Suomen Ortopedia ja traumatologia - 45. julkaisu 1/2022

Vol. 45 Nro 1 2022




Julkaisija Suomen Ortopediyhdistys – Ortopedföreningen i Finland ry.
Publisher Finnish Orthopaedic Association
Toimituksen osoite:
SOT-lehti / Heidi Danielson
Toimitus:
Internet: Taitto
Painopaikka ISSN
Sairaala ORTON Tenholantie 10
00280 Helsinki heidi.danielson@orton.fi
Päätoimittaja Heidi Danielson
Toimittaja
Ville Puisto
Sairaala ORTON ville.puisto@orton.fi
www.soy.fi Heli Roberts
AM Digipaino 0780-671X
Suomen Ortopedia ja Traumatologia Vol. 45
1 • 2022 SOT 1


Contents 1/2022
Editorial
Scientific program
Finnish-Austrian Orthopaedic Trauma Courses 1981–2022
Jan Lindahl and Jan-Magnus Björkenheim
Physical Examination and Imaging of the Foot and Ankle – What has Changed?
Beat Hintermann MD, Roxa Ruiz MD
Neglected Injuries to the Ligaments of Lateral Ankle
Beat Hintermann MD, Roxa Ruiz MD
Injuries to the Medial Ankle Ligaments – Fact or Fiction?
Roxa Ruiz MD, Beat Hintermann MD
The Progressive Break-Down of the Foot
Roxa Ruiz MD, Beat Hintermann MD
Current Treatment Options in Ankle Osteoarthritis
Beat Hintermann MD, Roxa Ruiz MD
Hallux rigidus
Timo Sirola
The role of primary hip arthroplasty in acetabular fracture surgery
A. Gänsslen
Long-term Outcome of Slipped Capital Femoral Epiphysis
Thomas Schlenzka
Treatment of Distal Femur Fractures : Retrospective analysis of 299 patients treated with lateral locking plate
Heini Sainio, Lasse Rämö, Jan Lindahl
Is primary knee arthroplasty an option for proximal tibial fractures?
A. Gänsslen
Is routine removal of syndesmotic screw needed? (RODEO trial)
Fay R K Sanders, Merel F Birnie, Siem A Dingemans, Michel P J van Bekerom,
Markus Parkkinen, Ruben van Veen, RODEO collaborator group, J Carel Goslings, Tim Schepers
Title: Biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome: protocol for a prospective multinational, multi-centre study involving patients with tibial fractures
First and last author: Abraham Nilsson and Jörg Schilcher
4 5 – 11 13
22
27
32
37
42
47
52
55
58
63 66
68
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Ocular traumatology for orthopaedic surgeons 72
Anna Schlenzka
The effect of the Covid-19 pandemic on paediatric trauma 76
Arimatias Raitio
Spinal endoscopy: Helsinki and Turku experience so far and what’s the future? 78
Jari Siironen
The evidence of HTO versus UKA for the treatment of medial knee osteoarthritis 82
Juuso Siren, MD; Lasse Rämö, MD, PhD; Jussi Kosola, MD, PhD; Jan Lindahl, MD, PhD
Evaluation of chondral injuries and cartilage repair 84
Jani Puhakka
Malpractice and Patient Injuries in Orthopedic and Trauma Treatment 88
Eero Hirvensalo
Treatment of lateral clavicle fractures 92
Karl Wieser
Bankart fractures: Conservative or operative treatment 94
Karl Wieser
Polviproteesin instabiliteetti 96
Mikko Manninen
Antibiotic impregnated bone graft to reduce infections after revision hip replacement; 99 The ABOGRAFT trial
Daphne Wezenberg, Andreas Meunier, Lars Palm, Jörg Schilcher
Suomen Ortopedia ja Traumatologia Vol. 45 1 • 2022 SOT 3


Welcome to the XXI Finnish-Austrian Orthopaedic Trauma Course!
The course is part of the professional education of the Finnish Orthopaedic Association. The Finnish-Austrian Orthopaedic Trauma Course has a long history dating back to 1981 and has been held biannually in various locations in Austria. The last course was held in hotel Forsthofgut congress centre in Leogang in 2019. The current
course will take place in Oberlech, hotel Montana’s Congress Center and it will be the 10th time the course has been held in this beautiful venue. Like the previous one, this will be a compact three-day course, making it easier to fit in the clinical schedule.
This course should have been held already in 2021, but due to the Covid pandemic it had to be postponed until now 2022. During the last two years practically all face-to-face meetings have been cancelled because of the Covid pandemic and the educational work has been organized trough webinars. Pandemic has shown that there is a great urge for physical face-to-face meetings and one sign of that is the very high number of participants to this course. We have been following the pandemic situation very carefully and now with good vaccination coverage we are confident that we are able to organize this course Covid-safe. All relevant health and safety measures will be strictly observed.
The aim of the Finnish-Austrian courses is to provide the participants with the latest updates, trends, and techniques on different interesting orthopedic subspecialities through lectures and group discussions. We have lecturers attending from Austria, Germany, Switzerland, Sweden, and Finland to provide the best experience in different aspects of orthopaedics and trauma treatment. The course is also a great way to meet again with old friends, make new ones and build international collaborations.
One important part of this historic event is of course the social program. The “bone head competition” will be of course organized this time again with slalom, maximum skiing speed and bob sled racing. The last winner of this downhill triathlon was Tomi Simons from Helsinki, and we shall see who will win the challenge cup this time!
Hopefully we will have a memorable course with learning, sharing knowledge and socializing together. On behalf of the organizing committee, I would like to thank the whole faculty for their priceless efforts. Warmest thanks to Jan Lindahl for putting together a very interesting scientific program, as well as to Thomas Ibounig, Mikko Manninen and Wolfgang Grechenig for making this course possible. We also wish to thank our course sponsors. Finally, our sincere thanks to family Ortlieb in hotel Montana for the opportunity to arrange this course in such a beautiful venue.
We look forward seeing you in Oberlech in March. Espoo, February 12th, 2022
Markus Parkkinen
Chair of the Organizing Committee markus.parkkinen@pihlajalinna.fi


XXI Finnish-Austrian Orthopaedic Trauma Course 6.-9.3.2022
Hotel Montana Congress Centre, Oberlech, Austria
Organizing Committee
Markus Parkkinen, Chairman Jan Lindahl, Program Chair Thomas Ibounig Mikko Manninen Wolfgang Grechenig
FINNISH ORTHOPAEDIC ASSOCIATION Established 1951


XXI Finnish-Austrian Orthopaedic Trauma Course 6.-9.3.2022
Hotel Montana Congress Centre, Oberlech, Austria
Scientific Program
Faculty
Robert Björkenheim, MD, PhD, Helsinki University Hospital, Helsinki, Finland
 Wolfgang Grechenig, MD, Prof., Graz University Clinic, Graz, Austria
Axel Gänsslen, MD, Klinikum Wolfsburg, Wolfsburg, Germany
Beat Hintermann, MD, Prof., Kantonsspital Baselland, Liestal, Switzerland Eero Hirvensalo, MD, Prof., Helsinki University Hospital, Helsinki, Finland Thomas Ibounig, MD, Helsinki University Hospital, Helsinki, Finland

Mikko Kirjavainen, MD, PhD, Mehiläinen Hospital, Helsinki, Finland
Olli Komulainen, MD, Helsinki University Hospital, Helsinki, Finland

Jussi Kosola, MD, PhD, Kanta-Häme Central Hospital, Hämeenlinna, Finland Jan Lindahl, MD, PhD, Helsinki University Hospital, Helsinki, Finland Tuomas Lähdeoja, MD, Helsinki University Hospital, Helsinki, Finland Mikko Manninen, MD, PhD, Orton Orthopaedic Hospital, Helsinki, Finland
 Oliver Michelsson, MD, Diacor Hospital, Helsinki, Finland

Mikko Ovaska, MD, PhD, Pihlajalinna Hospital, Helsinki, Finland
Markus Parkkinen, MD, PhD, Pihlajalinna Hospital, Helsinki, Finland
Jani Puhakka, MD, Schulthess Clinic, Zürich, Switzerland
Arimatias Raitio, MD, PhD, Turku University Hospital, Turku, Finland Mikko Rantasalo, MD, PhD, Terveystalo Hospital, Helsinki, Finland
Roxa Ruiz, MD, Kantonsspital Baselland, Liestal, Switzerland
Heini Sainio, MD, Helsinki University Hospital, Helsinki, Finland
Anna Schlenzka, MD, Helsinki University Hospital, Helsinki, Finland Thomas Schlenzka, MD, Helsinki University Hospital, Helsinki, Finland
Jörg Schilcher, MD, Linköping University Hospital, Linköping, Sweden
Jari Siironen, MD, PhD, Helsinki University Hospital, Helsinki, Finland
Petri Sillanpää, MD, PhD, Pihlajalinna Hospital, Tampere, Finland
Juuso Siren, MD, Helsinki University Hospital, Helsinki, Finland
Timo Sirola, MD, Helsinki University Hospital, Helsinki, Finland
Karl Wieser, MD, Zürich University Hospital, Zürich, Switzerland


XXI Finnish-Austrian Orthopaedic Trauma Course 6.-9.3.2022
Hotel Montana Congress Centre, Oberlech, Austria
Sunday, 6 March, 2022
15:00 Registration
18:00 Opening Ceremony
Scientific Program
Jan Lindahl
18:00 Welcome
Markus Parkkinen, MD, PhD
Chairman
18:10 Welcome to Oberlech Patrick Ortlieb
Olympic gold medalist and World champion in Downhill skiing
18:20 Program details Organizing committee
19.00 Dinner


Monday, 7 March, 2022
08:00 SESSION I - Foot and Ankle
Chairmen: Oliver Michelsson and Beat Hintermann
008:00 Physical examination and imaging of the foot and ankle – what has changed? (15+5)
Beat Hintermann, MD
08:20 Neglected injuries to the ligaments of lateral ankle (15+5) Beat Hintermann, MD
08:40 Injuries to the medial ankle ligaments – fact or fiction? (15+5) Roxa Ruiz, MD
08:55 The progressive break-down of the foot (15+5) Roxa Ruiz, MD
09:10 Current treatment options in ankle osteoarthritis (15+5) Beat Hintermann, MD
09:30 Hallux rigidus (10+5) Timo Sirola, MD
09:45 Discussion
09:50 Coffee and technical exhibition
10:10 SESSION II - Pelvis and Lower Extremity
Chairmen: Jan Lindahl and Axel Gänsslen
10:10 The role of primary hip arthroplasty in acetabular fracture surgery (15+5)
Axel Gänsslen, MD
10:30 Long-term outcome of slipped capital femoral epiphysis (15+5)
Thomas Schlenzka, MD
10:50 Treatment of distal femoral fractures (15+5) Heini Sainio, MD
Gänsslen, MD
11:30 Is routine removal of syndesmotic screw needed? (10+5) Markus Parkkinen, MD, PhD
11:45 Acute compartment syndrome (10+5) Thomas Ibounig, MD, Jörg Schilcher, MD
12.00 Lunch and technical exhibition
(15+5)
11:10 Is primary knee arthroplasty an option for proximal tibial fractures?
Axel


16:00 Discussions in groups (case presentations) I:
1) Ankle sprain (O. Michelsson, T. Sirola and M. Hautamäki) 2) Pelvis and lower leg (A. Gänsslen and J. Lindahl)
19:00 End of the day
Tuesday, 8 March, 2022
08:00 SESSION III - Special Issues
Chairmen: Eero Hirvensalo, MD, Prof. and Thomas Schlenzka
08:00 Ocular Traumatology for dummies and/or orthopaedic surgeons (10+5) Anna Schlenzka, MD
08:15 The effect of the Covid-19 pandemic on pediatric trauma (10+5) Arimatias Raitio, MD, PhD
08:30 Endoscopic spine surgery (15+5) Jari Siironen, MD, PhD
08:50 HTO vs. UKA for medial knee osteoarthritis (15+5) Juuso Siren, MD
09:10 Evaluation of chondral injuries and repair (15+5) Jani Puhakka, MD
09:30 Patient injuries – malpractise (15+5) Eero Hirvensalo, MD, Prof.
09:50 Coffee and technical exhibition
10:10 SESSION IV - Upper extremity
Chairmen: Thomas Ibounig and Karl Wieser
10:10 Treatment of lateral clavicle fractures (15+5) Karl Wieser, MD
10:30 Bankart fractures: Conservative or operative treatment? (15+5) Karl Wieser, MD
10:50 Treatment of distal humerus fractures (15+5) Tuomas Lähdeoja, MD
11:10 Comminuted radial head fractures (15+5) Thomas Ibounig, MD
11:30 Elbow dislocation – when surgical treatment is needed? (15+5)


Robert Björkenheim, MD, PhD 11.50 Course photography
12:00 Lunch and technical exhibition
16:00 Discussions in groups (case presentations) II:
1) Upper extremity (T. Ibounig and K. Wieser) 2) Patient injuries (E. Hirvensalo)
18:00 Fellowship year in Schulthess Clinic, Zürich, Switzerland Jani Puhakka, MD
19:00 End of the day
Wednesday, 9 March, 2022 08:00 SESSION V - Knee
Chairmen: Markus Parkkinen and Petri Sillanpää
08:00 Surgical management for patellar dislocation - when and how to corr abnormalities? (15+5)
Petri Sillanpää, MD, PhD
08:20 Intra-articular injections of the knee - current concepts (15+5) Jussi Kosola, MD, PhD
08:40 Operative techniques in meniscal surgery (15+5) Mikko Ovaska, MD, PhD
09:00 How to reduce the risk of ACL re-rupture (15+5) Mikko Kirjavainen, MD, PhD
09:20 Instability after total knee arthroplasty (15+5) Mikko Manninen, MD
09:40 Discussion
09:50 Coffee and technical exhibition
10:10 SESSION VI - Joint reconstruction
Chairmen: Olli Komulainen and Mikko Manninen
10:10 Nerve injuries in total joint arthroplasty surgery (15+5) Olli Komulainen, MD
e


10:30 Optimizing the outcomes in total knee arthroplasty with perioperative treatment protocols (25+5)
Mikko Rantasalo, MD, PhD
11:00 Robotics in total joint arthroplasty – better results or waste of money? (15+5) Mikko Rantasalo, MD
11:20 Hip joint preserving surgery (15+5) Matti Seppänen, MD
11:40 ABOGrAfT – antibiotic impregnated bone graft in hip revision surgery
Jörg Schilcher, MD
12:00 Lunch and technical exhibition
16:00 Case presentations 19:00 End of the day 19:00 Course dinner
Finnish-Austrian Orthopaedic Trauma Courses: Schruns 1981, Bad Hofgastein 1983, Ischgl 1985, Oberlech 1987, Oberlech 1989, Obergurgl 1991, Obergurgl 1993, Oberlech 1995, Ischgl 1997, Ischgl 1999, Oberlech 2001, Oberlech 2003, Obertauern 2005, Serfaus 2007, Oberlech 2009, Zauchensee 2011, Oberlech 2013, Oberlech 2015, Oberlech 2017, Leogang 2019, Oberlech 2022


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Part of


Finnish-Austrian Orthopaedic Trauma Courses 1981–2022
Jan Lindahl and Jan-Magnus Björkenheim
Helsinki University Hospital, University of Helsinki, Helsinki, Finland
Finnish-Austrian orthopaedic trauma courses celebrate their 41-year jubilee this year. The first combined trauma course was organised in 1981 in Schruns together with the Finnish Orthopaedic Association (FOA) and Österreichische Trauma Gesellschaft (Pictures 1-2). Since then, this course has been arranged biennially, except in 2021 when it was cancelled due to the Covid-19 pandemic. This year the 21st course will be held in Oberlech, Austria March 6-9, 2022.
Background
Members of every orthopaedic community around the world are interested in gaining new knowledge in their special field of interest. The common feature is to improve the professional skills and achieve new levels of knowledge. This can be done in many ways. The traditional and common way is to read and follow international and domestic journals, attend international courses, hands-on courses, and cadaver courses. Today the internet provides orthopaedic surgeons with an endless flow of information. Many courses have nevertheless been able to remain popular because they are well organized and focused on specific issues. These events provide participants excellent opportunities to network and exchange ideas. However, many of these courses have become “mega-courses” and very non-personal.
The Finnish-Austrian orthopaedic trauma course is unique in Europe. Both societies have been active in their neighbourhoods, particularly the Austrians in the German speaking federations. From the Finnish point of view, our main international networks are the Nordic Orthopaedic Federation (NOF), the European Federation of National Associations of Orthopaedics and Traumatology (Effort) and the many specialty organizations covering all the various fields of orthopaedics and traumatology. Large meetings, such as the AAOS meeting are very popular and many of our members regard it as the first choice for international meetings. All these established institutions still provide the individual surgeon very specialized and on-target information and knowledge.
On the other hand, there is a need for small meetings, since they are more personal making social contacts easier and effectively activate the course participants. Since 1981, this weeklong instructional course, organized every alternate year in Austria, has evolved through the co-operation of the Finnish Orthopaedic Association and the Österreichische Trauma Gesellschaft (Picture 3). 2021 was an exception to this rule, as the course was cancelled due to the Covid-19 pandemic.
The beginning
At the end of the 1970s, the Finnish Orthopaedic Association sought to arrange a combined meeting covering many aspects of traumatology with an orthopaedic society in central Europe. Traditionally we had good connections to the AO Foundation as well as to various German trauma centers. The first steps to arrange a combined trauma meeting were taken in April 1980 which quickly led to collaboration with Prof. Emil Beck. Prof. Beck was Head of the Hospital in Feldkirch as well as president of the Österreichische Trauma Gesellschaft. Happily, Prof. Beck found the idea of arranging a combined trauma course between Austria and Finland interesting. This new concept was quite extraordinary, since there had been virtually no
Suomen Ortopedia ja Traumatologia Vol. 45 1 • 2022 SOT 13


active contact in this aspect between our two countries. Many questions arose such as language barriers and potential cultural differences.
Scientific program
The cornerstone for a successful course is a scientific program of high standard covering concurrent topical issues. Testimony to the high standard of our course, many famous orthopaedic and trauma surgeons from all over the world have taken part in our events throughout the years. Since the very beginning, the aim of the scientific program was to cover the new rising field of interest such as endoprosthetic surgery, arthroscopic surgery, trauma surgery and the development of new surgical implants while providing both orthopaedic and traumatological post-graduate lectures and workshops (Pictures 4-5). A further aim was to encourage participants to present their work, accomplishments and experiences in the different topics. English was chosen as the course language in order to improve communication as well as participant language skills, though this was more apparent in the early days.
Organizing committees
The Austrian contribution during the early years concentrated on Innsbruck under the guidance of Prof. Emil Beck (Pictures 6-7), and later Prof. Gernot Sperner. During the late 1990s Jan-Magnus Björkenheim and Gernot Sperner arranged several courses together with the support of other members of the organizing committees. At the turn of the millennium, Sperner moved from Innsbruck University Hospital to a private clinic and resigned from the organizing committee as did Jan-Magnus Björkenheim following his retirement.
In 2000 the Finnish Orthopaedic Association named a new organizing committee: Harri Heliö, Jan Lindahl and Juha Kalske (Picture 8). Sperner decided to continue for one more year. To ensure the continuation of the course tradition Jan Lindahl contacted Gerolf Peicha of the Graz University Hospital and invited him to join the new committee. Peicha jumped to the opportunity and soon after Jan Lindahl also invited Prof. Wolfgang Grechenig who worked in the same university clinic in Graz. This started a long-lasting collaboration between the orthopaedic and trauma surgeons in Graz and Helsinki. In 2007 Mikko Manninen replaced Harri Heliö on the organizing committee. Subsequently Juha Kalske, Jan Lindahl and Mikko Manninen have chaired the courses and upheld the course tradition (Table 1, Picture 9).
Prof. Emil Becks position was key during the early years, and he was a driving force of this combined course. For his activity, Prof. Beck was appointed an honorary member of the Finnish Orthopaedic Association in 1987.
Faculty members
Although the majority of the lectures have been presented by either Austrians or Finns, many prominent international orthopaedic surgeons have contributed to the success of the course. Among others Adam Schreiber (Zürich), Robert Cofield and Frank Sim (Mayo Clinic), Gavril A Ilizarov (Kurgan), Angus Wallace (Nottingham), Davis Seligson (Louisville, Kentucky), Ted Hansen (Seattle), Peter Habermayer (Heidelberg), Dror Paley (Baltimore), Laurent Lafosse (Annecy), Thomas Schneider and Rüdiger Schmidt-Wiethoff (Cologne), Patrice Diebold (Nancy), Jochen Müller-Stromberg (Bonn), Stefan Sundelin (Stockholm), Alexej Barg (Basel), Matej Cimerman (Ljubljana), Bore Bakota and Mario Staresinic (Zagreb), Axel Gänsslen (Wolfsburg), Martin McNally (Oxford), Stefan Luck (Hamburg), Annette Moser (Liestal), Endre Varga (Szeged), Davide Donati (Bologna), Cyril Suter (Basel), and Beat Hintermann and Roxa Ruiz (Liestal).
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The Austrians who played a major and active role during the first two decades include Johannes Poigenfurst, Vladim Vecsei and Jurg Böhler from Vienna, Rudolf Szyszkowitz from Graz and Herbert Resh from Salzburg. Many younger colleagues such as Karl-Peter Benedetto, Herbert Daniaux, Karl Golser and Thomas Klestil have also contributed to the success of the course. Many of these colleagues have also participated in our national meetings in Finland.
During the last twenty years the input from Graz has been remarkable. Both Wolfgang Grechenig and Gerolf Peicha have been very active members in the organizing committee and invited several experts from Austria to the courses to share their expertise. Both are also excellent lecturers in their own right.
Other faculty members from Austria have been V. Smekal, Markus Wambacher and Franz Kralinger from Innsbruck, J. Schauer from Salzburg, F. Unger from Wels, Franz Ortner and W. Menth-Chiari from Wiener Neustadt, C. Kollersbeck, Manfred Mittermaier and F. Genelin from Schwarzach, Reinhard Lorber from Klagenfurt, Georg Thewanger from Linz, and Florian Fankhauser, Christian Boldin, Franz J. Seibert, Michael Fellinger, O. Leithgöb, R. Mauschitz, Hans Clement, and Jürgen Mandl from Graz, Jörg Schilcher from Linköping, and Karl Wieser from Zürich.
Topics
Knee arthroscopy was introduced into routine orthopedic work during the early 1980s. Therefore, it is natural that arthroscopic surgery has been a popular topic in all the courses covering not only the knee, but also the shoulder, elbow, wrist and ankle. Arthroscopic surgery has experienced technical refinements and has increasingly replaced conventional operative procedures. Arthroscopic surgery has played an important role in every course (Picture 10).
Endoprosthetic replacement of hip, knee and shoulder has been thoroughly discussed and the importance of optimal operative indications, correct operative techniques and choice of implants as well as effective follow-up, seen as the results from our national registers, has always been emphasized. Bone tumors had a session of their own conducted by the experience of the Mayo Clinic presented by Frank Sim.
New techniques for correcting and stabilizing the spine have also attracted much interest. The development of new instrumentations has had a revolutionary impact on the treatment of both orthopaedic disorders and traumatic injuries of the spine. The use of computer assisted navigation in spinal surgery was adopted in the 1990s and widely discussed and introduced in our courses.
Fracture care has evolved tremendously since the start of our combined meetings. New perspectives and ideas have been presented by Austrians and Finns. The introduction of new intramedullary implants and the LCP principle have also played an important role in the scientific program, together with new strategies in the management of open fractures and polytrauma. The principles of external fixation were presented in a memorable and eccentric way by Gavril Ilizarov. His lecture is still one of the highlights of our course history.
High energy pelvic fractures continue to present a serious challenge to trauma care. Over the last four decades, our knowledge has increased on the assessment, trauma mechanisms, classification, and manage- ment protocols for this particular potentially lethal injury. In the 1970s, external fixation devices became popular for the treatment of unstable pelvic injuries. The studies by Pär Slätis and Erkki Karaharju showed, that external fixators facilitated recovery more effectively than bed rest or a pelvic sling, with or without traction. These new results were presented also in our courses several times. Later, it became clear that an
Suomen Ortopedia ja Traumatologia Vol. 45 1 • 2022 SOT 15


anterior external frame could not restore enough stability to an unstable (type C) disruption of the pelvic ring to allow early mobilization of the patient.
In the 1980s, the concept of open reduction and internal fixation (ORIF) was introduced, for both anterior and posterior aspects of the pelvis. However, pubic rami fractures were considered less important, and they were stabilized only sporadically, even though it had been shown that the anterior arch was important for the overall stiffness of the pelvic ring. Therefore, the concept of plate fixation for treating displaced pubic rami fractures was initiated in Helsinki University Hospital, Töölö Hospital. Less invasive intrapelvic approach to anterior pelvic surgery was first described by the Helsinki group, Eero Hirvensalo and Jan Lindahl, in 1993. In addition, since the early 1990s, a less-invasive posterior approach has been used for open reduction and iliosacral screw fixation of sacral fractures in Töölö Hospital. Several presentations concerning this topic have been pre- sented at these courses. The intrapelvic approach is used nowadays both for pelvic ring and acetabular fracture surgery in trauma hospitals around the globe.
Management of H-shaped sacral fractures with spinopelvic dissociation were an especially difficult challenge in the 1990s, because there were no general guidelines or treatment protocols for these rare injuries. A new open reduction with segmental lumbopelvic fixation technique was developed in Töölö Hospital and the preliminary results were presented at the Finnish-Austrian trauma courses.
Knowledge of basic surgical anatomy is fundamental to surgical management of patients. The Graz group, led by Wolfgang Grechenig and Gerolf Peicha, have presented their scientific results and opened our eyes to new anatomical, biological and biomechanical findings to treat fractures and orthopaedic disorders effectively (Picture 11).
Many other topics have been on the agenda, such as alpine rescue, medical services of the Austrian alpine skiing team and introduction of new implants and techniques (Picture 12). Most of the lectures have been published in the Finnish Journal of Orthopaedics and Traumatology published by the Finnish Orthopaedic Association.
Workshops
The participants have during the years been able to improve their knowledge and skills in using new implants provided by industry. The external fixation workshop brought out artistic features among the participants and their designs turned out to be good examples of modern art.
Social program
Every meeting must have a good and inspiring social program as well. For the Finns, the opportunity to ski in the fabulous Austrian alpine centers has been a dream come true all while making the acquaintance of many inspiring Austrian colleagues.
The many floorball games outside the hotels have been a success. The Austrians painted in their national red and white and the Finns in blue and white national colors create a boisterous frolic every time. Many of the players could be chosen to the Hall of Fame, such as the incredible goal tender Johannes Poigenfürst, the magnificent center forward Frank Sim and the stone hard defender Esko Vainio and the non-corruptible referee Vesa Hamunen.
The evolution of the slalom competition shows the increasing skill of the participants. The competition is always arranged in a professional way and led by Olympic winners such as Patrick Ortlieb. The downhill
16 SOT 1 • 2022 Suomen Ortopedia ja Traumatologia Vol. 45


triathlon, nick-named “bone-head competition” consists of slalom, maximum skiing speed, and bob
sled competition, has been part of the course from the early days. Especially the bob sled competitions have provided many fantastic stories.
Future
Europe has changed into a more open society, permitting for different professions many opportunities to meet and exchange ideas. Orthopaedics and traumatology has branched off into many subspecialities. Our combined trauma course is nevertheless unique in Europe. Its strength is that it is small and truly connects orthopedic and trauma surgeons from Austria and Finland as well as from other European countries (Picture 13). It acts as a living forum to share knowledge, develop ideas and ties us strongly together for the benefit of all participants. The present format of a small intimate course is excellent for international networking and has an important function looking into the future (Picture 14).
Picture 1. The first course was held in Schruns 1981.
Picture 2. Finnish group 1981: Course chairman Veijo Vahvanen in the front and behind him from the left Pär Slätis, Timo Niinimäki, Kalevi Österman, Uolevi Kankaanpää, Veijo Ritsilä and Eva Ritsilä.
Suomen Ortopedia ja Traumatologia Vol. 45
1 • 2022 SOT 17


Picture 3. Oberlech 1985: Kalevi Österman (in the left), Risto Nikku, Austrian colleague, Markku Yli-Jama, Pertti Vänttinen, and Antti Eskola.
Picture 4. Ilizarov ring fixator workshop in Obergurgl 1991; Erkki Karaharju (in the left), Erik B. Riska, and Pär Slätis.
Picture 5. Ilizarov ring fixator workshop in Obergurgl 1991; Seppo Honkonen, Pär Slätis, Timo Kemilä, and Erkki Karaharju.
Picture 6. The seventh course in Obergurgl 1993;
Mrs. Emil Beck (in the right), Chairman Lauri Pasanen, and Emil Beck.
Picture 7. Oberlech 1995: Chairman of the course Jan-Magnus Björkenheim (in the left), Emil Beck, and Martti Hämäläinen.
Picture 8. The grand old man of Finnish-Austrian orthopaedic trauma courses Vesa Hamunen (in the left), Jan Lindahl, Harri Heliö and Seppo Honkonen in Obertauern 2005.
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Picture 9. Organizing committee 2007:
Wolfgang Grechenig (in the left), Mikko Manninen, Jan Lindahl, Juha Kalske, and Gerolf Peicha.
Picture 12. Matti Seppänen demonstrating the clinical examination of the hip joint in Oberlech 2017.
Picture 10. Jyrki Halinen talking about knee ligament injuries in Serfaus 2007.
Picture 13. Organizing committee Oberlech 2015: Mikko Manninen, Jan Lindahl, Wolfgang Grechenig, Juha Kalske, and Axel Gänsslen.
Picture 11. Wolfgang Grechenig in the 15th course in Oberlech 2009.
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Picture 14. Course picture Oberlech 2013.
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Year
Course place
Course Chairman
Organizing committee members
Participants
1981
Schruns
V. Vahvanen, P. Paavolainen
Emil Beck, Olai Snellman, Vesa Hamunen
56
1983
Bad Hofgastein
Turkka Tunturi
Jan-Magnus Björkenheim, Markku Mäki- nen, Vesa Hamunen
72
1985
Ischgl
Turkka Tunturi
Jan-Magnus Björkenheim, Markku Mäki- nen, Vesa Hamunen
94
1987
Oberlech
Jan-Magnus Björkenheim
Emil Beck, Pekka Paavolainen, Vesa Hamunen
112
1989
Oberlech
Jan-Magnus Björkenheim
Vesa Hamunen
106
1991
Obergurgl
Lauri Pasanen
Jan-Magnus Björkenheim, Timo Raatikai- nen, Timo Kemilä, Vesa Hamunen
90
1993
Obergurgl
Lauri Pasanen
Timo Raatikainen, Timo Kemilä, Vesa Hamunen
98
1995
Oberlech
Jan-Magnus Björkenheim
Gernot Sperner, Vesa Hamunen
84
1997
Ischgl
Jan-Magnus Björkenheim
Gernot Sperner, Vesa Hamunen
94
1999
Ischgl
Jan-Magnus Björkenheim
Gernot Sperner, Vesa Hamunen
88
2001
Oberlech
Harri Heliö
Jan Lindahl, Juha Kalske, Gernot Sper- ner, Gerolf Peicha, Vesa Hamunen
83
2003
Oberlech
Harri Heliö
Jan Lindahl, Juha Kalske, Gerolf Peicha, Vesa Hamunen
74
2005
Obertauern
Juha Kalske
Jan Lindahl, Harri Heliö, Wolfgang Gre- chenig, Gerolf Peicha, Vesa Hamunen
84
2007
Serfaus
Juha Kalske
Jan Lindahl, Mikko Manninen,
Wolfgang Grechenig, Gerolf Peicha, Vesa Hamunen
70
2009
Oberlech
Jan Lindahl
Juha Kalske, Mikko Manninen, Wolfgang Grechenig,, Vesa Hamunen
88
2011
Zauchensee
Jan Lindahl
Juha Kalske, Mikko Manninen, Wolfgang Grechenig, Gerolf Peicha,, Vesa Hamunen
101
2013
Oberlech
Jan Lindahl
Juha Kalske, Mikko Manninen, Wolfgang Grechenig,, Vesa Hamunen
90
2015
Oberlech
Jan Lindahl
Juha Kalske, Mikko Manninen, Wolfgang Grechenig,, Vesa Hamunen
77
2017
Oberlech
Mikko Manninen
Jan Lindahl, Juha Kalske, Wolfgang Grechenig
67
2019
Leogang
Mikko Manninen
Jan Lindahl, Thomas Ibounig, Markus Parkkinen, Wolfgang Grechenig
66
2022
Oberlech
Markus Parkkinen
Jan Lindahl, Mikko Manninen, Thomas Ibounig, Wolfgang Grechenig
Table 1. Finnish-Austrian orthopaedic trauma courses 1981-2022
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Physical Examination and Imaging of the Foot and Ankle – What has Changed?
Beat Hintermann MD, Roxa Ruiz MD
Center of Excellence for Foot and Ankle Surgery, Orthopeadic Clinic, Kantonsspital Baselland, Liestal, Switzerland
Though tremendous improvement in imaging mo- dalities to assess injuries and pathologies of foot and ankle (1), clinical assessment remains the main step in first assessment (2). It allows to initiate further diagnostics.
Clinical Assessment
Attempts to use physical examination findings to detect an acute injury date back more than a half century, and the conclusions did not change with more recent work (3, 4) that tenderness, ecchymosis, and swelling have relatively poor sensitivity, specifici- ty, positive or negative predictive value for instabili- ty. Nevertheless, after an acute injury with or without fracture, a thorough clinical investigation of the foot and ankle may help to make the diagnosis of a liga- ment injury. It should include a careful inspection and palpation to elucidate a hematoma and tender- ness. Preoperatively, when the patient is under anes- thesia, a stress test under fluoroscopy may help to verify a ligament injury and to quantify the resulting instability.
Chronic injuries to the ligaments typically cause an instability pattern that can mostly be seen when the patient is standing and distracted (Figure01). In most instances, a chronic instability must be suspe- cted if the patient feels the ankle ‘‘give way,’’ when walking on even ground, downhill, or downstairs, or if the patient experiences pain (1, 5).
A fixed deformity is seen to persist in functional assessment of the foot; whereas if it is seen to disap- pear when the patient is asked to go in tiptoe posi- tion, the deformity is supple, indicating that there is a segmental instability caused by loss of ligament support and/or muscular control. Often compensato-
ry overload and/or muscular activation can be detect- ed because of a chronic injury (6).
Clinical stress investigation is most reliable when the patient is seated on the table with hanging feet (Figure02) (2).
Radiographic Assessment
After an acute injury, radiographs serve to identify or to exclude a fracture or dislocation. In chronic pat- hologies, standard radiographs under weight-bearing should be done, including an anteroposterior view of the ankle as well as an anteroposterior and lateral view of the foot Additionally, a hindfoot alignment view for assessment of the hindfoot alignment should be added. Plain radiographs are also helpful in assessing deformities and the progression of deformities, seg- mental instabilities, and advanced-stage arthritis.
Computed Tomography (CT)
CT is sensitive to detect osteochondral lesions and fractures, thus being the mainstay in further asses- sing the foot and ankle after acute injuries. CT also outperforms conventional radiographs in detecting mal-reduction after surgical fracture treatment or reposition of dislocation injuries. In the last years, the weight-bearing CT has brought more insight in foot pathologies, especially about chronic patholo- gies such as instability, deformity, and osteoarthritic processes (7, 8).
The new generation of SPECT-CT (single-pho- ton emission computed tomography) imaging com- bines the high resolution of a spiral CT with the high sensitivity of bone scans to detect mechanically overloaded areas (9)
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Figure 01:
2.5 years after an ankle sprain, this 24-year-old female patient shows an asymmetric pronation position of the left injured foot, with flattening of the arche and abduction of the forefoot (A), that is seen to disappear win tip-toe position (B), indicating a medial ankle instability. The posterior tibial tendon is working normally. 4 years after a severe pronation trauma without a specific treatment, this 58-year-.old patient is not able to properly walk barefoot due to the medial ankle instability. To stabilize his ankle, he overpowers the flexor hallucis and anterior tibial tendon muscles which results in an elevation of first ray and a plantarflexed great toe, as seen from anteriorly (C) and medially (D)
MRI
After exclusion of gross pathologies, such as bone de- formity, osteoarthritic changes, fractures, and skeletal dissociation,MRimagingcanbeusedtoconfirmor disprove pathology of the anatomical structure suspe- cted to be the cause of clinical signs and symptoms (10-12). There is evidence, however, that CT scan may be of higher value in evaluating distinct patholo- gic conditions, such as fractures (e.g. acute injuries to the bone, stress fractures, fractures of the subchondral bone) or avascular necrosis (e.g. destruction of bony structures). Bone scan may be an additional mean to detect occult pathologies and to validate the appea-
rance of unclear pathologies (e.g. to confirm or to dis- prove the suspected pathology).
If MR imaging is advised, the foot and ankle surgeon therefore wants precise qualitative and qu- antitative information on individual anatomical structures of the foot and ankle, based on his or her preliminary conclusions of the clinical and radiolo- gical investigation.
Arthroscopy
Arthroscopy has become a useful adjuvant tool to understand the severity and complexity of the uns- table ankle prior to surgical reconstruction. Direct
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Figure 02:
Manual stress tests are best done when the patient is sitting with hanging legs, thereby being relaxed. This allows the surgeon to apply dislocation forces by gentle force application (A-B)
arthroscopic visualization ensures not only to vi- sualize and assess the lateral ankle ligaments after an acute sprain or in the chronically unstable con- dition, but also to detect associated osteochondral lesions. Besides this, it permits to understand the instability pattern (1, 13-15).
Ankle arthroscopy was found to be a useful ad- juvant tool to understand the severity and comple- xity of acute ankle fractures, as direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, associated osteochondral lesions, loose bodies, syndesmosis disruption and li- gamentous injuries.
Arthroscopic assessment of the syndesmosis has emerged as a useful technique to evaluate stability of the ankle ligamentous complex, allowing both direct visualization of the tibiofibular articulation as well as the ability to assess stability in multiple planes (coronal, transverse, sagittal) under simulat- ed loading conditions. Diagnosis of syndesmosis disruption can be made by ankle arthroscopy with a 100% accuracy (16).
Conclusions
In the last two decades, progressions in imaging te- chnology have brought tremendous improvement in detecting pathologies resulting from acute and chronic injuries to the foot and ankle. In particular, the weight-bearing CT has opened our eyes about many pathologic processes (Figure03). The Spect CT has further enlarged assessment of bone patho-
logies resulting from overload, degenerative disease, and avascular necrosis. The MRI, in contrast, remains the standard tool for assessing pathologies of the soft tissues, such as ruptures and inflammato- ry conditions of tendons, and tumors. It may be also used to assess the ligaments; however, its value for determining subsequent instability is very limited. The MRI has also certain value in assessing bone pathologies, e.g. osteochondral lesions and avascu- lar necrosis. Finally, arthroscopy has developed to a useful tool not only for diagnosis of intraarticular pathologies of the ankle, but also for less invasive surgical procedures in the treatment of intraarticu- lar pathologies, specific soft tissue conditions, and in fusions. Nevertheless, meticulous clinical assessment remains the mainstay in primary assessment of foot and ankle pathologies.
Literature
1. Hintermann B, Ruiz R. In: Hintermann B & Ruiz R (ed): Foot and Ankle Instability, Springer, Cham, 2021
2. Ruiz R, Hintermann B. Clinical Appearance of Medial Ankle Instability. Foot Ankle Clin. 2021 Jun;26(2):291-304. doi: 10.1016/j.fcl.2021.03.004. Epub 2021 Apr 17. PMID: 33990253.
3. Egol KA, Amirtharajah M, Tejwani NC, Capla EL, Koval KJ. Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am. 2004 Nov;86(11):2393-8. doi: 10.2106/00004623-200411000-00005.
4. Stenquist DS, Miller C, Velasco B, Cronin P, Kwon JY. Medial tenderness revisited: Is medial ankle tenderness
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Figure03:
55-year-old male patient complaining about anterolateral ankle pain 15 months after a pronation trauma in the stairs. Weight-bearing standard X-rays (A, D) are still the basic to assess foot and ankle pathologies. The WBCT scan has brought much more insight in understanding the ongoing pathologic process and structural changes of the joints (B, E). The MRI, in turn, may help to recognize pathologies of soft tissues, but its value for detecting bony pathologies and structural changes of the foot is very limited. (G, F).
predictive of instability in isolated lateral malleolus fractures? Injury. 2020 Jun;51(6):1392-1396. doi: 10.1016/j. injury.2020.03.029. Epub 2020 Apr 5. PMID: 32268964.
5. Hintermann B. Medial ankle instability. Foot Ankle Clin. 2003 Dec;8(4):723-38. doi: 10.1016/s1083-7515(03)00147-5. PMID: 14719838.
6. Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int. 1999 Oct;20(10):622-9. doi: 10.1177/107110079902001002. PMID: 10540992.
7. Lintz F, de Cesar Netto C, Barg A, Burssens A, Richter M; Weight Bearing CT International Study Group. Weight-bear- ing cone beam CT scans in the foot and ankle. EFORT
Open Rev. 2018 May 21;3(5):278-286. doi: 10.1302/2058- 5241.3.170066. PMID: 29951267; PMCID: PMC5994636.
8. Lintz F, de Cesar Netto C. Is Advanced Imaging a Must in the Assessment of Progressive Collapsing Foot Deformity? Foot Ankle Clin. 2021 Sep;26(3):427-442. doi: 10.1016/j. fcl.2021.05.001. Epub 2021 Jun 27. PMID: 34332728.
9. Eelsing R, Hemke R, Schepers T. The added value
of SPECT/CT in the painful foot and ankle: A review of the literature. Foot Ankle Surg. 2021 Oct;27(7):715-722. doi: 10.1016/j.fas.2020.09.009. Epub 2020 Sep 30. PMID: 33046381.
10. Kavanagh EC, Zoga AC. MRI of trauma to the foot and ankle. Semin Musculoskelet Radiol. 2006 Dec;10(4):308-27. doi: 10.1055/s-2007-972001. PMID: 17387644.
11. Hughes P, Miranda R, Doyle AJ. MRI imaging of soft tissue tumours of the foot and ankle. Insights Imaging. 2019 Jun 3;10(1):60. doi: 10.1186/s13244-019-0749-z. PMID: 31161474; PMCID: PMC6546775.
12. Mirghasemi SA, Trepman E, Sadeghi MS, Rahimi N, Rashidinia S. Bone Marrow Edema Syndrome in the Foot and Ankle. Foot Ankle Int. 2016 Dec;37(12):1364-1373. doi: 10.1177/1071100716664783. Epub 2016 Sep 1. PMID: 27587374.
13. Hintermann B, Regazzoni P, Lampert C, Stutz G, Gächter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br. 2000 Apr;82(3):345-51. doi: 10.1302/0301-620x.82b3.10064. PMID: 10813167.
14. Hintermann B, Boss A, Schäfer D. Arthroscopic findings in patients with chronic ankle instability.
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Am J Sports Med. 2002 May-Jun;30(3):402-9. doi: 10.1177/03635465020300031601. PMID: 12016082.
15. Schimmer RC, Dick W, Hintermann B. The role of ankle arthroscopy in the treatment strategies of osteochon- dritis dissecans lesions of the talus. Foot Ankle Int. 2001 Nov;22(11):895-900. doi: 10.1177/107110070102201107. PMID: 11722142.
16. Lucas DE, Watson BC, Simpson GA, Berlet GC, Hyer CF. Arthroscopic Evaluation of Syndesmotic Instability and Malreduction. Foot Ankle Spec. 2016 Dec;9(6):500-505. doi: 10.1177/1938640016666913. Epub 2016 Sep 20. PMID: 27613816.
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Neglected Injuries to the Ligaments of Lateral Ankle
Beat Hintermann MD, Roxa Ruiz MD
Center of Excellence for Foot and Ankle Surgery, Orthopeadic Clinic, Kantonsspital Baselland, Liestal, Switzerland
Lateral ankle ligament injuries are the most common injuries in sports and recreational acti- vities (1-3), and account for about 25% of the in- juries that occur in running and jumping sports (4). Seventy-five percent of all ankle injuries are ankle sprains (2, 3, 5), and 85% of these sprains are caused by an inversion trauma (6). Although most of these ligamentous ankle injuries can be treated successfully with physical rehabilitation and nonoperative treatment, 20% to 40% of the patients with these injuries will go on to experien- ce chronic instability and subsequent disability (3, 7, 8). Remaining pain and dysfunction often result from neglecting initially accompanying and hidden injuries (9). The goal of this paper is to elu- cidate some of the most often neglected injuries.
Avulsion Fracture of Distal Tibia
The most common tear site of the anterior talo-fi- bular ligament (ATFL) and calcaneo-fibular liga- ment (CFL) are their proximal attachments, with the deep layers being more often affected than the superficial layers (10, 11). The rupture typically starts at the proximal site of the common inser- tion area and continues distally, leaving the ATLF / CFL complex intact, however detached from the fibula. A special type of injury is an avulsion frac- ture of the lateral ankle ligaments at the fibula that is most seen among children and patients over 40 years of age (Figure01) (12). The clinical characte- ristics are different from those of ligament rupture, and, unlike nonoperative treatment of lateral li- gament rupture, nonoperative treatment of avul- sion fractures do not yield satisfactory results (13). Avulsion fractures at the talar end of the ATFL, in contrast, are less common since bone density is greater than at the fibular enthesis, and stress
is dissipated away from the talar enthesis by the 'wrap-around' fibrocartilaginous character of the ligament near the talar articular facet (14).
Osteochondral Fractures / Lesions
Osteochondral fractures after an acute ankle sprain can typically be found at the anterolateral talar dome or also on the medial talar dome (15). There is general agreement that if the bony frag- ment is thicker than 3 mm, it should be reattached by solid screw fixation. However, the treatment of chronic OCL remains controversial. Debridement with microfracturing is mostly preferred for super- ficial lesions of up to 15 mm in diameter (16), filling of the defect by osteochondral plugs (mosai- coplasty) or cancellous bone is used for greater defects and cystic lesions (17, 18). For deep cystic lesions, allografts are used for reconstruction of the talar surface (19, 20). A promising alternative is the use of a vascularized cortical-periosteal graft from the medial femur condyle (21).
Peroneal Tendon Tears
The incidence of peroneal tendon injuries after acute ankle sprains have been reported to be as high as 15% and, in most instances, are accom- panied by incomplete tears of the peroneus brevis tendon. If conservative treatment fails, surgical re- construction is advised. If partially ruptured, the tendon is debrided, and tubular sutures are done to obtain a solid tendon. If less than one third of the tendon remains intact, a transfer of the pero- neal longus tendon to the peroneal brevis tendon is considered (22).
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Figure01:
A bony avulsion of the lateral ankle ligaments (A) signifies a complete desattachement from the fibula, resulting in a significant anterolateral instability of the ankle. When applying varus stress, the bony fragment is typically seen to follow the ligaments, as a proof of a complete desattachement (B), and it can also be verified by arthroscopy (C). Surgical exposure of the ligaments confirm a complete desattachment of the anterior talo-fibular and calcaneo-fibular liga- ments, resulting in a significant instability (D). Current studies have found in approximately 60% of chronically unstable ankles that needed surgical treatment such a type of injury, indicating that this injury should best be treated surgically.
Chopart Joint Injuries
Injuries involving the Chopart joint complex are relatively rare and frequently missed or misdiag- nosed, often leading to a poor functional outcome (23). Typically, midtarsal sprains result from low- energy inversion-type ankle trauma. They are dis- tinct from Chopart joint fracture-dislocations, which result from high-energy trauma such as motor vehicle crashes.
Midtarsal sprains may affect the supporting li- gaments along the talo-calcaneo-navicular and cal-
caneo-cuboid joints. The most injured ligaments are the dorsal calcaneocuboid, bifurcate, and dorsal talonavicular ligaments (Figure 02) and the spring ligament complex, with plantar ligament injuries thought to be significantly less frequent (24, 25). The range of osseous injuries includes contusions, avul- sions, or impaction fractures of the anterior process of the calcaneus, talar head, cuboid bone, and navi- cular bone (24 - 26).
It is reported that 40.5% of the patients with chronic lateral ankle instability have clinical signs of damage to the bifurcate ligament of the midfoot (27).
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Conclusions
The tremendous increase of available imaging tools over the last two decades and progress made in ar- throscopy, have renewed surgeons’ interests for the unstable ankle. Nevertheless, meticulous clinical as- sessment remains the key for successful treatment.
A high incidence of persistent instability is related to bony avulsion injuries with subsequent disconne- ction of both the ATF and CF ligaments from the fibula. Therefore, reattachment of the fragment or ex- cision thereof, with reattachment of the ligaments to
the fibula is generally recommended (9, 13).
The role of associated lesions and pathologies in patients with lateral ankle instability is still not fully understood (9). The question often remains whether surgical reconstruction of the ligaments will be suf- ficient to restore ankle joint mechanics, treating the symptoms of associated pathologies, or whether pain and disability will continue due to the unaddressed pathologies. Furthermore, to which extent seconda- ry osteoarthritis of the ankle joint has its origin in untreated instability or in neglected associated pat-
hologies, is still not clear (8).
Figure 02:
This 32-year-old female patient sustained a complex trauma when falling from a horse. Radiographically, a distal bony avulsion of dorsal talo-navicular ligament was detected (A) and confirmed by CT scan (B) that evidenced in addition
a non-displaced fractur of anterior calcaneal process. Surgical exposure of the injury site at dorsal navicular evidences the extent of injury (C). Surgical reconstruction included fixation of the avulsion fractures by screws (D). Injuries to the Chopart joint need strict immobilization and 2 to 3 weeks longer for healing than injuries to the ankle.
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23. Kutaish H, Stern R, Drittenbass L, Assal M. Injuries to the Chopart joint complex: a current review. Eur J Orthop Surg Traumatol. 2017;27(4):425-31
24. Andermahr J, Helling HJ, Maintz D, Mönig S, Koebke J, Rehm KE. The injury of the calcaneocuboid ligaments. Foot Ankle Int. 2000 May;21(5):379-84. doi: 10.1177/107110070002100504. PMID: 10830655.
25. Walter WR, Hirschmann A, Alaia EF, Garwood ER, Rosenberg ZS. JOURNAL CLUB: MRI Evaluation of Midtarsal (Chopart) Sprain in the Setting of Acute Ankle Injury. AJR Am J Roentgenol. 2018 Feb;210(2):386-395. doi: 10.2214/ AJR.17.18503. Epub 2017 Nov 7. PMID: 29112474.
26. Hirschmann A, Walter WR, Alaia EF, Garwood E, Amsler F, Rosenberg ZS. Acute Fracture of the Anterior Process
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of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint? AJR Am J Roentgenol. 2018 May;210(5):1123- 1130. doi: 10.2214/AJR.17.18678. Epub 2018 Mar 23. PMID: 29570372.
27. Agnholt J, Nielsen S, Christensen H. Lesion of the ligamentum bifurcatum in ankle sprain. Arch Orthop Trauma Surg. 1988;107(5):326-8. doi: 10.1007/BF00451515. PMID: 3178448.
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Injuries to the Medial Ankle Ligaments – Fact or Fiction?
Roxa Ruiz MD, Beat Hintermann MD
Center of Excellence for Foot and Ankle Surgery, Orthopeadic Clinic, Kantonsspital Baselland, Liestal, Switzerland
Though progress has been made in understan- ding the functional anatomy and biomechanics of the deltoid-spring ligament complex, there is a lack in understanding the functional interplay of the various bundles of this ligament complex (Figure01). This is particularly true when defining
where motion is not physiological anymore and instability, with subsequent disability and progres- sive deformity, is present. Additionally, the role of posterior tibial tendon in the dynamic control of this functional interplay is also not fully unders- tood yet.
Figure 01:
Anatomic preparation showing the deltoid-spring ligament complex.
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Injury Mechanism
Isolated injuries to the deltoid and spring ligaments are often primarily missed, thus the orthopaedic surgeon is mostly faced with the problem after onset of chronic symptoms. Meticulous recording of the history and thorough clinical investigation are therefore man- datory for diagnosis. Imaging methods may serve to further confirm the diagnosis and to reveal morpholo- gical changes subsequent to the initial injury.
Among all ankle sprains, isolated deltoid ligament injuries account for approximately 5% to 15% of such injuries in athletic patient samples (Figure02) (286, 287). Sprains of the deltoid ligament complex more commonly occur with a concomitant injury including ankle fracture, syndesmosis injury, or lateral ligament
injury (1, 2). Overall, it was suggested, that the medial ankle ligaments are more often injured than gene- rally believed (3-5). Typically, injuries to the medial ankle ligaments occur during running down the stairs, landing on uneven surface and dancing while the body simultaneously rotated in the opposite direction.
Clinical and Imaging Findings
A key feature of the patients’ history is whether they have sustained a pronation (eversion) trauma, e.g., an outward rotation of the foot during simultaneous inward rotation of the tibia. Excessive lateral rotati- on may injure the tibiofibular and interosseous liga- ments at the syndesmosis. The anterior fibers of the deltoid ligament may also be involved in extreme ro-
Figure 02:
An isolated injury to the deltoid ligament can be detected in the MRI as an avulsion of its proximal insertion at anterior colliculus of medial malleolus, while the connection to the periosteum remains typically preserved (A). This lesion pattern can be confirmed by arthroscopy showing the rupture of the deep layers of the superficial deltoid ligament (B). The hematoma can often be detected only after dissection of the subcutaneous layers (C)., and the extent of the injury is seen after dissection of the fascia (D).
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tation injuries. In practice, however, this is not as easy as patients often report of having sustained one more multiple ankle sprains, but they are not able to clearly indicate the injury mechanism.
Complete deltoid ligament ruptures are someti- mes seen in association with lateral malleolar fractures (6), or in specific bimalleolar fractures (7).
Chronic deltoid ligament insufficiency can be in a number of conditions including posterior tibial tendon disorder, trauma and sports related deltoid dis- ruptions, as well as valgus talar tilting in those with previous triple arthrodesis or total ankle arthroplasty.
One concern may by the question whether pos- terior tibial (PT) dysfunction and medial ankle ins- tability are distinct conditions. Although possible, it is not clear yet if, or to which extent, a medial ankle instability may cause a secondary PT dysfunc- tion over time, as the tendon may become elongated and/or ruptured (2, 8).
Injury Types to the Deltoid-Spring
Ligament Complex
Injuries to the medial ankle ligaments can be diffe- rentiated into injuries to the superficial deltoid liga- ment with or without involvement of spring ligament (Figure02) and injuries to the deep deltoid ligament. A classification into 3 types was proposed by Hinter- mann et al in 2003 (4). Later, Hintermann and Ruiz (9) added a 4th Type,
Type I-injury
This most common injury includes the superficial layer of deltoid ligament at its tibial periosteal at- tachment with partial discontinuity, delamination, or a complete tear with or without lesions of the flexor retinaculum. Typically, the lesion is seen to conti- nue towards caudally into the interval between ti- bial-spring ligament (TSL) and tibio-calcaneal liga- ment (TCL), which is found to be separated. As a consequence, external rotation at talonavicular joint increases and the tibia tends to internally rotate when the foot is loaded. Typically, activation of PT muscle permits to compensate for this deformity forces.
Type I A-injury
This injury type includes the TNL and TSL. Typi- cally, a delamination of deep ligament portion at
tibial insertion is found while the superficial fibers may remain intact. In most instances, the tear is extended towards distally resulting in a partial tear of the interval.
Type I B-injury
The tear is extended further to the TCL, which is also partially desattached from its tibial insertion, showing a partial delamination. The colliculus anterius of medial malleolus is free from liga- ment leaving just a tiny superficial layer of TNL and TSL left at proximal insertion. In contrast
to Type I-A injury, the remaining ligaments are typically thickened and show transmural scar formation. In most instances, the tear is extended into the interval.
Type I C-injury
In this injury type, the delamination of TCL is extended to the whole insertion area at colliculus anterius, leaving just the superficial layers partially intact. The TNL and TSL are completely desat- tached from proximal insertion, and the tear also involves the interval.
Type II-injury
This less common injury is located mainly within the mid-substance of TSL and may also include the TNL. The injury pattern can vary from partial discontinuity to complete rupture. As a consequen- ce, the ligamentous buttress of talar head is lost when the foot is loaded which results in pronation and abduction of the foot. Activation of PT muscle may partially compensate for this deformity forces.
Type II A-injury
This injury type consists in a partial tear of TSL, as seen by a partial discontinuity of this ligament. The TNL may also be involved. The resulting incom- petence can best be seen while the foot is pronated and/or the forefoot is abducted. In most instances, the posterior part of TSL remain intact.
Type II B-injury
The TSL shows a complete tear that allows direct visualization of talar neck and sometimes even the proximal articular surface of medial talar head. The resulting defect is typically little, and it can
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be closed while the foot is held in supinated and adducted position.
Type II C-injury
The tear also involves part of the TCL, resulting in a major defect that cannot be closed by holding the foot in supinated and adducted position.
Type III-injury
The injury is located distally at the insertion to the navicular and involves mainly the distal part of TNL, TSL, superior medial calcaneo-navicular ligament (SMCNL) and inferior calcaneal-navicular ligament (ICNL). The rupture may continue along the na- vicular with avulsion of the PT tendon at its inser- tion to the tuberosity of navicular bone (9). This configuration is also often seen in the presence of an external tibial bone that is deattached along its connection to the navicular bone. As a consequen- ce, the support of talar head is lost when the foot is loaded which results in plantarflexion of talus and abduction and supination of the foot; whereas acti- vation of PT muscle may or may not be able to resist against this deformation process depending on its involvement in the injury. No talar tilt can be seen radiographically in the AP-view under weight-bea- ring and/or valgus stress view.
Type III A-injury
There is an avulsion of the ICNL and SMCNL from navicular while the PT tendon is not affected. The defect can be seen best while the foot is slightly supi- nated, and the PT tendon is kept away with a hook.
Type III B-injury
In this injury type, the PT tendon is also affected. Typically, an avulsion of the tendon can be seen at its main insertion at tuberosity of navicular, while its connection to the plantar ligamentous network remains intact. The ICNL and SMCNL may also evidence an avulsion or not; if present, it is usually rather small.
Type III C-injury
In contrast to the Type III B-injury, there is a bony avulsion of PT tendon from navicular. In most instances, this injury type can be seen with the presence of an external tibial bone that has become
disconnected from the navicular bone subsequently to a pronation-abduction trauma to the foot. In rare cases, an acute avulsion fracture from navicular can be found.
Type IV-injury
Injuries to the deep medial ankle ligaments can occur at the proximal insertion to medial malleo- lus, in the mid-substance of the ligaments or at the distal insertion to the talus. While the injury is typi- cally found for anterior tibio-talar ligament (ATTL) at its proximal insertion, involving also the super- ficial layers of the deltoid, injuries to the posterior tibio-talar ligemant (PTTL) are mostly seen near its medial talar insertion (318). The ICNL and SMCNL (Spring ligament), in contrast, are usually not affected. As a consequence, the talus tilts into valgus when the foot is loaded which results gradual- ly in valgus deformity of hindfoot and supination deformity of forefoot that cannot be compensat- ed by activation of PT muscle. Typically, a talar tilt can be seen radiographically in the AP-view under weight-bearing and/or valgus stress view, meaning that the destabilization process has involved also the tibiotalar (ankle) joint.
Type IV A-injury
This type of injury result mainly in a tear in the proximal area of TNL, TSL, TCL and STTL, while the ATTL is partially also affected. The resulting valgus tilt is <5°.
Type IV B-injury
In this type of injury, the tear extends further pos- teriorly, involving the ATTL and, partially, also the PTTL. The resulting valgus tilt may increase up to 10°.
Type IV C-injury
The whole deltoid ligament is disrupted whit a valgus destabilization that exceeds 10° of valgus tilt while the foot becomes loaded.
Surgical Treatment
The main strategy is to reconstruct all affected struc- tures to restore the stability of medial ankle joint complex. In the case of an extended injury with a long-standing instability, especially in a Type IV-inju-
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ry, the question is whether a primary reconstruction is feasible, or the use of an autograft or allograft will be necessary (10-15).
Correcting osteotomies to support the reconstruct- ed soft tissue structures may also be considered (2).
Conclusions
Injuries to the medial ankle ligaments exist, and they are more common than generally believed. However, injuries to the deltoid and spring ligaments are often primarily missed, thus the orthopaedic surgeon is mostly faced to the problem after onset of chronic symptoms. Meticulous record of the history and thorough clinical investigation are therefore manda- tory to make the diagnosis. Imaging methods may serve to further confirm the diagnosis and to reveal morphological changes after the initial injury.
Though better understanding of medial ankle instability and subsequent biomechanical changes, the question remains how an injury to the liga- ments of medial ankle joint complex should be best treated. While primary repair will work for most Type I-injuries, it may not for Type II- and Type III-injuries. A high incidence of persistent pain and disability is related to an injury to an accessory tibial bone or a disattachment of central slip of PT tendon insertion at navicular associated to a spring ligament rupture (9). Therefore, reattachment of accessory bone or excision with subsequent transosseous fixa- tion of PT tendon to the navicular is essential for treatment success. Controversies still exist whether bony procedures such as calcaneal lengthening os- teotomy should be considered to protect soft tissue reconstructions, however.
Literature
1. Buchhorn T, Sabeti-Aschraf M, Dlaska CE, Wenzel F, Graf A, Ziai P. Combined medial and lateral anatomic ligament reconstruction for chronic rotational instability of the ankle. Foot Ankle Int. 2011 Dec;32(12):1122-6. doi: 10.3113/ FAI.2011.1122. PMID: 22381196.
2. Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W. Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med. 2004 Jan- Feb;32(1):183-90. doi: 10.1177/0095399703258789. PMID: 14754742.
3. Crim JR, Beals TC, Nickisch F, Schannen A, Saltzman
CL. Deltoid ligament abnormalities in chronic lateral ankle instability. Foot Ankle Int. 2011 Sep;32(9):873-8. doi: 10.3113/FAI.2011.0873. PMID: 22097163.
4. Hintermann B. Medial ankle instability. Foot Ankle Clin. 2003 Dec;8(4):723-38. doi: 10.1016/s1083-7515(03)00147-5. PMID: 14719838.
5. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin. 2006 Sep;11(3):625-37. doi: 10.1016/j.fcl.2006.08.001. PMID: 16971253.
6. Hintermann B, Regazzoni P, Lampert C, Stutz G, Gächter A. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg Br. 2000 Apr;82(3):345-51. doi: 10.1302/0301-620x.82b3.10064. PMID: 10813167.
7. Tornetta P 3rd. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am. 2000 Jun;82(6):843-8. doi: 10.2106/00004623-200006000-00011. PMID: 10859104.
8. Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateral column and reconstruction of the medial soft tissue for treatment of acquired flatfoot deformity associated with insufficiency of the posterior tibial tendon. Foot Ankle Int. 1999 Oct;20(10):622-9. doi: 10.1177/107110079902001002. PMID: 10540992.
9. Hintermann B, Ruiz R. In: Hintermann B & Ruiz R (ed): Foot and Ankle Instability, Springer, Cham, 2021
10. Bastias GF, Dalmau-Pastor M, Astudillo C, Pellegrini
MJ. Spring Ligament Instability. Foot Ankle Clin. 2018 Dec;23(4):659-678. doi: 10.1016/j.fcl.2018.07.012. Epub 2018 Sep 22. PMID: 30414659.
11. Brodell JD Jr, MacDonald A, Perkins JA, Deland JT, Oh I. Deltoid-Spring Ligament Reconstruction in Adult Acquired Flatfoot Deformity With Medial Peritalar Instability. Foot Ankle Int. 2019 Jul;40(7):753-761. doi: 10.1177/1071100719839176. Epub 2019 Mar 22. PMID: 30902021.
12. Deland JT, de Asla RJ, Segal A. Reconstruction
of the chronically failed deltoid ligament: a new technique. Foot Ankle Int. 2004 Nov;25(11):795-9. doi: 10.1177/107110070402501107. PMID: 15574238.
13. Ellis SJ, Williams BR, Wagshul AD, Pavlov H, Deland JT. Deltoid ligament reconstruction with peroneus longus autograft in flatfoot deformity. Foot Ankle Int. 2010 Sep;31(9):781-9. doi: 10.3113/FAI.2010.0781. PMID: 20880481.
14. Jung HG, Park JT, Eom JS, Jung MG, Lee DO. Reconstruc- tion of superficial deltoid ligaments with allograft tendons in medial ankle instability: A technical report. Injury. 2016 Mar;47(3):780-3. doi: 10.1016/j.injury.2016.01.009. Epub 2016 Jan 16. PMID: 26822014.
15. Oburu E, Myerson MS. Deltoid Ligament Repair in Flatfoot Deformity. Foot Ankle Clin. 2017 Sep;22(3):503- 514. doi: 10.1016/j.fcl.2017.04.001. Epub 2017 Jun 2. PMID: 28779803.
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The Progressive Break-Down of the Foot
Roxa Ruiz MD, Beat Hintermann MD
Center of Excellence for Foot and Ankle Surgery, Orthopeadic Clinic, Kantonsspital Baselland, Liestal, Switzerland
Adult acquired flatfoot deformity (AAFD) repre- sents a pathology in Orthopaedic Foot and Ankle Surgery that we all commonly see, yet in many dif- ferent forms. Our experience has grown over the years thanks to the research and clinical experience and great insights of authors from all over the world. However, with the onset of new surgical techniques, technology, and imaging modalities, the understan- ding of the details of this complex pathology has grown exponentially. Despite these advances, it is often confusing not only when to decide to operate, but also which procedures to perform, how much correction to achieve, and even what to call the con- dition itself.
Recently, the consensus group advocated for the use of the term progressive collapsing flatfoot defor- mity (PCFD) instead of adult-acquired flatfoot de- formity (AAFD) for various reasons (1). Taking the word adult out allows us to include younger patients without a history of congenital foot disorder or coa- lition in the treatment algorithm for this pathology. The term progressive describes the natural history of the disorder. We have favored collapsing over flat- foot since many patients with a flat arch do not have pathology or pain. The use of foot deformity denotes that this is not just routine foot care but rather a true pathology that will help combat insurance denials that claim that “flatfoot” is routine foot care. It is only when the “arch” progresses on to collapse that it becomes a problem. We have used this terminology throughout the rationale statements.
Rational
PCFD is a progressive disorder secondary to degene- ration of the medial ligaments of the foot and pos- sibly ankle as well as failure of the posterior tibial tendon. This soft tissue failure leads to valgus and
abduction deformity of the hindfoot and midfoot resulting in progressive collapse of the medial lon- gitudinal arch, and less commonly, talar tilt at the ankle (2). The ligament pathology is as prevalent as posterior tibial tendinopathy (3). The ligament failure indeed creates the biggest problem, the pro- gressive collapse of the foot and possible involve- ment of the ankle. In the severe deformities of this condition, bony non-fusion correction may be ina- dequate and necessitate fusion of critical joints. Li- gament reconstruction rather than repair of dege- nerated weak ligaments may allow for preservation of critical joints when there is adequate remaining motion in those joints and the bony procedures give 50% or somewhat more but inadequate correction of the joints. These critical joints include the subta- lar, talonavicular, and ankle joints. There is evidence that reconstruction of the ligaments of these joints in addition to bony realignment procedures can give adequate correction of alignment and good func- tional outcomes in the severe flexible deformities. This makes for being able to avoid fusions of critical joints in properly selected patients.
Clinical Diagnosis
Diagnosis is made clinically (4). Clinical examina- tion should start with a visual gait analysis with the patient barefoot and both knees and ankles visible. It is particularly important to rule out proximal defor- mities because PCFD may be secondary to compen- sation of a varus knee. With the patient seated and feet hanging from the examination couch, palpation reveals pain mainly in the medial soft tissues around the ankle. Tibialis posterior tendon may be swollen and painful in different segments or all the way from the retromalleolar region down to its insertion in the navicular. In a very early stage, medial structures—
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spring ligament, deltoid, and the flexor tendons of the toes (hallucis longus and digitorum)—will have minor or no pain. With further progression of the condition, tenderness initially present may diminish and instead patients complain of fatigue and pain with a reduction in walking distance. Dynamic exa- mination should include a heel raise test—monopo- dal and bipodal—to address the presence of a hind- foot valgus and posterior tibial tendon function and power to invert the subtalar joint.
Imaging
Conventional standing radiographs (AP foot, AP or mortise ankle, lateral foot, and hindfoot align- ment view) have been the mainstay of evaluating the deformity, with several validated radiographic measurements that can distinguish a PCFD pre- sentation from a normal patient (5). In a blinded comparison of standing AP and lateral conventio- nal radiographic measurements, Younger and col- leagues demonstrated that several radiographic parameters, including talo-first metatarsal angle (Meary’s angle) and talonavicular (TN) coverage angle, can reliably and consistently differentiate between patients with symptomatic PCFD defor- mity and controls (6).
While standing weight-bearing radiographs remain the gold standard given their availabili- ty and affordability, weight-bearing CT (WBCT) offers several unique advantages including imp- roved spatial resolution that allows a multiplanar three-dimensional assessment, minimizing rotatio- nal and positional bias, as well as bony superimpo- sition (7, 8). In addition, studies have demonstrat- ed the reliability and reproducibility of using WBCT in the evaluation of PCFD, highlighting its ability to better quantify structural deformity compared to conventional plain radiographs and non-weightbearing images (Figure 01) (9-11).
One of the most important aspects of PCFD that has become much clearer and more easily and directly assessed with the advent of WBCT is the coronal plane component of the deformity, defor- med as markers of peritalar subluxation (12). Mul- tiple parameters associated with the severity of pe- ritalar subluxation were described and investigated in the literature. One very good example is the pre- sence of sinus tarsi and subfibular impingements.
Treatment
The treatment of PCFD involves slowing down the progression of the disease. Surgical techniques, such as soft tissue with medial or lateral column procedu- res, are widely used to avoid the progression of these fixed deformities (13). According to a previous study, the medial surgical approach permitted fusion without the development of non-union and provi- ded a significant correction of the fixed deformities. However, there are limited studies that compared the efficacy among these surgical techniques, and the best approach for treating PCFD still remains controversial (14).
Currently, the common surgical procedures in- cluded medial displacement calcaneal osteotomy, lateral column lengthening, modified triple (diple) arthrodesis, subtalar and naviculo-cuneiform ar- throdesis , and flexor digitorum longus tendon transfer. These strategies are widely used for mild deformities with flexibility, whereas no quantitati- ve indexes are constructed for operative indication. Previous studies have showed that these interven- tions can slow down the progression and relieve the clinical symptoms of PCFD, but a clear compari- son of the efficacy among these surgical procedures is still needed (15, 16)
Results
There is considerable surgeon-to-surgeon variabi- lity in the treatment of PCFD. Surgical treatment with a medial slide osteotomy and tendon transfer has been shown to provide consistently good results. Lateral column lengthening provides more correc- tion; thus, it should be considered for the patient with more severe deformity. However, there is a risk of lateral overload with this procedure, and care should be taken to avoid overcorrection and exces- sive stiffness. When multiple osteotomies are being performed, temporary fixation is recommended so that the final position and flexibility of the foot can be assessed before definitive fixation is placed. The patient with advanced stage of peritalar subluxation, particularly experiencing sinus tarsi or subfibular impingement, requires subtalar fusion, most com- monly involving a procedure to correct the forefoot supination (Figure(17). Positioning is important in achieving optimal functional result. Care should
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Figure01:
WBCT has brought more insight in pathologic changes of the flatfoot deformity, particularly the peritalar subluxati- on. Among other changes, it permits to evidence sinus tarsi impingement (A, B), to quantify peritalar subluxation at intermediate facet (C), lateral dislocation of calcaneus (D), and the talker uncoverage.
Figure 02:
Painful
tarsi
gement
even subfibu-
lar impinge-
ment indicate
progression of
peritalar sub-
luxation (A-D),
which needs subtalar fusion to reposition the talus on top of calcaneus (E-F). Soft tissue reconstruction and corre- cting bony procedure alone will no longer work. The associated break-down of medial arch (C, D) can be seen at talo-navicular, naviculo-cuneiform, or tarso-metatarsal level, or in combination. In this case, naviculo-cuneiform fusion was done to restore the medial arch (G, H)., a measure that also stabilized the talo-navicular joint (H).
sinus impin- and
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again be taken to avoid over- and undercorrection. More progress is needed in the management of an involvement of the ankle joint, typically seen in a valgus tilt of talus.
There is evidence indicating that the amount of bony correction performed in the setting of PCFD reconstructive surgery can be titrated within a re- commended range for a variety of procedures. The typical range for performing a medial disp- lacement calcaneal osteotomy should be 7 to 15 mm of medialization of the tuberosity. The typical range for performing a lateral column lengthening should be 5 to 10 mm of a laterally based wedge in the anterior calcaneus. The typical range for per- forming a plantarflexion opening wedge osteoto- my of the medial cuneiform (Cotton) osteotomy should be 5 to 10 mm of a dorsal wedge. Asso- ciated soft tissue procedures, in contrast, are still not elucidated as much to give raise to general re- commendations. However, in general, it is recom- mended to reconstruct the ligaments and tendons, with or without aide of augmentation procedures and tendon transfers.
Conclusions
PCFD encompasses a wide range of deformities. Originally known as posterior tibial tendon dys- function or insufficiency, PCFD was first descri- bed as tendon failure. However, failure of the li- gaments that support the arch also occurs, often resulting in progressive deformity of the foot. Deformities vary in severity, rate of progression, and location along the arch. Treatment has been effective in relieving pain. However, achieving maximum function remains a challenge. The end result of surgical treatment of the patient with AAFD has much to do with the management of the associated deformity. The principle of correc- ting the deformity while avoiding overcorrection and excessive stiffness is important in determining the outcome of the surgical treatment in these pa- tients. In all stages, there are benefits to achieving proper alignment and maintaining as much flexi- bility as possible. Working on the maximum achie- vement of these two goals is likely to continue to optimize the results for patients with PCFD.
Literature
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are involved? Foot Ankle Int. 2005 Jun;26(6):427-35. doi: 10.1177/107110070502600601. PMID: 15960907.
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6. Younger AS, Sawatzky B, Dryden P. Radiographic assessment of adult flatfoot. Foot Ankle Int. 2005 Oct;26(10):820-5. doi: 10.1177/107110070502601006. PMID: 16221454.
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and Radiographic Projection Angle on Measurement
of Supramalleolar Alignment on the Anteroposterior
and Hindfoot Alignment Views. Foot Ankle Int. 2015 Nov;36(11):1352-61. doi: 10.1177/1071100715591091. Epub 2015 Jun 26. PMID: 26116431.
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of hindfoot alignment measurements from standard radiographs using the methods of Meary and Saltzman. Foot Ankle Surg. 2019 Apr;25(2):237-241. doi: 10.1016/j. fas.2017.10.018. Epub 2017 Nov 11. PMID: 29409188.
9. de Cesar Netto C, Schon LC, Thawait GK, da Fonseca LF, Chinanuvathana A, Zbijewski WB, Siewerdsen JH, Demehri S. Flexible Adult Acquired Flatfoot Deformity: Comparison Between Weight-Bearing and Non-Weight-Bearing Measurements Using Cone-Beam Computed Tomography. J Bone Joint Surg Am. 2017 Sep 20;99(18):e98. doi: 10.2106/ JBJS.16.01366. PMID: 28926392.
10. Lintz F, Welck M, Bernasconi A, Thornton J, Cullen NP, Singh D, Goldberg A. 3D Biometrics for Hindfoot Alignment Using Weightbearing CT. Foot Ankle Int. 2017 Jun;38(6):684- 689. doi: 10.1177/1071100717690806. Epub 2017 Feb 9. PMID: 28183212.
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subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults. J Bone Joint Surg Am. 1999 Nov;81(11):1545-60. doi: 10.2106/00004623-199911000-00006. PMID: 10565646.
13. Kelly IP, Easley ME. Treatment of stage 3 adult acquired flatfoot. Foot Ankle Clin. 2001;6:153–66.
14. Tao X, Chen W, Tang K. Surgical procedures for treatment of adult acquired flatfoot deformity: a network meta-analysis. J Orthop Surg Res. 2019 Feb 21;14(1):62. doi: 10.1186/s13018-019-1094-0. PMID: 30791933; PMCID: PMC6385451.
15. Hiller L, Pinney SJ. Surgical treatment of acquired flatfoot deformity: what is the state of practice among academic foot and ankle surgeons in 2002? Foot Ankle Int. 2003 Sep;24(9):701-5. doi: 10.1177/107110070302400909. PMID: 14524521.
16. Zaw H, Calder JD. Operative management options for symptomatic flexible adult acquired flatfoot deformity:
a review. Knee Surg Sports Traumatol Arthrosc. 2010 Feb;18(2):135-42. doi: 10.1007/s00167-009-1015-6. PMID: 20049416.
17. Steiner CS, Gilgen A, Zwicky L, Schweizer C, Ruiz R, Hintermann B. Combined Subtalar and Naviculocuneiform Fusion for Treating Adult Acquired Flatfoot Deformity With Medial Arch Collapse at the Level of the Naviculocu- neiform Joint. Foot Ankle Int. 2019 Jan;40(1):42-47. doi: 10.1177/1071100718800295. Epub 2018 Oct 13. PMID: 30317867.
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Current Treatment Options in Ankle Osteoarthritis
Beat Hintermann MD, Roxa Ruiz MD
Center of Excellence for Foot and Ankle Surgery, Orthopeadic Clinic, Kantonsspital Baselland, Liestal, Switzerland
The ankle joint has a much lower incidence of symp- tomatic arthritis compared with other major joints. This is despite the fact that the articular cartilage in the ankle experiences the greatest contact force per unit area of any major joint in the body and the ankle joint is one of the most commonly injured areas in orthopaedic surgery.
A previous trauma is the most common cause of ankle osteoarthritis (1, 2). Despite posttrauma- tic changes will usually take some time to develop symptomatic osteoarthritis, patients are affected ty- pically in an earlier age than those with hip or knee osteoarthritis (3). Therefore, physical demands may be higher, and their treated ankle will be exposed to a longer period. Analogously, it is more likely that patients will encounter problems related to the treat- ment. Therefore, we have learned in the last years to select joint-preserving procedures, as long as joint congruency and joint surfaces are not significant- ly damaged, for treatment of ankle osteoarthritis before considering joint scarifying procedures, e.g. total ankle replacement or ankle arthrodesis (4-6).
Joint Preserving Procedures
A majority of patients with ankle osteoarthritic joint present with a malaligned hindfoot. Corrective os- teotomies aim to reduce peak pressures and restore biomechanics of the ankle joint to down the pro- gression of ankle joint osteoarthritis (Figure01) (4). Depending on the underlying pathology, they may be combined with procedures that balance the soft tissues (ligament reconstruction, tendon repairs and transfers). Supramalleolar deformities are corrected with supramalleolar osteotomies, paying great atten- tion to preserve or restore joint congruity. The type of supramalleolar osteotomy (opening and closing
wedge osteotomy, dome-shaped osteotomy) is de- termined by the level of deformity, the type of fixa- tion, soft tissue mantle, and the type of joint pre- sentation congruent vs incongruent joints (7). Best results were reported patients with Takakura stages 1-3a with 10-year survivorships of 82% (6). Main risk factors for early tilt are advanced stages of osteo- arthritis, a tilt >7 degrees, age >60 years, postopera- tive joint incongruity (8). Inframalleolar deformities result from variations of calcaneal shape, the shape and orientation of the subtalar joint, and forefoot deformities. They can be addressed calcaneal osteo- tomies; however, the effect on the ankle may not be predictable in patients with preserved inversion or eversion at the subtalar joint. The medial column is included the preoperative planning. A plantar- flexed talus (supinated forefoot) increases the risk for valgus tilting in the joint and thereby increases the load transfer laterally ankle joint. A plantarflexed medial column increases pressure on the anterome- dial aspect of the ankle joint.
Joint scarifying Procedures
Ankle arthrodesis has been the standard procedu- re in the treatment of symptomatic end-stage ankle OA (9, 10). However, the development of osteoar- thritic changes of the adjacent joints, especially of the subtalar joint, remain a concern. Several long- term studies have reported substantial degenerative changes of the adjacent joints after ankle arthrodesis (11). These patients were often functionally limited by foot pain (12, 13). Although ankle arthrodesis is a valid treatment option for osteoarthritis, its risks and sequelae cannot be ignored. Such problems with ankle arthrodesis promoted interest in total ankle replacement in the last 25 years (14).
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Figure01:
Correcting osteotomies are the mainstay in joint preserving surgeries for the osteoarthritic ankle joint. This 42-year- old former soccer player suffered from indreasing medial ankle pain subsequently to a progressive varus destabi- lization of his right ankle. (A) In the coronal plane, the distal tibial articular surface angle is seen deviated in varus, with narrowing of the medial tibiotalar joiunt space and subchondral osteosclerosis. (B) The hindfoot alignment view evidences a varus malalignment of the heel, indicating a varus moment arm of the Achilles tendon. (C) The lateral view evidences osteophyte formation at anterior ankle and a peritalar subluxation of the subtalar joint with closed sinus tarsi as an expression of compensatory pronation position of subtalar joint. (D) The DP view of the foot shows the decreased talo-calcaneal angle. 10 years after a supramalleolar correcting osteotomy (medial open wed- ge osteotomy), the ankle joint is well balanced with a congruent and preserved tibiotalar joint space (E), a neutral hell alignment (F), a well-balanced ankle in the sagittal plane (G), and a normalization of the footprint on ground (H). The patient is without pain and no limited for any physical activity.
Despite concerns persist with regard of bad bone and soft tissue quality, as often the case in elderly after previous trauma or systemic disease, total ankle replacement has evolved to a reliable and safe al- ternative to arthrodesis in the in the treatment of end-stage osteoarthritis with good clinical and ra- diographic outcomes (Figure02) (15-17). Recent re- search has shown a higher walking velocity attribu- table to both increases in stride length and cadence following total ankle replacement compared to pa- tients who underwent an ankle arthrodesios. Fur- thermore, a more natural gait pattern was evident
in patients following total ankle replacement (18, 19). By maintaining motion at the level of the ankle joint, total ankle replacement prevents hypermobi- lity of the peritalar joints. This may impact on the progression of subtalar joint osteoarthritis (20-22). Reduction in device constraint realized by the con- temporary designs in comparison with the first-ge- neration devices and improved instrumentation has markedly contributed to this higher success (23). Clinical longevity of total ankle replacement is de- pendent upon a correct balance between the intrin- sic mobility allowed by the design and the presen-
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Figure 02:
In this advanced stage of ankle osteoarthritis after a Type C ankle fracture with valgus destabilization of the hindfoot due to avascular necrosis of anterolateral tibial plafond, total ankle replacement is suitable for preser- ving motion; however, it requires balancing of the ankle joint complex. The preoperative standard weight-bearing radiographs show the complex destabilization and valgus malalignment of the ankle joint complex (A-D. With insertion of the ankle prosthesis, the deltoid-spring ligament complex was tightened which has restored the talar position and the hindfoot alignment, as seen at 12 years follow-up control (E-H).
ting pathology of the patient (24). This is further influenced by the ability of the surgeon to appropri- ately balance the soft tissue constraints, and correct- ly align the components. Despite improvement in design appropriate surgical training, experience and technique will ultimately determine the results of total ankle replacement.
Conclusions
As >60% patients with ankle osteoarthritis present with a malalignment, supramalleolar osteotomies have gained in popularity for the treatment of early and mid-stage arthritis (4). These procedures work by improving altered biomechanics and restoring normal alignment. Supramalleolar alignment cor- rection in the varus and valgus arthritic ankle has
shown to improve function while reducing pain and even radiological signs of arthritis. Recent studies in- dicate that osteoarthritis of the ankle joint is often not due to a single plane deformity, and instead may entail a complex pattern involving the ankle joint, as well as the neighboring joints and the stabilizing surrounding soft tissues (25, 26). In these patients, biplanar osteotomies and adjunct procedures are often necessary. Joint sacrificing options for end-sta- ge ankle osteoarthritis include ankle arthrodesis and total ankle replacement. However, arthrodesis of the ankle joint has been shown to result in functional restriction, gait abnormalities, and the development of secondary degenerative changes in the adjacent joints (12, 13), therefore total ankle replacement might be a better option as a primary treatment, as long as bone stock and integrity of soft-tissue mantle
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are preserved. In the last years, progresses in implant design, instrumentation and surgical technique have contributed to higher success (27-29)
Literature
1. Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, Amendola A. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44-6. PMID: 16089071; PMCID: PMC1888779.
2. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009 Jul;467(7):1800-6. doi: 10.1007/s11999- 008-0543-6. Epub 2008 Oct 2. PMID: 18830791; PMCID: PMC2690733.
3. Huch K, Kuettner KE, Dieppe P. Osteoarthritis in ankle and knee joints. Semin Arthritis Rheum. 1997 Feb;26(4):667- 74. doi: 10.1016/s0049-0172(97)80002-9. PMID: 9062947.
4. Hintermann B, Knupp M, Barg A. Supramalleolar Osteotomies for the Treatment of Ankle Arthritis. J Am Acad Orthop Surg. 2016 Jul;24(7):424-32. doi: 10.5435/JAAOS-D- 12-00124. PMID: 27195382.
5. Hintermann B, Knupp M, Barg A. Joint-preserving surgery of asymmetric ankle osteoarthritis with peritalar instability. Foot Ankle Clin. 2013 Sep;18(3):503-16.
doi: 10.1016/j.fcl.2013.06.010. Epub 2013 Jul 27. PMID: 24008215.
6. Knupp M, Bolliger L, Hintermann B. Treatment of posttraumatic varus ankle deformity with supramalleo- lar osteotomy. Foot Ankle Clin. 2012 Mar;17(1):95-102. doi: 10.1016/j.fcl.2011.11.007. Epub 2011 Dec 6. PMID: 22284554.
7. Knupp M, Stufkens SA, Bolliger L, Barg A, Hintermann B. Classification and treatment of supramalleolar deformities. Foot Ankle Int. 2011 Nov;32(11):1023-31. doi: 10.3113/ FAI.2011.1023. PMID: 22338950.
8. Pagenstert GI, Hintermann B, Barg A, Leumann A, Valderrabano V. Realignment surgery as alternative treatment of varus and valgus ankle osteoarthritis. Clin Orthop Relat Res. 2007 Sep;462:156-68. doi: 10.1097/ BLO.0b013e318124a462. PMID: 17563701.
9. Espinosa N, Klammer G. Treatment of ankle osteoarthri- tis: arthrodesis versus total ankle replacement. Eur J Trauma Emerg Surg. 2010 Dec;36(6):525-35. doi: 10.1007/s00068- 010-0058-1. Epub 2010 Nov 13. PMID: 26816307.
10. Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PMID: 19589303.
11. Sheridan BD, Robinson DE, Hubble MJ, Winson IG. Ankle arthrodesis and its relationship to ipsilateral arthritis of the hind- and mid-foot. J Bone Joint Surg Br. 2006 Feb;88(2):206-7. doi: 10.1302/0301-620X.88B2.17065. PMID: 16434525.
12. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-trau- matic arthritis. J Bone Joint Surg Am. 2001 Feb;83(2):219-28. doi: 10.2106/00004623-200102000-00009. PMID: 11216683.
13. Fuchs S, Sandmann C, Skwara A, Chylarecki C. Quality of life 20 years after arthrodesis of the ankle. A study of adjacent joints. J Bone Joint Surg Br. 2003 Sep;85(7):994-8. doi: 10.1302/0301-620x.85b7.13984. PMID: 14516034.
14. Glazebrook M, Burgesson BN, Younger AS, Daniels TR. Clinical outcome results of total ankle replacement and ankle arthrodesis: a pilot randomised controlled trial. Foot Ankle Surg. 2021 Apr;27(3):326-331. doi: 10.1016/j. fas.2020.10.005. Epub 2020 Oct 17. PMID: 33148476.
15. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007 Sep;89(9):1899-905. doi: 10.2106/JBJS.F.01149. PMID: 17768184.
16. Gougoulias N, Khanna A, Maffulli N. How successful are current ankle replacements?: a systematic review of the literature. Clin Orthop Relat Res. 2010 Jan;468(1):199-208. doi: 10.1007/s11999-009-0987-3. Epub 2009 Jul 18. PMID: 19618248; PMCID: PMC2795846.
17. Barg A, Zwicky L, Knupp M, Henninger HB, Hintermann B. HINTEGRA total ankle replacement: survivorship
analysis in 684 patients. J Bone Joint Surg Am. 2013
Jul 3;95(13):1175-83. doi: 10.2106/JBJS.L.01234. PMID: 23824385.
18. Flavin R, Coleman SC, Tenenbaum S, Brodsky JW. Comparison of gait after total ankle arthroplasty and ankle arthrodesis. Foot Ankle Int. 2013 Oct;34(10):1340-8. doi: 10.1177/1071100713490675. Epub 2013 May 13. PMID: 23669163.
19. Jastifer J, Coughlin MJ, Hirose C. Performance of
total ankle arthroplasty and ankle arthrodesis on uneven surfaces, stairs, and inclines: a prospective study. Foot Ankle Int. 2015 Jan;36(1):11-7. doi: 10.1177/1071100714549190. Epub 2014 Sep 8. PMID: 25201334.
20. Pedowitz DI, Kane JM, Smith GM, Saffel HL, Comer C, Raikin SM. Total ankle arthroplasty versus ankle arthrodesis: a comparative analysis of arc of movement and functional outcomes. Bone Joint J. 2016 May;98-B(5):634-40. doi: 10.1302/0301-620X.98B5.36887. PMID: 27143734.
21. McHenry BD, Exten EL, Long J, Law B, Marks RM, Harris G. Sagittal subtalar and talocrural joint assessment with weight-bearing fluoroscopy during barefoot ambulation. Foot Ankle Int. 2015 Apr;36(4):430-5. doi: 10.1177/1071100714559540. Epub 2014 Nov 7. PMID: 25380773.
22. Sokolowski M, Krähenbühl N, Wang C, Zwicky L, Schweizer C, Horn Lang T, Hintermann B. Secondary Subtalar Joint Osteoarthritis Following Total Ankle
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Replacement. Foot Ankle Int. 2019 Oct;40(10):1122-1128. doi: 10.1177/1071100719859216. Epub 2019 Jul 22. PMID: 31327242.
23. Barg A, Knupp M, Henninger HB, Zwicky L, Hintermann B. Total ankle replacement using HINTEGRA, an uncon- strained, three-component system: surgical technique
and pitfalls. Foot Ankle Clin. 2012 Dec;17(4):607-35.
doi: 10.1016/j.fcl.2012.08.006. Epub 2012 Oct 12. PMID: 23158373.
24. Hintermann B, Susdorf R, Krähenbühl N, Ruiz R. Axial Rotational Alignment in Mobile-Bearing Total Ankle Arthroplasty. Foot Ankle Int. 2020 May;41(5):521-528. doi: 10.1177/1071100720902838. Epub 2020 Jan 29. PMID: 31996033.
25. Hintermann B, Ruiz R, Barg A. Novel Double Osteotomy Technique of Distal Tibia for Correction of Asymmetric Varus Osteoarthritic Ankle. Foot Ankle Int. 2017 Sep;38(9):970-981. doi: 10.1177/1071100717712543. Epub 2017 Jul 1. PMID: 28670918.
26. Scheidegger P, Horn Lang T, Schweizer C, Zwicky L, Hintermann B. A flexion osteotomy for correction of a distal tibial recurvatum deformity: a retrospective case series. Bone Joint J. 2019 Jun;101-B(6):682-690. doi: 10.1302/0301- 620X.101B6.BJJ-2018-0932.R2. PMID: 31154842.
27. Zaidi R, Cro S, Gurusamy K, Siva N, Macgregor A, Henricson A, Goldberg A. The outcome of total ankle replacement: a systematic review and meta-analysis. Bone Joint J. 2013 Nov;95-B(11):1500-7. doi: 10.1302/0301- 620X.95B11.31633. PMID: 24151270.
28. Shah NS, Umeda Y, Suriel Peguero E, Erwin JT, Laughlin R. Outcome Reporting in Total Ankle Arthroplasty:
A Systematic Review. J Foot Ankle Surg. 2021 Jul- Aug;60(4):770-776. doi: 10.1053/j.jfas.2021.02.003. Epub 2021 Mar 4. PMID: 33766479.
29. Palanca A, Mann RA, Mann JA, Haskell A. Scandinavian Total Ankle Replacement: 15-Year Follow-up. Foot Ankle Int. 2018 Feb;39(2):135-142. doi: 10.1177/1071100717738747. PMID: 29389250.
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Hallux rigidus
Timo Sirola
Helsinki University Hospital and University of Helsinki, Finland
Hallux rigidus is a term used for a stiff and painful first metatarsophalangeal joint (MTPJ). The diagnosis of hallux rigidus includes radiographic osteoar- thritic findings in plain radiographs, including narrowing of the joint space, dorsal osteophyte formation and flattening of the metatarsal head. (1) The aetiology of osteoarthritis is not clear.(2, 3) The most common condition associated with hallux rigidus is idiopathic osteoarthritis (OA) of the first MTPJ. Other less common predisposing conditions are inflammatory joint diseases and post-traumatic conditions. (4,5) The prevalence of hallux rigidus has been reported to be 2,5% in a population over 50 years.(5)
The primary treatment of hallux rigidus is nonsurgical. At present, there is weak evidence supporting the role of orthotics and supportive shoes in the treatment of hallux rigidus. (6) Currently, there is no comparative evidence supporting injection therapies, manipulation, physiotherapy interventions, extracorporeal shockwave therapy, iontophoresis, and ultrasonography therapy.(7-9) In a long-term cohort study of patients who declined surgery, pain levels remained constant in 92% of the patients in a 14-year follow-up. Nonetheless, 75% of these patients stated that they would make the same decision again. (10)
Several surgical treatment methods for hallux rigidus have been introduced, including arthrodesis, cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty, and interpositional arthroplasty. However, comparative evidence on the best surgical method is scarce. (11) There is one RCT comparing first MTPJ arthrodesis with total joint arthroplasty, showing superior results with arthrodesis. (12) There are only two RCTs comparing surgical methods for hallux rigidus. In both studies first MTPJ arthrodesis yielded better outcomes. (12,13) Arthrodesis is widely accepted as the gold standard method for operative treatment of hallux rigidus.(15-16) The purpose of this article is to present the current scientific evidence on the various treatment options of hallux rigidus.
Johdanto
Hallux rigidus on yksi tavallisimpia ortopedisia vaivoja. Prevalenssi vaivalle on laskettu olevan 1,7 %. (5) Yli 50-vuotiaalla väestöllä isovarpaan tyvinivelen artroosivaivaa on todettu 2,5%:lla.(4) Naisilla tautia on todettu olevan kaksinkertaisesti miehiin verrat- tuna. (17) Taudin etiologia on useimmiten idiopaat- tinen osteoartroosi, mutta hallux rigidus voi kehit-
tyä myös trauman jälkitilana tai tulehduksellisen nivelsairauden aiheuttamana. IHallux rigidusta on kuvattu esiintyvän myös pitkän ykkössäteen, koho- tetun ykkössäteen ja adduktiossa olevan ykkössäteen seurauksena. (30) Oirekuvaan kuuluu tyypillisesti rasituksessa paheneva kipu isovarpaan tyviniveles- sä, liikekipu etenkin ääriasennoissa ja nivelen lii- kelaajuuden vähittäinen väheneminen. Isovarpaan tyvinivelen normaalina liikelaajuutena pidetään 75
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asteen dorsifleksiota ja 35 asteen plantaarifleksiota. (29) Diagnoosi varmennetaan rtg-kuvalla, CT- tai MRI-kuvausta ei yleensä tarvita. Rtg-kuvassa hallux rigiduksen löydöksiin kuuluu nivelraon kaventumis- ta, osteofyyttejä etenkin dorsaalisesti ja metatarsaali 1 luun distaalipään tasoittumista. Hallux rigiduksen luokittelussa käytetyin on Coughlinin ja Shurnasin esittelemä 5-portainen luokittelu, jossa on mukana sekä radiologinen että kliininen löydös (taulukko 1). (18) Tämä ei kuitenkaan korreloi potilaan oireisiin ja ei ole siksi sovellettavissa kliiniseen käytäntöön. (32)
Konservatiivinen hoito
Ensisijainen hoito on aina konservatiivinen. Kon- servatiivinen hoito pitää sisällään isovarpaan kivu- liasta liikettä vähentävien tukevan kengän, kovan pohjallisen tai nk. keinukengän käytön. Kipulääki- tystä ja injektiohoitoja voidaan kokeilla lyhytaikai- seksi avuksi. Konservatiivisella hoidolla voi pärjätä pitkäänkin. 22 potilaan (24 jalan) pitkäaikaisessa 14 vuoden seurannassa oireilu säilyi samana 92%:lla potilaista, mutta silti 75% oli valmis samaan kon- servatiiviseen hoitoratkaisuun seurannan jälkeenkin. (10) Retrospektiivisessa 772 potilaan tutkimuksessa
todettiin 55% hallux rigidus potilaista tyytyväisiksi konservatiiviseen hoitoon pohjallisten, kenkävalin- nan ja kortikosteroidi-injektioiden avulla. (6) Kor- tisoni-injektiolla liikehoitojen lisäksi on saatu lyhy- taikaista apua luokkien 1-2 hallux rigidus potilailla. Hyaluronaatti-injektiolla saatiin kortisoni-injektiota parempi teho 56 päivän seurannassa 40 jalan ran- domisoidussa tutkimuksessa. Molemmat ryhmät hyötyivät injektioista ainakin lyhytaikaisesti. (20) Vakuuttavaa näyttöä ei ole esitetty monista muista konservatiivisen hoidoin keinoista: fysioterapia, ma- nipulaatio, ultraäänihoito, iontophoreesi. (7-9)
Kirurginen hoito
Jos konservatiivinen hoito ei ole auttanut, voidaan tarjota kirurgista hoitoa. Hallux rigiduksen ki- rurginen hoito voidaan jakaa nivelen säilyttäviin ja nivelen tuhoaviin leikkauksiin. Erilaisia leik- kauksia on paljon ja oikean leikkausmetodin va- lintaan vaikuttavat taudin aste, potilaan odotukset ja toiveet leikkauksen lopputulokselta sekä poti- laan motivaatio. Leikkaushoidon tavoitteena on kivun hoito, jalan funktion parantaminen, MTP I nivelen stabiliteetin säilyttäminen ja elämänlaa- dun parantaminen. (21)
Taulukko 1
Kliininen ja radiologinen hallux rigidus luokittelu (Coughlin – Surnas)
aste
dorsifleksio
radiologinen löydös
kliininen löydös
0
40-60°
normaali
vain jäykkyyttä, liikelaajuus hieman alentunut
1
30-40°
dorsaalisia osteofyyttejä, minimaalista nivelraon kaventumista, MT I pään tasoit- tumista, skleroosia
lievää ja/tai ajoittaista kipua max dorsifleksiossa ja/tai max plantaarifleksiossa
2
10-30°
periartikulaarisia osteofyyttejä, lievää/ kohtalaista nivelraon kaventumista, MT I pään tasoittumista, skleroosia
kohtalaista tai kovaa kipua ja jäykkyyttä toistuvasti, kipua jo ennen max liikelaajuuksia
3
10° tai alle
sama kuin 2, mutta lisäksi subkondraa- lisia kystiä ja todennäköisesti sesam-lui- den muodonmuutoksia
lähes jatkuvaa kipua ja jäykkyyttä, kipua etenkin ääriasennoissa
4
10° tai alle
sama kuin 3
sama kuin 3, mutta kipua on myös liikkeen keskivaiheilla
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