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Background: In cases of tibialis anterior tendon (TAT) ruptures associated with significant tendon defect, an interposition graft is often needed for reconstruction. Both auto- and allograft reconstructions have been described in the literature. Our hypothesis was that both graft types would have a good integrity and provide comparable outcomes. Methods: Patients who underwent TAT reconstruction using either an auto- or allograft were identified. Patient-reported outcomes (PROs) were collected using the 12-Item Short Form Health Survey (SF-12) questionnaire, the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the Foot Function Index (FFI), and the Karlsson-Peterson score. Functional outcome was assessed by isokinetic strength measurement. Outcomes were further assessed with magnetic resonance imaging (MRI) evaluation of graft integrity. All measurements were also performed for the contralateral foot. Results: Twenty-one patients with an average follow-up of 82 months (20-262 months), comprising 12 allograft and 9 autograft TAT reconstructions, were recruited. There were no significant differences in patient-reported outcomes between allograft reconstructions and autografts: SF-12 (30.7 vs 31.1, P = .77); AOFAS (83 vs 91.2, P = .19); FFI (20.7% vs 9.5%, P = .22); and Karlsson-Peterson (78.9 vs 87.1, P = .23). All grafts (100%) were intact on MRI with a well-preserved integrity and no signs of new rupture. There were no major differences in range of motion and functional outcomes as measured by strength testing between the operative and nonoperative side. Conclusion: Reconstructions of TAT achieved good PROs, as well as functional and imaging results with a preserved graft integrity in all cases. There were no substantial differences between allograft and autograft reconstructions. Level of Evidence: Level IV, retrospective case series.

Restriction of greater toe dorsiflexion without degeneration of the first metatarsophalangeal joint is defined as hallux limitus. We assume that in hallux limitus the limitation of greater toe dorsiflexion takes place in the terminal stance phase because of massive tightening of the calf and plantar structures. The current study investigated the role of a tight plantar fascial structure in impairing dorsiflexion of the greater toe. For the purpose of the study, 7 lower limbs from Thiel-fixated human cadavers were evaluated. To simulate double-limb standing stance, the tibia and fibula were mounted on a materials testing machine and constantly loaded with 350N. Additionally, the tendons of the specimens were loaded using a custom-made system. The plantar fascia was fixed to a clamp and tensioned using a threaded bar. Four different tensile forces were then applied to the plantar fascia (approximately 100, 200, 300, and 350 N) and the extension of the first toe was measured. The results show a significant positive correlation between the decrease in extension of the hallux and the tension applied to the plantar fascia reaching a maximum mean decrease of 4.2° (117% compared with the untightened situation) for an applied tension of 364N.

Objective To determine potential predictive associations between patient-/lesion-specific factors, clinical outcome and anterior ankle impingement in patients that underwent isolated autologous matrix-induced chondrogenesis (AMIC) for an osteochondral lesion of the talus (OLT). Design Thirty-five patients with a mean age of 34.7 ± 15 years who underwent isolated cartilage repair with AMIC for OLTs were evaluated at a mean follow-up of 4.5 ± 1.9 years. Patients completed AOFAS (American Orthopaedic Foot and Ankle Society) scores at final follow-up, as well as Tegner scores at final follow-up and retrospectively for preinjury and presurgery time points. Pearson correlation and multivariate regression models were used to distinguish associations between patient-/lesion-specific factors, the need for subsequent surgery due to anterior ankle impingement and patient-reported outcomes. Results At final follow-up, AOFAS and Tegner scores averaged 92.6 ± 8.3 and 5.1 ± 1.8, respectively. Both body mass index (BMI) and duration of symptoms were independent predictors for postoperative AOFAS and Δ preinjury to postsurgery Tegner with positive smoking status showing a trend toward worse AOFAS scores, but this did not reach statistical significance ( P = 0.054). Nine patients (25.7%) required subsequent surgery due to anterior ankle impingement. Smoking was the only factor that showed significant correlation with postoperative anterior ankle impingement with an odds ratio of 10.61 when adjusted for BMI and duration of symptoms (95% CI, 1.04-108.57; P = 0.047). Conclusion In particular, patients with normal BMI and chronic symptoms benefit from AMIC for the treatment of OLTs. Conversely, smoking cessation should be considered before AMIC due to the increased risk of subsequent surgery and possibly worse clinical outcome seen in active smokers.

Background Biomechanical studies have shown a higher compressive force and higher torsional stiffness for fixation with three screws compared to two screws. However, clinical data to compare these fixation techniques is still lacking. Methods A retrospective analysis of 113 patients was performed, who underwent isolated subtalar fusion between January 2006 and April 2018. Results Revision arthrodesis was required in 8% (n = 6/36) for 3-screw-fixation and 38% (n = 35/77) for 2-screw-fixation. For 3-screw-fixation, non-union, was observed in 14% (n = 5/36) compared to 35% (n = 27/77) in 2-screw fixation. Non-union (p = .025) and revision arthrodesis (p = .034) were significantly more frequent in patients with 2 screws. A body mass index ≥30 kg/m2 (p = .04, OR = 2.6,95%CI:1.1–6.3), prior ankle-fusion (p = .017,OR = 4.4,95%CI:1.3–14.5) and diabetes mellitus (p = .04,OR = 4.9,95%CI:1.1–17.8) were associated with a higher rate of revision arthrodesis. Conclusions Our findings suggest that successful subtalar fusion is more reliably achieved with use of three screws. However, future prospective studies will be necessary to further specify this recommendation.

Die Versteifung des oberen Sprunggelenks (OSG-Arthrodese) ist eine seit Langem etablierte Therapieoption fur die hochgradige tibiotalare Arthrose mit guten klinischen Ergebnissen. Die genaue klinische Untersuchung und Abwagung von Komorbiditaten, Anforderungen und Patientenaussichten sind entscheidend fur die Indikationsstellung zur Arthrodese. Zudem gibt die radiologische Standardbildgebung und ggf. eine zusatzliche Schnittbildgebung die Richtung fur eine Entscheidung zur Arthrodese oder Prothese sowie fur das geplante operative Vorgehen vor. In diesem Beitrag werden verschiedene operative Strategien vorgestellt, von arthroskopisch-assistiert uber mini-open bis hin zu vorderen und seitlichen Zugangen mit entsprechenden Korrekturmoglichkeiten und Osteosyntheseverfahren.

Plantar fasciitis (PF) is a common degenerative disorder and a frequent cause of heel pain, mostly affecting patients in their fourth and fifth decades. Diabetic patients are particularly at risk due to the presence of common risks and co-morbidities such as obesity or a sedentary lifestyle. The diagnosis of PF is mainly clinical. Imaging is not recommended for the initial approach. The initial management is conservative and should include physiotherapy, off-loading, stretching exercises, and nonsteroidal anti-inflammatory drugs. Glucocorticoid injections or surgery is an option at a later stage in recalcitrant cases. The overall management of PF does not differ between patients with diabetic foot problems and non-diabetic patients, although the details can differ. This narrative review summarizes the state of the art in terms of the risk factors, pathophysiology, diagnosis, assessment, and management of PF in diabetic patients.

Background Several risk factors for adult acquired flatfoot deformity (AAFD) have been identified in literature. To this date, little attention has been paid to the lateral ligament complex and its influence on AAFD, although its anatomic course and anatomic studies suggest a restriction to flatfoot deformity. The aim of this study was to assess the influence of the anterior talofibular ligament (ATFL) on AAFD and on radiologic outcome following common operative correction by lateral calcaneal lengthening. Methods We reviewed all patients that underwent lateral calcaneal lengthening for correction of AAFD between January 2008 and July 2018 at our clinic. Patients were grouped according to the preoperative MRI findings into those with an intact ATFL and those with an injured ATFL. Two independent readers assessed common radiographic flatfoot parameters on preoperative and postoperative radiographs. Results Sixty-four flatfoot corrections in 63 patients were included, whereby the ATFL was intact in 29 cases, and in 35 cases the ligament was injured. An ATFL lesion was overall radiologically associated with increased flatfoot deformity with a statistically significant difference between the two groups for preoperative talometatarsal-angle (p = 0.002), talocalcaneal-angle (p = 0.000) and talonavicular uncoverage-angle (p = 0.005). No difference between the two groups could be observed regarding the success of operative correction or operative consistency after lateral calcaneal lengthening. Conclusion The ATFL seems to influence the extent of AAFD. In patients undergoing lateral calcaneal lengthening, the integrity of the ligament seems not to influence the degree of correction or the consistency of the postoperative result., BMC Musculoskeletal Disorders, 20 (1), ISSN:1471-2474

Background Progressive collapsing foot deformity (PCFD) is a complex 3-dimensional (3-D) deformity with varying degrees of hindfoot valgus, forefoot abduction, and midfoot varus. The first aim of this study was to perform a 3-D analysis of the talus morphology between symptomatic PCFD patients that underwent operative flatfoot correction and controls. The second aim was to investigate if there is an impact of individual talus morphology on the success of operative flatfoot correction. Methods We reviewed all patients that underwent lateral calcaneal lengthening for correction of PCFD between 2008 and 2018 at our clinic. Radiographic flatfoot parameters on preoperative and postoperative radiographs were assessed. Additionally, 3-D surface models of the tali were generated using computed tomography (CT) data. The talus morphology of 44 flatfeet was compared to 3-D models of 50 controls without foot or ankle pain of any kind. Results Groups were comparable regarding demographics. Talus morphology differed significantly between PCFD and controls in multiple aspects. There was a 2.6° increased plantar flexion (22.3° versus 26°; p = 0.02) and medial deviation (31.7° and 33.5°; p = 0.04) of the talar head in relation to the body in PCFD patients compared to controls. Moreover, PCFD were characterized by an increased valgus (difference of 4.6°; p = 0.01) alignment of the subtalar joint. Satisfactory correction was achieved in all cases, with an improvement of the talometatarsal-angle and the talonavicular uncoverage angle of 5.6° ± 9.7 (p = 0.02) and 9.9° ± 16.3 (p = 0.001), respectively. No statistically significant correlation was found between talus morphology and the correction achieved or loss of correction one year postoperatively. Conclusion The different morphological features mentioned above might be contributing or risk factors for progression to PCFD. However, despite the variety of talar morphology, which is different compared to controls, the surgical outcome of calcaneal lengthening osteotomy was not affected. Level of evidence III.

Background: Peroneal tendon lesions can cause debilitating pain, but operative treatment remains controversial. Some studies recommend peroneal tenodesis or transfer if more than half of the tendon is affected. However, clinical outcomes and inversion/eversion motion after peroneal transfer have not been investigated yet. Methods: Patients who underwent distal peroneus longus to brevis transfer for major peroneus brevis tendon tears with a minimum follow-up of 2 years were included. Clinical outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, the German Foot Function Index (FFI-D), and Karlsson-Peterson score. Functional outcome was tested with a standardized active range-of-motion (ROM) and isokinetic strength measurement protocol, including concentric and eccentric eversion and inversion tests. Results: Of total 23 eligible patients, 14 (61%) were available for follow-up. Clinical outcome scores were good with AOFAS 86 ± 16 points, FFI-D pain 26% and FFI-D disability 26%, and Karlsson-Peterson score 78 ± 23 points. There was no difference in strength in comparison to the contralateral foot (all P > .05). Isokinetic strength was 16.3 ± 4.9 Nm (108% of contralateral side) and 18.8 ± 4.5 Nm (101%) at concentric 30 deg/s and eccentric 30 deg/s eversion tests, as well as 15.7 ± 5.2 Nm (102%) and 18.7 ± 3.3 Nm (103%) at concentric 30 deg/s and eccentric 30 deg/s inversion tests, respectively. There was no difference in ROM compared to the contralateral side (eversion/inversion 14.5-0-18.7 vs 14.1-0-16.1 degrees). Conclusion: Peroneus longus to brevis transfer is a viable option for treating severe peroneus brevis tendon tears and does not compromise measurable strength or ROM in inversion or eversion in comparison to the contralateral ankle joint. Level of Evidence: Level IV, prospective case series.

Background:Autologous matrix-induced chondrogenesis (AMIC) has been shown to result in favorable clinical outcomes in patients with osteochondral lesions of the talus (OLTs). Though, the influence of ankle instability on cartilage repair of the ankle has yet to be determined.Purpose/Hypothesis:To compare the clinical and radiographic outcomes in patients with and without concomitant lateral ligament stabilization (LLS) undergoing AMIC for the treatment of OLT. It was hypothesized that the outcomes would be comparable between these patient groups.Study Design:Cohort study; Level of evidence, 3.Methods:Twenty-six patients (13 with and 13 without concomitant ankle instability) who underwent AMIC with a mean follow-up of 4.2 ± 1.5 years were enrolled in this study. Patients were matched 1:1 according to age, body mass index (BMI), lesion size, and follow-up. Postoperative magnetic resonance imaging and Tegner, American Orthopaedic Foot & Ankle Society (AOFAS), and Cumberland Ankle Instability Tool (CAIT) scores were obtained at a minimum follow-up of 2 years. A musculoskeletal radiologist scored all grafts according to the MOCART (magnetic resonance observation of cartilage repair tissue) 1 and MOCART 2.0 scores.Results:The patients’ mean age was 33.4 ± 12.7 years, with a mean BMI of 26.2 ± 3.7. Patients with concomitant LLS showed worse clinical outcome measured by the AOFAS (85.1 ± 14.4 vs 96.3 ± 5.8; P = .034) and Tegner (3.8 ± 1.1 vs 4.4 ± 2.3; P = .012) scores. Postoperative CAIT and AOFAS scores were significantly correlated in patients with concomitant LLS ( r = 0.766; P = .002). A CAIT score >24 (no functional ankle instability) resulted in AOFAS scores comparable with scores in patients with isolated AMIC (90.1 ± 11.6 vs 95.3 ± 6.6; P = .442). No difference was seen between groups regarding MOCART 1 and 2.0 scores ( P = .714 and P = .371, respectively).Conclusion:Concurrently performed AMIC and LLS in patients with OLT and ankle instability resulted in clinical outcomes comparable with isolated AMIC if postoperative ankle stability was achieved. However, residual ankle instability was associated with worse postoperative outcomes, highlighting the need for adequate stabilization of ankle instability in patients with OLT.

An established treatment strategy in surgical site infection after hindfoot and ankle surgery is a two-stage procedure with debridement and placement of a cement spacer, followed by antibiotic treatment and secondary arthrodesis. However, there is little evidence to favor this treatment over a one-stage procedure with debridement, followed by primary arthrodesis with an Ilizarov external fixator and antibiotic treatment. We compared the infection control and clinical and radiological outcome of a two-stage and a one-stage procedure. In this study, 7 patients with a two-stage revision and 11 patients with a one-stage revision between 2005 and 2015 were included. The primary outcome was infection control (absence of the Musculoskeletal Infection Society PJI criteria) 2 years after the ankle or hindfoot arthrodesis. Secondary outcome measures were the AOFAS hindfoot score and radiological consolidation rate. Infection control was 85% (6 out of 7 patients) in the two-stage group and 81% (9 out of 11 patients) in the one-stage group (p = 1.0). One patient (14%) of the two-stage and two patients (18%) in the one-stage group needed below-knee amputation. In the two-stage group, the mean postoperative AOFAS score was 74.8 (SD: ±11.3) versus 71.7 (SD: ±17.8) in the one-stage group. Radiological consolidation could be achieved in 71% in the spacer group (n = 5) and in 72% in the Ilizarov external fixator group (n = 9). Infection control, AOFAS score, and radiologic consolidation of hindfoot and ankle arthrodesis were comparable in both groups of patients with complicated postsurgical hindfoot or ankle infections.

Aim Currently, cohort studies reported the use of minimally invasive arthrodesis of the first metatarsophalangeal joint (MTP I). The aim of this systematic literature review was to analyse clinical, radiological outcome and complications with this technique. Methods A systemic literature search of the databases Google Scholar, PubMed, Scopus, EMBASE and Cochrane to identify studies reporting on clinical, radiological outcome or complications of minimally invasive MTP I arthrodesis was conducted. Results A total of 6 studies (1 Level V, 5 Level IV) reporting on 109 minimally invasive MTP arthrodesis in 105 patients were included. Validated scores were reported in 103 cases. Clinical outcome improved in 57 cases from a mean of 36.9 to 82.6 points American Orthopedic Foot and Ankle Score (AOFAS) and in 46 cases from 38.7 to 18.4 points Manchester Oxford Foot Questionnaire (MOXFQ). Radiological fusion rate was 87% (n = 94 out of 109) achieved after 6-12 weeks. Overall complication rate was 11.9% (13 cases) leading to revision surgeries in 5.5% (6 cases). Most common complications Most common complications were symptomatic non-union (n = 6, 5.5%), asymptomatic non-union (n = 2, 1.8%) and subsequent interphalangeal joint arthritis (n = 2, 1.8%). Conclusion Minimally invasive MTP I arthrodesis is a promising technique with comparable clinical, radiological outcome and complication rates to open surgery in hallux rigidus and rigido-valgus. Future studies are needed providing higher level of evidence to prove the potential benefit of minimally invasive compared to open MTP I arthrodesis.

INTRODUCTION Haemophilic ankle arthropathy is caused by recurrent spontaneous joint haemorrhaging and leads to pain, deformity and loss of function. In the presence of advanced articular deterioration, therapeutic options are confined to either arthroplasty or arthrodesis, the latter still being referred to as the procedure of choice. However, total ankle replacement (TAR) has recently gained acceptance as an alternative. AIM To investigate the mid- to long-term results of TAR in haemophilic ankle arthropathy. MATERIALS AND METHODS Seventeen TARs in 14 male patients (mean age: 43 years [range, 27.4-57.6]), implanted between 1998 and 2012, were retrospectively analysed. Implant survival was estimated using Kaplan-Meier analysis. Haemophilic/viral status, complications and revision surgeries were recorded. Follow-up assessment of 12 TARs was performed 9.6 years (range, 3.3-17.8) postoperatively, including clinical examination, pain and satisfaction scales, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, and the SF-36. Radiographic evaluation of pre- and follow-up radiographs was conducted. RESULTS Estimated implant survival was 94% at 5, 85% at 10 and 70% at 15 years, respectively. Three cases required revision surgery. At follow-up, 9.6 years (range, 3.3-17.8) postoperatively, the level of satisfaction was 76% (range, 50-100) and of pain 2/10 (range, 0-6) on the VAS. Range of motion had increased significantly (P = .037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot score averaged 81 points (range, 73-90). All radiographs revealed component loosening or periprosthetic radiolucency. CONCLUSION Total ankle replacement in the presence of advanced haemophilic arthropathy is a viable treatment option with favourable mid-/long-term results, maintaining mobility of the ankle joint.

Failed conservative treatment and complications are indications for foot reconstruction in Charcot arthropathy. External fixation using the Ilizarov principles offers a one-stage procedure for deformity correction and resection of osteomyelitic bone. The aim of this study was to determine whether external fixation with an Ilizarov ring fixator leads reliably to walking ability. 29 patients treated with an Ilizarov ring fixator for Charcot arthropathy were retrospectively analyzed. Radiologic fusion at final follow up was assessed separately on conventional X-rays by two authors. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher’s exact test. Mean follow up was 35 months (range 5.3–107) months; mean time of external fixation was 113 days. Ten patients (34.5%) reached fusion, but 19 did not (65.5%). Two patients needed below knee amputation. 26 of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of osteomyelitis at the time of reconstruction and from the presence of fusion. Foot reconstruction with an Ilizarov ring fixator led to limb salvage in 93%. The vast majority (96.3%) of patients with successful limb salvage was ambulatory, independent from radiologic fusion, and presence of osteomyelitis at the time of reconstruction. These findings encourage limb salvage and deformity correction in this difficult-to-treat disease, even with underlying osteomyelitis.

Category: Bunion Introduction/Purpose: An optimal osteotomy angle can avoid shortening of the first metatarsal bone after hallux valgus surgery and therefore reduce the risk of transfer-metatarsalgia. Up to date the osteotomy is performed free-hand without guidance and is therefore prone to unwanted variability in accuracy. The purpose of the present ex-vivo study was to investigate whether overlaying a hologram (augmented reality, AR) would improve accuracy of the distal osteotomy during hallux valgus surgery. Methods: A polyamide foot skeleton was constructed based a CT scan of a cadaveric foot and covered with medical silicon soft tissue. Three different polyamide first metatarsals were inserted to simulate a light, moderate and severe hallux valgus deformity. Distal Osteotomies of the first metatarsals were performed by two surgeons with different levels of surgical experience each with (AR, n=15x2) or without (controls, n=15x2) overlay of a hologram depicting an angle of osteotomy perpendicular to the second metatarsal in the transverse plane. Subsequently, the deviation to the plumb line of the second metatarsal in the transverse plane of all 60 osteotomies angles were optically measured and statistically analyzed. Results: Overall, the AR-guided osteotomies were more accurate (4.9 ± 4.2°) compared to the freehand cuts (6.7± 6.1°) by tendency (p=0.2). However, while the inexperienced surgeon performed more accurate osteotomies with AR with a mean angle of 6.4± 3.5° compared to freehand 10.5 ± 5.5° (p=0.02), no significant difference was noticed for the experienced surgeon with an osteotomy angle of around 3° in both cases. Conclusion: This pilot-study suggests that augmented reality guided osteotomies can potentially improve accuracy during hallux valgus surgery, particularly for less experienced surgeons. However, clinical studies are needed to investigate the clinical benefit of augmented reality in hallux valgus surgery.

Osteoarthritis (OA) of the glenohumeral joint constitutes the most frequent indication for nontraumatic shoulder joint replacement. Recently, a small critical shoulder angle (CSA) was found to be associated with a high prevalence of OA. This study aims to verify the hypothesis that a small CSA leads to higher glenohumeral joint reaction forces during activities of daily living than a normal CSA. A shoulder simulator with simulated deltoid (DLT), supraspinatus (SSP), infraspinatus/teres minor (ISP/TM), and subscapularis (SSC) musculotendinous units was constructed. The DLT wrapping on the humerus was simulated using a pulley that could be horizontally adjusted to simulate the 28° CSA found in OA or the 33° CSA found in disease-free shoulders. Over a range of motion between 6° and 82° of thoracohumeral abduction joint forces were measured using a six-axis load cell. An OA-associated CSA yielded higher net joint reaction forces than a normal CSA over the entire range of motion. The maximum difference of 26.4 N (8.5%) was found at 55° of thoracohumeral abduction. Our model thus suggests that a CSA typical for OA predisposes the glenohumeral joint to higher joint reaction forces and could plausibly play a role in joint overloading and development of OA. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1047-1052, 2016.

Background context The human iliolumbar ligament connects the transverse process of L5 to the iliac crest and contributes to lumbosacral stability and has been associated with low back pain. However, different opinions exist regarding the functional relevance of the ligament. Purpose In the present study, we analyze the regional molecular composition of the ligament extracellular matrix. Study design Special attention is given to the attachment sites, to determine whether the ligament is subjected to a certain mechanical environment. Methods Iliolumbar ligament samples, extending from one enthesis to the other, were removed from 11 cadavers and fixed in methanol. Cryosections were immunolabeled with a panel of antibodies directed against collagens, glycosaminoglycans, proteoglycans, matrix proteins, and neurofilament. Results The mid-substance of the ligament labeled for all the molecules normally found in dense fibrous connective tissue including types I, III, and VI collagen, versican, dermatan -, chondroitin 4 -, and keratan sulfate. However, both entheses were fibrocartilaginous and labeled for type II collagen, aggrecan, and chondroitin 6- sulfate. A common feature was fat between the fiber bundles near the entheses. Occasionally this fat contained nerve fibers. Conclusions The existence of fibrocartilaginous entheses suggests that the insertion sites of the ligament are subject to both tensile and compressive loading—probably because of insertional angle changes between ligament and bone during loading. Our findings support the suggestion that the iliolumbar ligament might play an important role in the stabilization of the lumbosacral junction.

Category: Ankle Arthritis Introduction/Purpose: Hemophilia is a rare hematological disease associated with spontaneous joint hemorrhaging causing hemophilic arthropathy. Symptoms comprise joint pain and deformity, paired with loss of function. In the presence of advanced joint deterioration, therapeutic options are confined to either arthroplasty or arthrodesis. For the ankle, the latter is still referred to as the procedure of choice. However - in light of its capacity to reduce pain while preserving ankle motion - total ankle replacement (TAR) has recently gained acceptance as an alternative. The aim of this study was to investigate the mid- to long-term results of TAR in hemophilic ankle arthropathy. Methods: Seventeen TARs were implanted between 1998 and 2012 (mean age: 43 years). Preoperative demographic and disease specific data, complications and revision surgeries were recorded. With a mean follow-up of 9.3 years (range, 2.2-17.8) implant survival was estimated using Kaplan-Meier analysis. Follow-up assessment of 12 TARs was performed after 9.6 years (5 lost to follow-up). Satisfaction and pain scales, the AOFAS hindfoot-score, and the SF-36 were obtained to assess clinical outcome. Radiographic evaluation of pre- and follow-up radiographs was conducted. Results: Three cases (17.6%) had undergone TAR removal secondary to loosening at an average interval of 7.5 years. The estimated implant survival was 94% at 5, 85% at 10, and 70% at 15 years (95% CI, 11.9-17.7). The mean estimated implant survival was 14.77 years (95% CI, 11.9-17.7). The mean level of satisfaction was 76%, and of pain 2/10 (VAS). ROM had increased significantly (p=0.037). The SF-36 summary scores were comparable to those of a matched standard population. The AOFAS hindfoot-score averaged 81/100 points. Conclusion: TAR is a viable treatment option for advanced hemophilic ankle arthropathy. Based on the herein presented follow- up, implant survival compares to that of non-hemophilic populations. Clinical mid- to long-term results are favorable. However, the majority of follow-up radiographs revealed component loosening and/or periprosthetic lucency. Considering the study population’s young age and specific risk factors, need for revision surgery secondary to symptomatic component loosening may arise.

AimThe aim of this prospective study was the comparison of four emergency medical service (EMS) systems—emergency physician (EP) and paramedic (PM) based—and the impact of advanced live support (ALS) on patients status in preclinical care.MethodsThe EMS systems of Bonn (GER, EP), Cantabria (ESP, EP), Coventry (UK, PM) and Richmond (US, PM) were analysed in relation to quality of structure, process and performance when first diagnosis on scene was cardiac arrest (OHCA), chest pain or dyspnoea. Data were collected prospectively between 01.01.2001 and 31.12.2004 for at least 12 month.ResultsOver all 6277 patients were included in this study. The rate of drug therapy was highest in the EP-based systems Bonn and Cantabria. Pain relief was more effective in Bonn in patients with severe chest pain. In the group of patients with chest pain and tachycardia ≥120beats/min, the heart rate was reduced most effective by the EP-systems. In patients with dyspnoea and SpO2

The precise planning of metatarsal (MT) I length in hallux valgus surgery is important. However, currently no tool exists which allows the surgeon to reliably predict this parameter.30 virtual 3-dimensional hallux valgus surgeries were performed on varied deformation models based on cadaveric feet scans. The shortening of the first ray during distal metatarsal I osteotomy for different osteotomy angles were measured. An algebraic 2-dimensional calculation was done and compared to the results obtained from the 3-dimensional models.Inadvertent shortening of the first metatarsal bone can be as much as 8 mm depending on the amount of intermetatarsal angle (IMA) correction and osteotomy angle. Comparison of the 3 dimensional simulations and the 2 dimensional model resulted in a very strong correlation (R0.99 p0.00001). Based on our findings an anterior pointing osteotomy of approximately 10° is necessary to restore the length in distal metatarsal I hallux valgus surgery.A slight misdirection of the osteotomy plane in distal hallux valgus surgery may result in relevant unwanted alterations in first metatarsal bone length and triangulation by eye is insufficient in this complex geometrical situation without appropriate planning. The present study provides surgeons a practical tool to plan and control the change of first metatarsal length during hallux valgus procedure through exact orientation of the osteotomy angle. If no alteration of length is intended, it may be generalized that an anterior direction of the cut relative to the second metatarsal bone will preserve the length of the first metatarsal bone.