Thibaut Leemrijse

La chirurgie de l'hallux valgus en 2005. Chirurgie conventionnelle, mini-invasive ou percutanée ? Uni- ou bilatérale ? Hospitalisation ou ambulatoire ?

There remains a good deal of controversy concerning forefoot surgery. Certain concepts such as conventional procedures, minimally invasive surgery, or percutaneous surgery are promoted because of their specific advantages including rapid recovery and compatibility with a short hospital stay or even outpatient surgery. Nevertheless, in 2005 many questions remain unanswered and highly variable practices have been basically founded on personal experience rather than scientific evidence. In addition, financial and lobbying pressure appears to have an influence on our choices, affecting the freedom of our therapeutic decision-making. Developed over a long period, conventional surgery has proven reliability, reproducibility and adaptability. Procedures termed minimally invasive are defined by the limited incision. Percutaneous surgery is not less invasive than other procedures; the techniques are performed under indirect visual control and often assisted with more or less sophisticated radioscopic techniques depending on the surgeons own experience. In our opinion, percutaneous surgery should be considered as a new concept based on rapid and functional results. Patients often raise the question of a bilateral procedure. For hallux valgus, there is no consensus on whether unilateral or bilateral procedures are better, the best solution depending on postoperative weight bearing and thus on the technique employed. From a cost expenditures point of view, bilateral procedures have an impact. For the advantages in terms of macroeconomy for professional incapacity, the question is less univocal for healthcare authorities. Advances in perioperative anesthesia and analgesia have enabled a broader approach to ambulatory surgery. Outpatient surgery appears to have benefits in terms of organization and economics. Variables studied were as follows: duration of hospital stay, postoperative edema, number of days of sick leave and preoperative and early and late postoperative pain. Patients who underwent minimally invasive procedures had a significantly shorter hospital stay compared with three other groups. For bilateral procedures, hospital stay on average was longer than in the two other groups. There was no correlation between postoperative edema and pain or between the degree of edema at 15 days and two months. Mean sick leave was 54.6 days. This was significantly shorter for percutaneous procedures compared with conventional surgery or minimally invasive techniques. Preoperative pain was noted four to five on the Visual Analogue Scale (VAS). There was no significant difference between the different groups as a function of the type of surgery performed. Statistically, there is very little difference in the short term between the different techniques. A much longer study would be necessary to obtain evidence to guide our practices. While there is certainly no reason to condemn one method or another, surgeons must be careful about the promises given to patients which are generally based on personal experience but not necessarily supported by rigorous scientific data.

Travaux des spécialitésLa chirurgie de l’hallux valgus en 2005. Chirurgie conventionnelle, mini-invasive ou percutanée ? Uni- ou bilatérale ? Hospitalisation ou ambulatoire ?Hallux valgus surgery in 2005. Conventional, mini-invasive or percutaneous surgery? Uni- or bilateral? Hospitalisation or one-day surgery?☆

There remains a good deal of controversy concerning forefoot surgery. Certain concepts such as conventional procedures, minimally invasive surgery, or percutaneous surgery are promoted because of their specific advantages including rapid recovery and compatibility with a short hospital stay or even outpatient surgery. Nevertheless, in 2005 many questions remain unanswered and highly variable practices have been basically founded on personal experience rather than scientific evidence. In addition, financial and lobbying pressure appears to have an influence on our choices, affecting the freedom of our therapeutic decision-making. Developed over a long period, conventional surgery has proven reliability, reproducibility and adaptability. Procedures termed minimally invasive are defined by the limited incision. Percutaneous surgery is not less invasive than other procedures; the techniques are performed under indirect visual control and often assisted with more or less sophisticated radioscopic techniques depending on the surgeons own experience. In our opinion, percutaneous surgery should be considered as a new concept based on rapid and functional results. Patients often raise the question of a bilateral procedure. For hallux valgus, there is no consensus on whether unilateral or bilateral procedures are better, the best solution depending on postoperative weight bearing and thus on the technique employed. From a cost expenditures point of view, bilateral procedures have an impact. For the advantages in terms of macroeconomy for professional incapacity, the question is less univocal for healthcare authorities. Advances in perioperative anesthesia and analgesia have enabled a broader approach to ambulatory surgery. Outpatient surgery appears to have benefits in terms of organization and economics. Variables studied were as follows: duration of hospital stay, postoperative edema, number of days of sick leave and preoperative and early and late postoperative pain. Patients who underwent minimally invasive procedures had a significantly shorter hospital stay compared with three other groups. For bilateral procedures, hospital stay on average was longer than in the two other groups. There was no correlation between postoperative edema and pain or between the degree of edema at 15 days and two months. Mean sick leave was 54.6 days. This was significantly shorter for percutaneous procedures compared with conventional surgery or minimally invasive techniques. Preoperative pain was noted four to five on the Visual Analogue Scale (VAS). There was no significant difference between the different groups as a function of the type of surgery performed. Statistically, there is very little difference in the short term between the different techniques. A much longer study would be necessary to obtain evidence to guide our practices. While there is certainly no reason to condemn one method or another, surgeons must be careful about the promises given to patients which are generally based on personal experience but not necessarily supported by rigorous scientific data.

Value of computed tomography arthrography with delayed acquisitions in the work-up of ganglion cysts of the tarsal tunnel: report of three cases

Ganglion cysts are a common cause of tarsal tunnel syndrome. As in other locations, these cysts are believed to communicate with neighboring joints. The positive diagnosis and preoperative work-up of these cysts require identification and location of the cyst pedicles so that they may be excised and the risk of recurrence decreased. This can be challenging with ultrasonography and magnetic resonance (MR) imaging. We present three cases of symptomatic ganglion cysts of the tarsal tunnel, diagnosed by MR imaging, where computed tomography (CT) arthrography with delayed acquisitions helped to confirm the diagnosis and identify precisely the topography of the communication with the subtalar joint. These cases provide new evidence of the articular origin of ganglion cysts developing in the tarsal tunnel.

Ostéoarthrite tarsienne: une localisation rare de la tuberculose.

We report the case of a 39-year-old woman with an uneventful medical history who presented an inflammatory left foot with no notion of trauma or fever. The plain x-ray and magnetic resonance imaging demonstrated talonavicular and subtalar osteoarthritis. A surgical biopsy with excision of inflammatory and necrotic tissue and removal of a fistular tract was performed. Histology revealed the presence of granulomas with caseous central necrosis suggesting tuberculosis of the bone. The diagnosis was confirmed when bacteriology samples grew Mycobacterium tuberculosis. Antituberculosis drugs were administered for twelve months. At 24 months, the patient presents a painful stiff rear foot after the development of secondary talonavicular degeneration. This case illustrates a particular clinical presentation of tuberculosis. This diagnosis should be considered in the presence of atypical bony lesions with a chronic course. Early diagnosis enables proper therapeutic management. Useful diagnostic imaging techniques include plain x-rays, computed tomography, and magnetic resonance imaging. Certain diagnosis is based on bacteriological and histological examinations.

Association française de chirurgie du piedLe pied bot varus équin : traitement chez l’enfant et devenir à l’âge adulte

UNLABELLEDnPURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions.nnnMANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDRENnIdiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction.nnnOUTCOME IN ADULTHOODnThere have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion.nnnCONCLUSIONnA child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

Biomecánica del gran artejo o hallux

El gran artejo (o hallux), situado en el extremo anteromedial del antepie, forma parte de una cadena osteoarticular de tres componentes, que prolonga el arco medial y pertenece al pie astragalino, al que corresponde la funcion propulsora. Incluye dos falanges articuladas mediante una trocoide y unidas al sistema musculotendinoaponeurotico a traves de un mecanismo sesamoideo. Ocho musculos (cuatro de ellos intrinsecos) dan movimiento al gran artejo, que se conecta a todas las estructuras proximales, lo que explica la precision de su funcionamiento como efector final del paso. Sus trastornos, tanto traumaticos como degenerativos, son extremadamente frecuentes; tambien se encuentra afectado en las enfermedades inflamatorias o metabolicas. Aunque no es estrictamente indispensable para la locomocion, el dolor que puede provocar una alteracion es lo bastante invalidante como para alterar la marcha y su modulacion. Iniciar el tratamiento de las enfermedades que lo afectan requiere conocer bien su biomecanica. A veces es dificil restablecer su funcion si se quieren garantizar a la vez ausencia de dolor, movilidad, estabilidad y fuerza de apoyo, ya que posee los dos ultimos pivotes de la marcha a nivel de las articulaciones metatarsofalangicosesamoidea e interfalangica, donde las tensiones dinamicas a veces son enormes. Estos pivotes de movimiento deben intervenir en la aceleracion, la marcha rapida, la carrera y distintas actividades, entre ellas las deportivas. Por estas razones, el gran artejo puede calificarse como dedo del rendimiento. A veces es necesario sacrificar su movilidad mediante una artrodesis para garantizar una fuerza de apoyo eficaz. El ajuste optimo de su posicion requiere tener en cuenta la biomecanica del pie y de la marcha en el contexto del morfotipo individual. La precision de su biomecanica debe tenerse en cuenta para la concepcion de las artroplastias ya que, segun la amplitud de movimiento, la articulacion metatarsofalangicosesamoidea puede comportarse como una bisagra o como una articulacion diartrodial bicondilea compleja, lo que se aleja bastante de la rotula esferica o de la condilea simple, que a menudo han servido de modelo para la concepcion de las artroplastias totales.

Management of Painful Malleolar Gutters After Total Ankle Replacement

Total ankle replacement is a technically challenging procedure that has the potential to restore a pain-free, mobile, and stable ankle. Despite high satisfaction rates reported in the literature, patients complaining about malleolar gutter pain range from 2 to 23.5 % between various total ankle replacement prostheses and ankle arthritis etiologies. The exact cause has not been fully understood and appears to be multifactorial. However, recent literature reports that malleolar gutter pain is often a sign of overloading caused by malalignment of the hindfoot and the ankle or by malpositioning of the total ankle replacement components. Therefore, detailed clinical and radiographic assessment is essential to identify the incriminating factors provoking the malleolar gutter pain. These factors should always be addressed in association with debridement of the malleolar gutters in order to prevent recurrence of the patients’ symptoms. The present chapter explores the potential inciting factors of the gutter pain after total ankle replacement and how they can be managed.