Amputationen an Vor- und Mittelfu?

Objective

Partial foot amputations are feasible regardless of the causal condition, including peripheral vascular disease with a few exceptions. Compared to higher amputation levels, a good foot stump permits full end bearing and enables the patient, even with a hindfoot stump, to walk without the need for a prosthesis. The more peripheral the amputation level selected, the greater the need for gentle tissue handling and meticulous postoperative care, but also the greater the risk of a breakdown requiring stump revision surgery. In the forefoot, partial amputation of the metatarsals preserves the length of the stump and, thus, minimizes the loss of weight-bearing surface. The resection of metatarsal and midfoot bones without removing the toes, called a ??hidden?? amputation, is more acceptable to the patient who does not feel as if he/she has become an amputee. In addition, no neuroma or phantom pain is experienced. Biomechanically, this amputation hardly differs from a classical amputation.

Indications

Amputation cannot be avoided by any conservative or operative means.

Contraindications

Absolute: rapidly progressing peripheral arterial diseases, i.e., Buerger-Winiwarter??s disease. Relative: renal failures requiring dialysis or kidney transplantation.

Surgical technique

Patient in prone position, keep foot and calf free, protect heel from pressure. Mark the skin incisions. A long plantar flap covers the bones and is sutured to the short dorsal flap at the dorsum of the foot. Begin with the dorsal incision down to the bones. After separating the bones, turn the distal part down and separate the plantar soft tissue flap. The bones are well aligned and shaped. Longitudinal amputations preserve a larger load-bearing surface and, therefore, are preferred, if possible. Another alternative is the ??hidden?? amputation. Except for amputations in peripheral vascular diseases, the digits and their neurovascular supplies are preserved. Only the bones are resected, from transmetatarsal to Chopart. The toes will retract within a few weeks. The patients do not feel as if she/he has become an amputee, although the biomechanics of the foot are about the same as after a total amputation. In case of infection, wound debridement, open wound treatment, and delayed primary closure are recommended.

Postoperative management

Full plantar weight bearing in plaster cast or walker is possible 4?C6?weeks after surgery. In the case of diabetic foot, healing can require weeks. Total contact prosthesis without limiting the range of motion (ROM) of the ankle and the subtalar joint after 6?weeks. Best results are obtained with prostheses using the silicone technique. Alternative: orthopedic footwear.

Results

It is desirable to maintain the greatest length possible; wound healing disorders are observed in over half of all cases. Operative stump corrections are justified in 20?C30%; a transtibial amputation is seldom necessary.     

Mittelfußverletzungen im Kindesalter

Midfoot injuries of children are rare entities and often caused by high energy trauma mechanisms. Foot fractures in children may pose a diagnostic challenge but they usually have a good prognosis. In special cases computed tomography is necessary to find the right diagnosis in addition to plain X-rays. Based on two cases of midfoot injuries, a type II open Lisfranc fracture dislocation and a dislocation of a Chopart's joint, we describe the causes, diagnosis, and possibilities for treatment of juvenile midfoot injuries.     

Amputationen am R��ckfu?

Objective

Obtaining a durable, weight-bearing stump with minimal or no loss of limb length, and stable soft tissue coverage with preservation of the original sensation of the sole of the foot at the heel.

Indications

Complex trauma to the foot with devitalized or nonreconstructable forefoot and midfoot, deep bony and soft tissue infection, infected Charcot foot with threatening sepsis, necrosis or gangrene of the forefoot and midfoot with vasculopathy, malignant tumors, certain infections, gigantism of the forefoot.

Contraindications

Possible reconstruction of the midfoot and forefoot beyond the midtarsal (Chopart) joint, loss or irreversible destruction of the sole of the foot or the distal tibial metaphysis.

Surgical technique

The skin incision is designed to retain a long plantar flap with a maximum amount of weight-bearing sole 5?C7?cm below amputation level and a shorter anterior flap 1?C2?cm below amputation level. Exarticulation or bone resection is performed from anterior to posterior, while preserving the posteromedial vessels to supply the heel flap. The Chopart stump is held in a neutral position avoiding equinus with a tibiotalar external fixator and additional tendon balancing with a noninfected posterior tibialis and one of the peronaeal tendons from medial and lateral through the talar head and Achilles tendon lengthening. Alternatively, a Pirogoff stump with minimal limb length loss (about 2?cm) is achieved with minimal resection at the anterior calcaneal process. The calcaneus is rotated 70?C80° and fused to the distal end of the tibia with lag screws or an external frame. Alternatively, a Syme stump is covered with the heel skin after resection of the malleoli flush to the tibial plafond. If anterior wound closure cannot be obtained without tension, temporary vacuum-assisted closure and later definitive coverage with skin grafts, local or free flaps is obtained. In cases of deep infection, the amputation is performed as a staged procedure.

Postoperative management

Nonweight bearing until stable scar formation, early mobilization in a total contact cast. Interim prosthesis after 2?C4?weeks, fitting of the definitive prosthesis with special shoewear after 2?C3?months.

Results

Over a 12-year period, 15?Chopart, 7?Pirogoff, and 2?Syme amputations were performed. A total of 15?patients had sustained a complex foot trauma, 9?had a deep infection, among them 7 in a diabetic Charcot foot. In 16?patients, among them all with deep infection, 1?C4 planned revisions were performed. In 5?patients (20.8%), the stumps were revised subacutely to a more proximal amputation level. In 2?patients with Chopart amputation, a hindfoot fusion was performed to correct equinus, while 1?Chopart and 1?Pirogoff stump were subjected to resection of a prominent exostosis. Except for 2?patients with Charcot foot, all patients with hindfoot amputation could walk barefoot over short distances.     

Behandlungsergebnisse bei Mittelfußknochenbrüchen

Ohne Zusammenfassung     

Luxationen im Bereich des Mittelfußes

Ohne Zusammenfassung (Mit 13 Abbildungen.)     

Zur Frage derDeutschländerschen Mittelfußerkrankung

Ohne Zusammenfassung Mit 10 Abbildungen.     

Die Epiphysennekrose der Mittelfußknochenköpfchen

Ohne Zusammenfassung Herrn Prof. Dr. Alban K?hler in Verehrung gewidmet.     

Über seltenere Erkrankungen der Mittelfußzenhengelenke

Ohne Zusammenfassung (Mit 6 Abbildungen.)     

Die basale Distorsionsfraktur des 5. Mittelfußknochens

Zusammenfassung Wird der Mittelfu? gegen die Fu?wurzel gewaltsam abgeknickt, w?hrend sich der Fu? in Supinations- und Spitzfu?stellung befindet, so erfolgt bei geringerem Trauma eine Distorsion des Gelenkes zwischen 5. Metatarsus und Os cuboideum, in schwereren F?llen noch dazu ein quer verlaufender Knickungs-und Ri?bruch der Basis des 5. Metatarsus. Der Bruch erfolgt in der Regel ohne Dislokation, weil die Fragmente durch feste Bandmassen miteinander und mit der Umgebung fixiert sind. Als Nebenbefund kann auch ein Abri?bruch der Tuberositas metatarsi V vorkommen. Die Prognose der Fraktur ist günstig, die Heilung wird durch elastische Kompressionsverb?nde erreicht; auch nachher ist für die Erhaltung der Belastungsf?higkeit des Fu?es Vorsorge zu treffen.     

Behandlung des veralteten Klumpfußes mit Osteotomie der Mittelfußknochen

Ohne Zusammenfassung     

Frakturen und Luxationen am Fuß

Ligamentous injuries of the knee joint account for the highest incidence among all orthopedic problems in today’s practice. These injuries usually occur in the patellofemoral or tibiofemoral joint. A precise diagnosis can only be made when all available modalities are used, such as thorough clinical examination and imaging techniques. Acute instabilities have to be separated from chronic and single ligament from multiple ligament injuries to choose the appropriate treatment algorithm, which differs substantially for each type of injury. This article describes a step-by-step approach for initial care, imaging techniques, and final treatment options to provide a guideline for optimal therapy of ligamentous injuries of the knee joint.     

Zementfreier Endoprothesenwechsel am Großzehengrundgelenk

We report about a 36 year old patient with insufficient silicone implant arthroplasty of the great toe. For a change of endoprothesis we successfully used an non-cemented modular alloarthroplasty system.     

Wiederherstellende Maßnahmen am Penisschaft

Ohne Zusammenfassung Mit 3 Textabbildungen in 10 Einzeldarstellungen     

Salter-Harris-Typ-IV-Epiphysenfraktur am Außenknöchel

This is a case presentation of a 9-year-old boy who sustained a rare Salter-Harris type IV distal fibular fracture including an avulsion fracture of the anterior inferior tibiofibular ligament at the fibular attachment. Treatment consisted of open reduction and internal fixation by Kirschner wire and cerclage. Possible posttraumatic growth disturbances and the major implications are highlighted.     

Autologe Matrix-induzierte Chondrogenese am Großzehengrundgelenk

Clinical stages guide the treatment of hallux rigidus. Therapy options comprise conservative and surgical approches the application of which has to be determined individually. The presented case report describes treatment of an osteochondral lesion (OCL) on the head of the first metatarsale bone by use of the AMIC^®-technique. Not only an increased range of motion but also pain cessation could be achieved by the procedure.     

Eine seltene Sehnenzerreißung am Daumen

Ohne Zusammenfassung