Dysfunction of the tendon of tibialis posterior.
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Arthrodesis↗
Biomedical subjects
H J Trnka
Publications and source records attributed to H J Trnka.
[Stress fractures of the tarsal navicular bone. Causality, diagnosis, therapy, prophylaxis].
Stress fractures of the tarsal navicular bone are a challenge in diagnosis and therapy. First and foremost you have to think about this fracture. The origin of the injury can be detected in a wrong or too heavy strain of the bone especially in long distance runners and recruits. The MRI is the diagnostic tool of first choice. Therapy of displaced or comminuted fractures as well as pseudarthrosis is best done with surgical procedures like direct screw fixation or interposition of autologous bone depending on the circumstances and the age of injury. Conservative treatment with a plaster of Paris is useful in non-displaced and non-comminuted fractures. Prophylaxis with technical aids and a changing habits is recommended.
Bone Screws↗
[Airlimb. Initial experiences with a new immediate early management prosthesis with individually adjustable air chambers].
Amputations of the lower extremity are still a common problem in diabetic feet and peripheral vasculopathies. The presented paper introduces a new device for an easier and faster mobilization of below-the-knee amputees. It is based on a new modular prostheses with individual inflatable air bladders. The compliance rate is higher with this device and it could be used from the day of surgery until the definitive prostheses is made. A biomechanical cadaver study with the prostheses will also be presented.
Adult↗
Surgical treatment of chronic lower extremity neuropathic pain.
The current authors retrospectively reviewed 147 lower extremity peripheral nerve procedures in 114 patients (average age, 42 years) with chronic lower extremity neuropathic pain to determine whether surgical treatment based on an empirically derived algorithm could reduce pain and improve function. This algorithm assigns crush, stretch, and chronic transection injuries to treatment with transection and containment. Peripheral nerve stimulation was used in conjunction with transection and containment for patients with more chronic presentations for whom previous transections had been unsuccessful. Patients with adhesive neuralgia underwent revision neurolysis with vein wrapping. Patients with repetitive nerve trauma (overuse) underwent primary or revision neurolysis. Duration of symptoms averaged 37 months, and mechanisms of nerve injury included chronic transection, crush, adhesive neuralgia, stretch, repetitive trauma, and idiopathic etiology. Time to followup averaged 38 months. Pain and dysfunction were ranked from 0 points (no pain or dysfunction) to 10 points (pain prompting request for amputation or functional deficit warranting wheelchair use); preoperative and followup work status were documented. Average pain and dysfunction scores improved: 8.8 to 5.6 points and 7.6 to 5.0 points, respectively. Of the 114 patients, 52 (46%) patients improved their work status, including 35 of 87 (40%) involved in workers' compensation. There were no statistically significant differences in outcome based on mechanism of nerve injury or type of procedure. The consistent average improvement suggests this algorithm assigns the appropriate procedure to a given mechanism of injury.
Adolescent↗
Dorsiflexion contracture after the Weil osteotomy: results of cadaver study and three-dimensional analysis.
For metatarsalgia caused by a dislocated lesser metatarsophalangeal (MTP) joint and isolated over-long lesser metatarsals, surgical treatment options without sacrificing the joint are limited. Recently, the Weil osteotomy has been advocated for the treatment of this deformity. In our experience, preliminary results with this technique have revealed a high rate of dorsiflexion contracture of the MTP joints at follow-up. We performed a cadaver study and a three-dimensional analysis on sawbones to investigate this phenomenon. In the cadaveric portion of this study, the second MTP joints of two fresh-frozen cadavers were dissected; the entire ray, with the metatarsal shaft, MTP joint, toe, and plantar fascia, was removed en bloc. After gross anatomic structures were photographed, a Weil osteotomy was performed at 25 degrees relative to the long axis of the metatarsal shaft. The positions of muscles, ligaments, and tendons were noted and photographed before and after the osteotomy. In the sawbones portion of this study, a Weil osteotomy was performed at four different angles (25 degrees, 30 degrees, 35 degrees, and 40 degrees) relative to the long axis of the metatarsal. To ensure reproducibility, the sawbone models were fixed proximally to a vertical milling machine with the second metatarsals inclined 15 degrees to simulate the anatomic position. After making the cut, the plantar fragment was translated along the dorsal fragment proximally for a distance of 5 mm. Before and after the osteotomy, selected x, y, and z coordinates were obtained using a Microscribe 3D digitizer. Data analysis was performed with Microsoft Excel, and ANOVA was used to determine significant differences (p < 0.05) between the various osteotomies. Analysis of the cadaver dissection revealed that after the Weil osteotomy, the tendons of the interosseous muscles move dorsally with respect to the axis of the MTP joint due to the depression of the plantar fragment of the metatarsal. The loss of their flexion effect on the joint permits the pull of the extensor to dorsiflex the toe. The size of the depression for the various osteotomies averaged: 25 degrees osteotomy, 3.03 mm (range, 1.8 to 3.8 mm); 30 degrees osteotomy, 3.2 mm (range, 1.9 to 4.0 mm); 35 degrees osteotomy, 3.5 mm (range, 1.7 to 5.7 mm); and 40 degrees osteotomy, 4.2 mm (range, 2.8 to 6.4 mm). Amounts of shortening relative to the long axis of the metatarsal for the various osteotomies averaged: 25 degrees osteotomy, 5.03 mm (range, 4.77 to 5.30 mm); 30 degrees osteotomy, 4.59 mm (range, 3.47 to 5.19 mm); 35 degrees osteotomy, 4.27 mm (range, 2.87 to 5.00 mm); and 40 degrees osteotomy, 3.65 mm (range, 3.20 to 4.31 mm). According to our analysis, depression of the plantar fragment always occurs after a Weil osteotomy. This depression changes the center of rotation of the MTP joint, and the interosseous muscles then act more as dorsiflexors than as plantarfexors.
Cadaver↗
Subtalar distraction bone block arthrodesis.
This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5 degrees and 4.9 degrees before operation, 25.9 degrees and 8.3 degrees immediately after, and 24.6 degrees and 7.7 degrees at the final follow-up, respectively. The mean talar declination angle improved from 6.5 degrees (-10 to 22) before operation to 24.8 degrees (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up.
Adolescent↗
Moderate to severe hallux valgus deformity: correction with proximal crescentic osteotomy and distal soft-tissue release.
Between 1991 and 1995, 96 patients (114 feet) were treated with a proximal crescentic metatarsal osteotomy and distal soft-tissue procedure for moderate to severe hallux valgus deformity [intermetatarsal (IM) angle > 15 degrees, or hallux valgus (HV) angle > 30 degrees]. At an average follow-up of 26 months, 8 men and 62 women (86 feet) with a mean age of 53.2 years were retrospectively reviewed. The HV angle averaged 41.1 degrees preoperatively and 14.6 degrees postoperatively. The respective values for the IM angle were 17.8 degrees and 7.8 degrees. Neither the average metatarsal shortening of 3 mm nor the dorsal angulation at the osteotomy site seen in 9% of cases evidenced any clinical significance at follow-up. Patient satisfaction was excellent or good in 91%, and the mean Mayo Clinic Forefoot Score (total 75 points) improved from 37.2 to 61.1 points. Complications included 8 cases of hallux varus and 5 cases of hardware failure. Based on this first study exclusively focusing on moderate to severe hallux valgus deformity, we conclude that proximal first metatarsal osteotomy in combination with a lateral soft-tissue procedure is effective in correcting moderate to severe symptomatic hallux valgus deformity with metatarsus primus varus (IM angle > 15 degrees or HV angle > 30 degrees).
Adolescent↗
[Post-traumatic metatarsalgia. Early results of treatment with a new insole].
Injuries of the forefoot are a challenge for orthopaedic surgeons. After healing of bone and soft tissue damage, posttraumatic metatarsalgia can persist. The paper presents a therapy algorithm with newly designed insoles, which consist of the common orthopaedic adaptations like a rocker bottom and a stiffening of the sole. The therapy is shown on two cases. With these orthotics adequate is possible and pain relief realistic.
Adult↗
[Metatarsalgia. Treatment of the dorsally dislocated metatarsophalangeal joint].
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Arthroplasty, Replacement↗
Six first metatarsal shaft osteotomies: mechanical and immobilization comparisons.
Because malunion (usually with dorsal elevation of the first metatarsal) has been reported after the treatment of severe hallux valgus deformities by proximal osteotomies, the current study was designed to compare the sagittal stability of six different metatarsal shaft osteotomies: the proximal crescentic, proximal chevron, Mau, Scarf, Ludloff, and biplanar closing wedge osteotomies. A plate was used in the biplanar closing wedge osteotomy; all others used screws for fixation. Ten fresh-frozen, human anatomic lower extremity specimens were used for each osteotomy. Failure loads were measured as units of force (newtons) and converted to pressure (kilopascals). Then the F-Scan system, which uses a thin insole to measure plantar pressure, was used to evaluate the pressure under the first metatarsal of seven volunteers using four types of shoes. According to the results, in patients with normal bone stock who are compliant, any of the four shoe types tested may be used after a Ludloff, Scarf, biplanar wedge (plantar screw fixation), or Mau osteotomy, but the wedge-based shoe should be used after a proximal crescentic or chevron osteotomy or for patients with severe osteopenic bone.
Biomechanical Phenomena↗
Isolated subtalar arthrodesis.
BACKGROUND: The purposes of this retrospective study were to review the results of isolated subtalar arthrodesis in adults and to identify factors influencing the union rate. The hypotheses were that (1) the overall outcome is acceptable but is not as favorable as previously reported, (2) complication rates, especially the nonunion rate, are higher than previously reported, and (3) factors contributing to a less favorable union rate can be identified. METHODS: Between January 1988 and July 1995, 184 consecutive isolated subtalar arthrodeses were performed in 174 adults (115 men and fifty-nine women) whose average age was forty-three years (range, eighteen to seventy-nine years). Eighty patients (46 percent) were smokers. The indications for the procedure included posttraumatic arthritis after a fracture of the calcaneus (109 feet), a fracture of the talus (thirteen feet), or a subtalar dislocation (thirteen feet); primary subtalar arthritis (thirteen feet); failure of a previous subtalar arthrodesis (twenty-eight feet); and residual congenital deformity (eight feet). Rigid internal fixation with one or two screws was used for all feet. Bone graft was used in 145 feet; the types of graft material included cancellous autograft (ninety-four feet), structural autograft (twenty-nine feet), cancellous allograft (seventeen feet), and structural allograft (five feet). Bone graft was not used in the remaining thirty-nine feet. RESULTS: Clinical and radiographic follow-up examinations were performed for 148 (80 percent) of the 184 feet at an average of fifty-one months (range, twenty-four to 130 months) postoperatively. The average ankle-hindfoot score according to the modified scale of the American Orthopaedic Foot and Ankle Society (maximum possible score, 94 points) improved from 24 points preoperatively to 70 points at follow-up. Thirty feet had clinical evidence of nonunion. The union rate was 84 percent (154 of 184) overall, 86 percent (134 of 156) after primary arthrodesis, and 71 percent (twenty of twenty-eight) after revision arthrodesis. The union rate was 92 percent (ninety-three of 101 feet) for nonsmokers and 73 percent (sixty-one of eighty-three feet) for smokers (p < 0.05). Intraoperative inspection revealed that 42 percent (seventy-eight) of the 184 feet had evidence of more than two millimeters of avascular bone at the subtalar joint; all thirty nonunions occurred in this group (p < 0.05). A nonunion occurred in three of the five feet that had been treated with structural allograft and in two of the six feet in which the subtalar arthrodesis had been performed adjacent to the site of a previous ankle arthrodesis. After elimination of the subgroups of feet in patients who smoked, those that had had a failure of a previous subtalar arthrodesis, those that had been treated with a structural graft, and those that had had the subtalar arthrodesis adjacent to the site of a previous ankle arthrodesis, the union rate improved to 96 percent (seventy-three of seventy-six). Complications other than nonunion included prominent hardware requiring screw removal (thirty-six of 184 feet; 20 percent), lateral impingement (fifteen of 148 feet; 10 percent), symptomatic valgus malalignment (five of 148 feet; 3 percent), symptomatic varus malalignment (four of 148 feet; 3 percent), and infection (five of 184 feet; 3 percent). CONCLUSIONS: To the best of our knowledge, the present study includes the largest reported series of isolated subtalar arthrodeses in adults. Our results suggest that the outcome following isolated subtalar arthrodesis is not as favorable as has been reported in previous studies. The rate of union was significantly diminished by smoking, the presence of more than two millimeters of avascular bone at the arthrodesis site, and the failure of a previous subtalar arthrodesis (p < 0.05 for all). Other factors that probably affect the union rate include the use of structural allograft and performance of the arthrodesis adjac
Adult↗
Correction of hallux valgus. Metatarsal osteotomy versus excision arthroplasty.
The long-term retrospective results (followup range, 10-22 years) of an uncontrolled series of basal metatarsal closing wedge osteotomies and Keller's excision arthroplasties performed in patients 14 to 40 years of age are analyzed. In the osteotomy group, 34 patients (50 feet) were available for clinical review and 26 patients (37 feet) were available for radiologic review. In the Keller group, 24 patients (37 feet) were reviewed clinically and 23 patients (34 feet) were reviewed radiologically. Patients were assessed using the Hallux Metatarsophalangeal Interphalangeal Scale of the American Foot and Ankle Society, an additional clinical score, weightbearing radiographs, the patient's record, and clinical investigation. Statistical analysis revealed significantly better results of the clinical and radiologic outcomes after osteotomy. In the osteotomy group, the first metatarsal was elevated dorsally in 14 feet (38%). The incidence of varus deformities was higher with basal osteotomy (18% versus 5.4%). Metatarsalgia occurred similarly in both groups (28% versus 27%). It is known that these techniques should be applied to different patient populations. However, they formerly were used for the same indication. This long-term analysis shows that the Keller arthroplasty should be abandoned for the treatment of hallux valgus in young and active patients. The basal metatarsal closing wedge osteotomy is conceptually the correct treatment for hallux valgus deformity for the younger patient; nevertheless, it is technically demanding and is associated with a higher risk of failure. The long-term results of both procedures are unacceptable for the patient and the surgeon. The short and middle-term results of the newer basal type osteotomies, such as the proximal crescentic osteotomy, the proximal chevron osteotomy, or the proximal oblique osteotomy combined with distal soft tissue releases, suggest a more satisfying long-term outcome.
Adult↗
The chevron osteotomy for correction of hallux valgus. Comparison of findings after two and five years of follow-up.
BACKGROUND: The chevron osteotomy, an accepted method for the correction of mild and moderate hallux valgus, is generally advocated for patients younger than the age of fifty years. The purposes of this prospective study were to compare the short-term (two-year) and intermediate-term (five-year) results of this operation with respect to patient satisfaction, flexion and extension of the metatarsophalangeal joint, maintenance of correction, and development of arthrosis and to determine whether the effectiveness of the procedure was limited by age. METHODS: Between April 1991 and September 1992, the chevron osteotomy was performed for the treatment of mild-to-moderate hallux valgus deformity in sixty-six consecutive feet. Forty-three patients (fifty-seven feet) were available for follow-up at both two and five years postoperatively. The two-year and five-year clinical assessments were based on the American Orthopaedic Foot and Ankle Society's hallux-metatarsophalangeal-interphalangeal scale. RESULTS: Between the two-year and five-year follow-up evaluations, there was only a minimal change in overall patient satisfaction, and the average score on the hallux-metatarsophalangeal-interphalangeal scale was unchanged. The passive range of motion of the first metatarsophalangeal joint decreased between the preoperative assessment and the two-year follow-up evaluation and was unchanged at the five-year follow-up evaluation. Radiographic evaluation showed no changes in the hallux valgus or intermetatarsal angle between the two-year and five-year evaluations, although the number of feet with arthrosis of the metatarsophalangeal joint increased slightly, from eight to eleven. Patients aged fifty years or older did as well as younger patients. CONCLUSIONS: At these two follow-up periods, the chevron osteotomy was found to be a reliable procedure for the correction of mild and moderate hallux valgus deformity, and outcome did not differ on the basis of age.
Case-Control Studies↗
Arthrography of the foot and ankle. Ankle and subtalar joint.
Arthrography is the intra-articular injection of contrast media. This article reviews the normal and pathologic findings of standard arthrography and MR imaging arthrography of the ankle and subtalar joint. Standard arthrography is used primarily after acute ankle sprains, whereas MR imaging arthrography is used for staging and detecting osteochondritis dissecans of the talus, anterolateral soft tissue impingement, and chronic lateral ankle instability.
Ankle Injuries↗
Arthrodesis procedures for salvage of the hallux metatarsophalangeal joint.
First metatarsophalangeal (MTP) fusion has been recommended as a means to salvage various great toe deformities. These deformities include failed hallux valgus procedures, failed silicon implants, previous infection, rheumatoid arthritis, post-traumatic conditions, hallux rigidus, severe hallux valgus deformities, and neuromuscular disorders. A variety of complications, such as hallux varus, first MTP joint instability, infection, recurrent hallux valgus, and avascular necrosis of the first metatarsal head can develop from hallux valgus deformity treatment procedures.
Adult↗
The role of calcaneal osteotomies for correction of adult flatfoot.
The surgical treatment of flatfoot deformity has evolved during the past three decades. Soft tissue procedures alone fail to reestablish anatomic bony alignment, and bony procedures alone fail to provide dynamic support to the arch. The goal of any procedure is to reestablish the inherently stable bony configuration with adequate soft tissue balance (tendon transfer) to maintain stability in the dynamic situation. Therefore, a combination of procedures, such as soft tissue procedures combined with calcaneal displacement osteotomies and/or lateral column lengthening, may provide optimal results. The focus of this review is the role of bony correction in the treatment of the adult acquired flatfoot deformity.
Adult↗
Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints.
We retrospectively reviewed the outcome of 30 patients who were treated surgically for metatarsalgia resulting from dislocation of one or more lesser metatarsophalangeal (MTP) joints. We used two treatments, including an osteotomy of the metatarsal head (Weil osteotomy, N = 15) or an osteotomy of the metatarsal shaft (Helal osteotomy, N = 15). Before surgery, all patients had been treated with various nonoperative modalities for a minimum of 6 months. Between 1991 and 1993, 15 consecutive patients underwent a Helal osteotomy (22 metatarsals), and 15 consecutive patients were subsequently treated between 1994 and 1995 with a Weil osteotomy (25 metatarsals). All patients were evaluated clinically and radiographically at a mean follow-up period of 22 months (range, 12-39 months), noting especially persistent subluxation or dislocation, recurrent metatarsalgia, and transfer lesions. Patients managed with a Weil osteotomy had significantly higher satisfaction (P = 0.049), lower incidence of recurrent metatarsalgia (0 vs. 27%, P = 0.107), and fewer transfer lesions (0 vs. 41%, P = < 0.001) than those managed with a Helal osteotomy. Furthermore, those managed with the Weil procedure had a higher percentage of radiographic reduction and maintenance of the MTP joint dislocation (21 of 25, 84%; vs. 8 of 22, 36%; P = 0.002) than those managed with the Helal procedure. In the Weil group, there was also no malunion or pseudoarthrosis; in the Helal group there were five malunions and three pseudoarthroses. Although the follow-up period for the Weil osteotomy (15 months) was shorter than that for the Helal osteotomy (26 months), the former group had higher American Orthopaedic Foot and Ankle Society forefoot scores, which were significantly different from the results attained with the Helal osteotomy. A telephone update was performed on the Weil osteotomy group at an average of 27 months postsurgery, and no patient had experienced changes since the clinical follow-up. We concluded that the Weil procedure is a satisfactory method for correcting metatarsalgia caused by dislocation of the MTP joint and that, because of the high complication rate, the Helal osteotomy is not an acceptable procedure for correcting this condition.
Adult↗
Basal closing wedge osteotomy for correction of hallux valgus and metatarsus primus varus: 10- to 22-year follow-up.
Between 1974 and 1985, 59 patients (83 feet) underwent basal closing wedge osteotomy in combination with a bunionectomy and a lateral soft tissue release for correction of hallux valgus and metatarsus primus varus at this institution. Of the original 59 patients, 42 patients (60 feet) with at least 10 years of follow-up (average, 194 months; range, 144-266 months) were available for this study. Results were analyzed by review of the medical records and plain radiographs, a standardized clinical questionnaire, and physical examination. Of the 60 feet, patients rated outcomes as excellent or good in 51 feet (85%) and rated cosmesis as excellent or good in 44 feet (73%). Radiographically at final follow-up, hallux valgus and intermetatarsal angles averaged 19.9 degrees (range, 0-40 degrees) and 6.7 degrees (range, 0-18 degrees), respectively. The sesamoid position was corrected from an average preoperative grade of 2.6 to a grade of 0.9 at final follow-up. The average shortening of the first metatarsal was 5 mm. The disadvantages of the closing wedge osteotomy are that it is technically demanding and it entails the risk of shortening, dorsal malalignment, and metatarsalgia. In the current study, long-term complications included hallux varus deformity (16 feet), dorsal malalignment (15 feet), and metatarsalgia (14 feet). Despite good correction of the intermetatarsal angle and sesamoid position, the clinical results and the incidence of complications after basal closing wedge osteotomy were not as favorable as those reported for other procedures in the literature. Therefore, alternative procedures, such as the basal crescentic osteotomy or the basal chevron osteotomy, should be used.
Adolescent↗