Background Clubfoot is one of the most prevalent musculoskeletal congenital defects. Gold standard treatment of idiopathic clubfoot is the conservative Ponseti method, including the reduction of deformity with weekly serial plaster casting and percutaneous Achilles tenotomy. It is well known that parents of children with severe and chronic illnesses are mentally stressed, but in recent studies regarding clubfoot treatment, parents were only asked about their satisfaction with the treatment. Largely unknown is parental distress before and during plaster casting in clubfoot. Therefore, we want to determinate first, how pronounced the parents’ worries are before treatment and if they decrease during the therapy. Second, we hypothesized that parents faced with an extreme deformity (high Pirani score), reveal more distress, than parents whose children have a less pronounced deformity (low Pirani score). Therefore, we wanted to investigate whether the Pirani score correlates with the parents’ mental resilience in relation to the therapy of the child as a global distress parameter. Methods To answer this question, we developed a questionnaire with the following emphases: Physical capacity, mental resilience, motion score, parents score, and child score with point scores 1 (not affected) to 6 (high affected). Subsequently, we interviewed 20 parents whose children were treated with clubfeet and determined the Pirani score of the infants at the beginning ( T 0 ) and at the end ( T E ) of the treatment with plaster casting. Results High values were obtained in child score (Mean ( M ) = 3.11), motion score ( M = 2.63), and mental resilience ( M = 2.25). During treatment, mental resilience improved ( p = 0.015) significantly. Spearman correlation coefficient between Pirani score ( T 0 ) and mental resilience ( T 0 ) is 0.21, so the initial hypothesis had to be rejected. Conclusion The issues of the children are in the focus of parental worries concerning clubfoot treatment, especially the assumed future motion and the assumed ability to play with other children. Particular emphasis should be placed on educating parents about the excellent long-term results in the function of the treated feet especially as this topic shows the greatest parental distress.

The aim of the study was to evaluate changes in plantar pressure distribution in feet affected by hallux valgus compared with their contralateral non-affected feet and with the feet of healthy control subjects. Thirty-six patients with unilateral hallux valgus who were indicated for surgery and 30 healthy subjects were assessed on a pedobarographic instrumented treadmill for step length and width, mean stance phase, and plantar foot pressure distribution. Plantar pressure distribution was divided into eight regions. Significantly higher plantar pressures were observed in hallux valgus feet under the second and third metatarsal heads (p = .033) and the fourth and fifth toes (p < .001) than in the healthy control feet. Although decreased pressures were measured under the hallux in affected feet (197 [82–467] kPa) in contrast to the contralateral side (221 [89–514] kPa), this difference failed to reach statistical significance (p = .055). The gait parameters step width, step length, and single-limb support did not show any differences between hallux valgus and control feet. Although the literature on changes in plantar pressures in hallux valgus remains divided, our findings on transferring load from the painful medial to the central and lateral forefoot region are consistent with the development of transfer metatarsalgia in patients with hallux valgus.

ABSTRACT Objective: Infection after total hip (THA) and knee arthroplasty (TKA) is a serious complication which typically leads to a long lasting and intensive surgical and medicamentous treatment. The aim of this study was to identify factors that influence outcome after revision surgery caused by prosthetic infection. Methods: We retrospectively analyzed 64 patients who had revision surgery between 1989 and 2009 due to periprosthetic infection. We examined a total of 69 joints (TKA: 36%, THA: 64%), follow-up 5.1 years (0.5-21 years) after the initial surgical intervention. The mean patient age at time of surgery was 67 years old (43-79 years old). Clinical data and scores including the Western Ontario and McMaster Universities (WOMAC)-Index, the Harris Hip Score (HHS) and the Hospital for Special Surgery Score (HSS) were surveyed. Results: There was no difference in clinical scores regarding treatment between a single and a multiple stage treatment regime. Infections with multiple microorganisms and Enterococcus spp. lead to a significantly higher number of interventions. Using a modified Tsukayama system we classified 24% as type I, 34% type II and 42% type III- infections, with no differences in clinical outcome. Overweight patients had a significantly lower HHS and WOMAC-score. Immunosuppression leads to a worse WOMAC and HSS-Score. An increased number of procedures was associated to a limping gait. Conclusion: Thorough surgical technique leads to good clinical results independent of infection-type and treatment philosophy. Level of Evidence III, Case Control Study.

Anterior knee pain is often associated with patellar maltracking and instability. However, objective measurement of patellar stability under clinical and experimental conditions is difficult, and muscular activity influences the results. In the present study, a new experimental setting for in vitro measurement of patellar stability was developed and the mediolateral force–displacement behavior of the native knee analyzed with special emphasis on patellar tilt and muscle loading.

BACKGROUND AND OBJECTIVES: Despite the recommendations of national and international societies for the treatment of patients with acute neck and back pain, still too many radiologic examinations were performed. The purpose of this study was to analyze and optimize diagnostics and treatment of patients with acute back pain.METHODS: The medical records of 484 patients presented to the emergency clinic with acute neck or back pain were analyzed for clinical history, physical examination, radiographic findings and therapy.RESULTS: Radiographs of the lumbar, cervical, or thoracic spine were performed in 338 cases (70%). Radiographs were normal in 142 patients (42%) and degenerative changes were identified in 123 patients (36%). Only 2 patients (0.4%) had radiographic findings that had direct therapeutic relevance: 1 patient with metastatic disease and 1 patient with posttraumatic C1-C2 instability. For most patients without sensorimotor deficits and absent specific indications for radiography ("red flags"), therapy was not affected by the results of radiography.CONCLUSIONS: Plain radiography of the spine was unnecessary in most patients initially evaluated with non-specific acute back pain and does not improve the clinical outcome. The implementation of national and international guidelines is a slow process, but helps to reduce costs and to protect patients from unnecessary ionizing radiation exposure.

Hallux varus is defined as a medial deviation of the phalanx at the first metatarsophalangeal joint and can be congenital or acquired. Brachymetatarsia is defined as shortening of the metatarsal bones. A combination of hallux varus and brachymetatarsia is rare. A 15-year-old girl presented to our outpatient clinic complaining of problems with her feet. A distinctive hallux varus was present bilaterally combined with a brachymetatarsia of the first metatarsals. The patient reported discomfort. She was restricted in her activities and had severe psychological strain owing to the deformity. We decided on surgery. First, a Pennig MiniFixator for callus distraction of the first metatarsal bone was applied. Owing to the increased plantar subluxation of the phalanx during distraction, an extension of the external fixator was administered so that the hallux could be repositioned to a physiologically satisfying position. After sufficient callus formation, the hardware was removed 14 weeks after surgery. Thereafter, the phalanx moved back to the subluxed position. Finally, an arthrodesis of the first metatarsophalangeal joint was performed with a locking plate. Surgery should not be made only for cosmesis and associated psychological aspects; but, discomfort should be the deciding factor. The postoperative clinical and cosmetic results in our case were good, and the patient was quite satisfied. There was no longer any preoperative discomfort and pain.

Considering the discrepant results of the recent biomechanical studies, the purpose of this study was to simulate dynamic muscle-loaded knee flexion with a large number of specimens and to analyse the influence of total knee arthroplasty (TKA) without and with patellar resurfacing on the patellofemoral pressure distribution.

Hallux varus is defined as a medial deviation of the phalanx at the first metatarsophalangeal joint and can be congenital or acquired. Brachymetatarsia is defined as shortening of the metatarsal bones. A combination of hallux varus and brachymetatarsia is rare. A 15-year-old girl presented to our outpatient clinic complaining of problems with her feet. A distinctive hallux varus was present bilaterally combined with a brachymetatarsia of the first metatarsals. The patient reported discomfort. She was restricted in her activities and had severe psychological strain owing to the deformity. We decided on surgery. First, a Pennig MiniFixator for callus distraction of the first metatarsal bone was applied. Owing to the increased plantar subluxation of the phalanx during distraction, an extension of the external fixator was administered so that the hallux could be repositioned to a physiologically satisfying position. After sufficient callus formation, the hardware was removed 14 weeks after surgery. Thereafter, the phalanx moved back to the subluxed position. Finally, an arthrodesis of the first metatarsophalangeal joint was performed with a locking plate. Surgery should not be made only for cosmesis and associated psychological aspects; but, discomfort should be the deciding factor. The postoperative clinical and cosmetic results in our case were good, and the patient was quite satisfied. There was no longer any preoperative discomfort and pain.

Zusammenfassung Hintergrund: Arthrodese und Endoprothese sind kontrovers diskutierte Therapieverfahren der endgradigen Arthrose des oberen Sprunggelenks. Um eine Orientierungshilfe zur Wertigkeit beider Verfahren zu geben, werden eigene klinische, radiologische und biomechanische Ergebnisse in Bezug zum aktuellen Stand der Literatur gesetzt. Material und Methoden: 15 Patienten nach Schraubenarthrodese bei isolierter Arthrose des oberen Sprunggelenks wurden nach 4 (1,9–8,8) Jahren klinisch und radiologisch nachuntersucht, wobei der AOFAS-Score sowie der Score nach Kellgren und Lawrence erhoben wurden. Des Weiteren wurde in einem dynamischen Fußmodell der Abrollvorgang des Fußes exemplarisch anhand eines Kadaverpräparats simuliert. Unter Ansteuerung von 6 extrinsischen Sehnen mittels Seilzügen und hydraulischer Kraftapplikation wurden unter Zuhilfenahme einer sich bewegenden Bodenplatte der Abrollvorgang simuliert und die Druckbelastungen im talonavikularen Gelenk und im Kalkaneokuboidgelenk ermittelt. Ergebnisse: Im AOFAS-Score verzeichneten wir für die Unterkategorie Schmerz einen mittleren Wert von 28 ± 12 Punkten, in der Unterkategorie Funktion 38 ± 9 Punkte. Der mittlere AOFAS-Score lag somit bei 66 ± 18 Punkten. Bei 6 Patienten traten radiologisch Anschlussdegenerationen im talonavikularen Gelenk auf. Der Score nach Kellgren und Lawrence lag um 2,3 (1–4) Punkte über dem der Gegenseite. Bei 6 Patienten war der Score im subtalaren Gelenk verglichen zur Gegenseite um 1,6 (1–3) Punkte erhöht. Dagegen war nur in einem Fall eine Anschlussdegeneration im kalkaneokuboidalen Gelenk zu verzeichnen. Die Untersuchung im Fußmodell zeigte unter nativen Bedingungen ein kontinuierliches Ansteigen der Kraftübertragung in beiden Abschnitten des Chopart-Gelenks. Nach Simulation einer tibiotalaren Arthrodese stieg die Kraftübertragung im talonavikularen Gelenk signifikant in der 2. Hälfte des Abrollzyklus. Im kalkaneokuboidalen Gelenk hingegen sank die Kraftübertragung ab. Schlussfolgerung: Die Arthrodese stellt nach aktueller Studienlage bei teilweise widersprüchlichen Untersuchungen im Vergleich zur Prothese aufgrund der niedrigeren Komplikationsrate das sicherere Verfahren zur Behandlung der schweren Sprunggelenksarthrose dar. Ein vergleichbares klinisches Ergebnis im kurzfristigen Verlauf ist beschrieben. Es treten im langfristigen Verlauf höhere Raten an Anschlussdegenerationen im Subtalar- und Talonavikulargelenk auf. Ursächlich hierfür sind komplexe 3-dimensionale kinematische Veränderungen der Rückfußmechanik, welche im vorliegenden Artikel beschrieben werden.

The aim of this study was to analyze the influence of the patellofemoral groove design in TKA on patellar kin ematics and pressures with a special regard to an individua l esign adaption. Five different designs of the patellofemo ral groove were created based on the Genesis II prosthesis. Mu cle loaded knee flexion was simulated on 10 human knee specimens while measuring the patellar kinematics a nd patellofemoral pressure distribution. For 3 specime ns, additional individual implants were developed based on CTscans. The largest influence was found for the completely flat design, where increased medal shift and lateral til t were measured after TKA compared to the native knee. The ot r designs only showed small differences. Therefore, a moderate groove should be sufficient to guarantee s able motion. Considering the patellofemoral peak pressu re, on average the designs only had a small effect, althou g large individual differences were found. The individually adapted designs did not show an improvement, which might be attributed to the alteration of overall knee biomec hanics during TKA. Therefore, an individual choice between different standard implants might be a good option.

Although mid- to long-term results after total ankle replacement have improved because of available second- and third-generation devices, failure of total ankle replacement is still more common compared with total hip replacement and total knee replacement . The portfolio of available total ankle replacement revision component options is small. Furthermore, the bone stock of the tibiotalar region is scarce making it difficult and in some situations impossible to perform revision total ankle replacement. In these cases tibiotalar and tibiotalocalcaneal fusions are valuable options. This article describes which surgical procedures should be performed depending on the initial situation and gives detailed advice on surgical technique, postoperative care, and clinical results.

OBJECTIVE The aim of this study was to analyze the setting for dislocations and redislocations after primary and revision total hip arthroplasty (THA), identify risk factors and optimize treatment. METHODS This study included 56 patients with a dislocated hip following THA (n=5,205) between 1984 and 2005 and a matched control group (n=55). Hospital charts and radiographs of all patients in both groups were analyzed. Thirty-one patients in the study group were followed both clinically and radiologically. RESULTS The dislocation rate after primary THA was 1.1% (56/5,205) and the redislocation rate after a first occurrence was as high as 39%. There was a positive correlation between the time intervals from the surgery to first dislocation and from the first dislocation to second dislocation (r=0.4). Most of the primary dislocations occurred within a short period of time after surgery, thus favoring consecutive dislocations. Female gender, as well as revision arthroplasty, was associated with a higher incidence of dislocations. No relation was found between the orientation of the acetabular cup and dislocation. CONCLUSION To prevent redislocations after the first occurrence, we suggest thorough evaluation of possible technical faults which should be addressed surgically. Considering the high redislocation rate, we also advocate a stringent conservative treatment regime especially after the first THA dislocation.

BACKGROUND:Posterior cruciate ligament (PCL) retaining (CR) and -sacrificing (PS) total knee arthroplasties (TKA) are widely-used to treat osteoarthritis of the knee joint. The PS design substitutes the function of the PCL with a cam-spine mechanism which may produce adverse changes to joint kinematics and kinetics.METHODS:CR- and PS-TKA were performed on 11 human knee specimens. Joint kinematics were measured with a dynamic knee simulator and motion tracking equipment. In-situ loads of the PCL and cam-spine were measured with a robotic force sensor system. Partial weight bearing flexions were simulated and external forces were applied.RESULTS:The PS-TKA rotated significantly less throughout the whole flexion range compared to the CR-TKA. Femoral roll back was greater in the PS-TKA; however, this was not correlated with lower quadriceps forces. Application of external loads produced significantly different in-situ force profiles between the TKA systems.CONCLUSIONS:Our data demonstrate that the PS-design significantly alters kinematics of the knee joint. Our data also suggest the cam-spine mechanism may have little influence on high flexion kinematics (such as femoral rollback) with most of the load burden shared by supporting implant and soft-tissue structures.

Background: Proximal metatarsal osteotomy combined with a distal soft-tissue procedure is a common treatment for moderate to severe hallux valgus. Secure stabilisation of the metatarsal osteotomy is necessary to avoid complications such as delayed union, nonunion or malunion as well as loss of correction. The aim of this study was to report our results using a single screw for stabilisation of the osteotomy.Methods: We retrospectively reviewed 151 patients with severe hallux valgus who were treated by the above mentioned way with full postoperative weightbearing in a stiff soled shoe. Mean age of patients at time of surgery was 54 years, 19 patients were male and 132 female. Assessment of clinical and radiographic results was performed after 2 days and 6 weeks. Results were also correlated to the experience of the performing surgeon.Results: Mean preoperative HVA (hallux valgus angle) was 36.4 degrees, and then 3.5 degrees 2 days and 13.4 degrees 6 weeks after the procedure (p < 0.001). Mean preoperative IMA (intermetarsal angle) was 16.8 degrees, and then 6.4 degrees after 2 days and 9.8 degrees after 6 weeks (p < 0.001). Mean preoperative first metatarsal length of 56.4 mm decreased to 53.6 mm after 6 weeks. Possible non-union of the osteotomy was observed in 4 patients (2.6%) after 6 weeks. Performing residents (n = 40) operated in 65 minutes and attending surgeons (n = 111) in 45 minutes, with no significant differences in radiographic measurements between both groups.Conclusions: Single screw stabilisation of proximal chevron osteotomy is a reliable method for treating severe hallux valgus deformities with satisfactory results.

The editor regrets that this paper was published erroneously as a case report.It is in fact an original article. The editor regrets that this paper was published erroneously as a case report. It is in fact an original article. Translational and rotational knee joint stability in anterior and posterior cruciate-retaining knee arthroplastyThe KneeVol. 18Issue 6PreviewThis study investigated passive translational and rotational stability properties of the intact knee joint, after bicruciate-retaining bi-compartmental knee arthroplasty (BKA) and after posterior cruciate retaining total knee arthroplasty (TKA). Fourteen human cadaveric knee specimens were used in this study, and a robotic manipulator with six-axis force/torque sensor was used to test the joint laxity in anterior–posterior translation, valgus–varus, and internal–external rotation. The results show the knee joint stability after bicruciate-retaining BKA is similar to that of the native knee. Full-Text PDF

The authors present an unusual case of untreated gout leading to major bony destructions in both metatarsophalangeal joints, leading to joints of enormous dimensions. If untreated, gout can cause disabling destructions with direct influence on both private and working life, even in young patients. In potentially noncompliant patients, simple surgical procedures and postoperative regimes are valuable treatment options resulting in acceptable clinical results.

Cadaveric in vitro studies are essential to test hypotheses concerning surgical manipulations in the same individual. Robotic technologies as well as different knee-models have been developed to get an in-depth comprehension of knee joint kinematics. The purpose of this study was to compare utilization of these different established principles.Ten human cadaveric knee specimens were used to measure the kinematics during a weight-bearing flexion in a 6-degrees-of-freedom knee simulator. While flexing the knee, joint quadriceps muscle forces were dynamically simulated to reach a vertical ground reaction force of 100N. Fourteen knee specimens were mounted in 6-degrees-of-freedom robotic manipulator with a universal force sensor. The unloaded flexing motion of each specimen was measured by finding positions for each degree of flexion where all forces are minimal (passive path). The kinematic data of the knee-simulator and the robot concerning internal-external rotation, anterior-posterior translation, varus-valgus motion, and medial-lateral translation was examined.For all investigated degrees of freedom the kinematics of the robotic passive path differed from the loaded kinematics in the knee simulator.Simulated bodyweight as well as the examination method used has a substantial influence on joint kinematics during flexion which has to be considered when interpreting biomechanical studies as well as clinical tests.