULTS In 19% of all cases, intraoperative image analysis resulted in immediate adjustment of the reduction or hardware exchange. These revisions were based on Iso-C3D views of the articular surface that were not visible using fluoroscopy. Of the 129 postoperative CT scans, five cases revealed a technical error of the joint reconstruction, and a secondary revision procedure was performed. CONCLUSION In conclusion, the Iso-C3D was a valuable intraoperative tool, providing additional information about the articular surface compared with conventional fluoroscopy in a variety of anatomic regions.

Computer-assisted analysis of lower limb geometry: higher intraobserver reliability compared to conventional method

Exact radiographic evaluation of lower limb alignment, joint orientation and leg length is crucial for preoperative planning and successful treatment of deformities, fractures and osteoarthritis. Improvement of the accuracy of radiographic measurements is highly desirable. To determine the intraobserver reliability of conventional analysis of lower extremity geometry, 59 long leg radiographs were randomly analyzed 5 times by a single surgeon. The measurements revealed a standard deviation between 0.36° and 1.17° for the angles mLPFA, mLDFA, MPTA, LDTA, JLCA and AMA (nomenclature according to Paley), and 0.94 mm and 0.90 mm for the MAD and leg length, respectively. Computer-assisted analysis with a special software significantly reduced the standard deviation of the mLDFA, MPTA, LDTA, JLCA (each p < 0.001), AMA (p = 0.032) and MAD (p = 0.023) by 0.05–0.36° and 0.14 mm, respectively. Measuring time was reduced by 44% to 6:34 ± 0:45 min (p < 0.001). Digital calibration by the software revealed an average magnification of conventional long leg radiographs of 4.6 ± 1.8% (range: 2.7–11.9%). Computer-assisted analysis increases the intraobserver reliability and reduces the time needed for the analysis. Another major benefit is the ease of storage and transfer of digitized images. Due to the varying magnification factors on long leg radiographs, the use of magnification markers for calibration is recommended.

Long-term results after functional nonoperative treatment of achilles tendon rupture.

Background: Nonoperative treatment of complete Achilles tendon ruptures generally involves a long period of cast immobilization and is associated with frequent reruptures. Functional nonoperative treatment of complete Achilles tendon ruptures involves the use of a high-shaft boot with a 3-cm hindfoot elevation, in which physical therapy is begun after 3 weeks of wear. We reviewed our long-term results with this treatment protocol to determine its effectiveness. Methods: The indications for nonoperative treatment, defined by ultrasound, were a distance of 10 mm or less between the tendon ends with the ankle in neutral position and complete apposition of the tendon ends in 20 degrees of plantarflexion. From 1990 to 1996, 168 patients were treated; 125 (74%) were available for followup at a mean of 5.5 (2 to 12.7) years after the injury. Results: Good or excellent results were achieved in 92 (73.5%) with complete rehabilitation and return to sports activity at their pre-injury levels. Satisfactory (9%) and poor results (17.5%) were due to pain in the Achilles tendon region, a lengthened Achilles tendon, markedly reduced strength, or a marked reduction of calf size in 25 patients (76%). Eight patients (6.4%) sustained a rerupture. Conclusions: Functional nonoperative treatment achieved good results in patients who had precise sonographic evaluation and who were compliant. As a result of our study, we modified our protocol: (1) a repeat ultrasound examination is done by an experienced sonographer 2 to 5 days after the first to confirm the indications for nonoperative treatment, (2) the use of the 3-cm hindfoot elevation is extended from 6 to 8 weeks to provide a longer protection of the tendon, and (3) patients then wear shoes with 1-cm hindfoot elevation for another 3 months.

Navigated intraoperative analysis of lower limb alignment

Introduction: Accurate intraoperative assessment of lower limb alignment is crucial for the treatment of long bone fractures, implantation of knee arthroplasties and correction of deformities. During orthopaedic surgery, exact real time control of the mechanical axis is strongly desirable. The aim of this study was to compare conventional intraoperative analysis of the mechanical axis by the cable method with continuous, 3-dimensional imaging with a navigation system. Materials and methods: Twenty legs of fresh human cadaver were randomly assigned to conventional analysis with the cable method (n=10) or navigated analysis with a fluoroscopy based navigation system (n=10). The intersection of the mechanical axis with the tibia plateau was presented as percentage of the tibia plateau (beginning with 0% at the medial border and ending with 100% laterally). CT-scans were performed for all legs and the CT-values of the mechanical axis were compared to the measurements after cable method and navigation. Furthermore, the radiation time and dose area product of both groups for single analysis of the mechanical axis was compared. Results: Conventional evaluation of the mechanical axis by the cable method showed 6.0±3.1% difference compared to the analysis by CT. In the navigated group the difference was 2.6±1.8% (P=0.008). Radiation time and dose area product were highly significantly lower after conventional measurement. Conclusions: Navigated intraoperative evaluation of the mechanical axis offers increased accuracy compared to conventional intraoperative analysis. Furthermore, navigation provides continuous control not only of the mechanical axis, but also of the sagittal and transverse plane. Using the cable method, radiation exposure depends on the number of measurements and is lower compared to the navigation system for single intraoperative analysis of the mechanical axis, but may be higher in case of repeated intraoperative measurements.

Percutaneous iliosacral screw fixation of unstable pelvic injuries by conventional fluoroscopy.

ZusammenfassungOperationszielGeschlossene Reposition und Retention von translatorisch instabilen Verletzungen des Beckenrings (Typ-C-Verletzungen) zur Wiederherstellung der Form und Funktion des dorsalen Beckenrings durch perkutane iliosakrale Schraubenosteosynthese mit Hilfe konventioneller Bildwandlertechnik.IndikationenDefinitive Behandlung des dorsalen Beckenrings bei Typ-C-Verletzungen (AO-Klassifikation) mit kompletter Sakrumfraktur, Luxation des Sakroiliakalgelenks (SI-Gelenk), transiliakaler oder transsakraler Luxationsfraktur des SI-Gelenks mit unbedeutend kleinem Fragment und Sakrumausbruchverletzungen, die sich geschlossen nahezu anatomisch reponieren lassen.KontraindikationenSchlechter Allgemeinzustand, lokaler Weichteilschaden, rotationsinstabile Beckenverletzungen vom Typ B sowie Typ-C-Verletzungen, die sich geschlossen nur unzureichend reponieren lassen.OperationstechnikGeschlossene Reposition, Stichinzision und perkutane Stabilisierung des hinteren Beckenrings durch transiliosakrale Schraubenosteosynthese unter Bildwandlerkontrolle.WeiterbehandlungTeilbelastung der verletzten Seite mit 15 kg für 8–12 Wochen mit zwei Unterarmgehstützen.Implantatentfernung 6–12 Monate nach der Verletzung.ErgebnisseBei 20 Patienten mit transforaminaler Sakrumfraktur im Rahmen einer Beckenverletzung vom Typ C wurde unter Bildwandlerkontrolle eine transiliosakrake Fixation mit kanülierten 7,3-mm-Schrauben in den Wirbelkörper S1 durchgeführt. Die durchschnittliche präoperative Fehlstellung von 3,8 mm konnte im Rahmen der geschlossenen Reposition postoperativ auf 1,6 mm reduziert werden. Die mittlere Operationszeit betrug 55 min, die mittlere Durchleuchtungszeit 2,22 min. Eine Schraubenfehllage ohne Konsequenz wurde bei drei Patienten beobachtet; iatrogene Nervenverletzungen lagen nicht vor. Alle Frakturen heilten innerhalb von 3 Monaten aus.AbstractObjectiveClosed reduction and retention of translatory unstable pelvic injuries (type C injuries), in order to restore the form and function of the posterior pelvis by percutaneous iliosacral screw osteosynthesis, using conventional fluoroscopy.IndicationsDefinitive treatment of the posterior pelvis in type C injuries (AO classification) with complete sacral fracture, sacroiliac joint (SI joint) dislocation, transiliac or transsacral dislocation fracture of the SI joint with insignificant small fragment and sacroiliac avulsion injuries which can be reduced almost anatomically in closed technique.ContraindicationsPoor general health, local soft-tissue damage, rotationally unstable type B pelvic injuries as well as type C injuries which cannot be reduced satisfactorily in closed technique.Surgical TechniqueClosed reduction, stab incision and percutaneous stabilization of the posterior pelvis by transiliosacral screw osteosynthesis, guided by fluoroscopy.Postoperative ManagementPartial loading of the injured side with 15 kg for 8–12 weeks with two underarm crutches.Implant removal 6–12 months after injury.Results20 patients with a transforaminal sacral fracture consistent with a type C pelvic injury underwent screw fixation with fluoroscopy with 7.3-mm cannulated screws, placed in a transiliosacral position in the vertebral body of S1. The average preoperative displacement of 3.8 mm was decreased by closed reduction to 1.6 mm postoperatively. The average operating time was 55 min, the average screening time 2.22 min. Incorrect screw position with no consequences was observed in three patients; iatrogenic nerve damage was not found. All fractures healed within 3 months.

Management of calcaneal fractures in adults. Conservative versus operative treatment.

Significant progress has been made in the management of calcaneal fractures. This is reflected in the marked decrease in complication rates associated with the current intervention of these potentially devastating injuries. The treatment priorities that are key to achieve best results in a displaced calcaneal fracture are an anatomic reconstruction of the entire calcaneus including articular surfaces, height, alignment, and length, with a function directed postoperative management. The value of these priorities is confirmed by long term followup results. Conservative treatment should be considered only in cases of extraarticular fractures, in cases of minor displaced intraarticular fractures in patients who are nonambulatory, and in cases where there is a clear contraindication for surgery. An anatomic reconstruction of an os calcis fracture is difficult to obtain. In two-part fractures, according to the classification described by Sanders et al, an anatomic reduction is obtainable in more than 80% of cases. However, if the articular cartilage damage that is typically present is considered, a 70% rate of good to excellent results is more realistic. In three-part fractures, anatomic reduction is attainable in approximately 60% of cases with a 70% rate of good results. These two subgroups comprise approximately 90% of all calcaneal fractures. It has been put into practice recently to optimize the extended lateral approach using posteromedial and anterolateral windows, so that an anatomic reduction can be achieved in more than 60% of os calcis fractures considered as Type III according to the classification described by Sanders et al. Additional scientific work in this area of trauma orthopaedics would benefit most from a general consensus on a fracture classification system and on a clinical scoring system, with 5-year followup studies using these treatment methods and evaluation systems.