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PubMed1996

Clinical and radiological results after Austin bunionectomy for treatment of hallux valgus.

The results of the Austin osteotomies for hallux valgus deformity performed at the Orthopedic Hospital Gersthof were reviewed at least 1 year after surgery. Of the 53 consecutive patients (66 operations) with an average follow-up of 24.3 months, 49 patients (62 feet) were interviewed. Of the reviewed patients 86.6% achieved good or excellent clinical results. The complication rate was 8%, including hallux varus n (3), superficial n (1) and deep n (1) wound infections, hypoaesthesia n (2), and reflex sympathetic dystrophy n (1). There was one case of avascular necrosis of the first metatarsal head and none of non-union. The Austin osteotomy is a safe and effective treatment of mild and moderate hallux valgus deformity.

Adolescent↗

PubMed1992

Indications for neurosurgical treatment of chronic pain.

Guidelines are presented for the neurosurgical treatment of chronic pain. In these guidelines a distinction is made between the pain of cancer and neurogenic pain. In cancer pain the survival time and the location of the lesion are the important guidelines. Possible procedures are: opioids via CSF route, lesions in nociceptive pathways and PV-PAG stimulation of the thalamus. In neurogenic pain, neurostimulation procedures, tailored to the location of the pain are procedures of first choice. There are however specific indications for other procedures depending on the aetiology of the pain. Causalgia and reflex sympathetic dystrophy: sympathetic blockade; Tic douloureux: radio-frequency lesion, glycerol, balloon inflation of the ganglion of Gasser, and microvascular decompression; Plexus avulsion: dorsal root entry zone lesion (D.R.E.Z.). There is a need for controlled prospective neurosurgical trials in which as a minimal rule an independent party should evaluate the results of the surgical procedure.

Chronic Disease↗

PubMed1995

The value of one-portal endoscopic carpal tunnel release: a prospective randomized study.

A randomized prospective study was carried out to compare one-portal endoscopic carpal tunnel release with an open procedure. There were 47 patients (mean age 52.6 years); 25 underwent an endoscopic and 22 an open release. The aim of the study was to evaluate the risks against the benefits for pain, grip, key-pinch strength and ability to return to work. The distribution of age, occupation, sex, neurographic findings and operated hand was similar in both groups. We detected no serious nerve complications. One "open" patient developed a hypertrophic scar, a second "open" patient a disabling reflex sympathetic dystrophy, one "endo" patient a transient neurapraxia. The remaining patients experienced complete relief of symptoms. Improvement of grip strength is significantly better after endoscopic release (P = 0.0001 at 3 months). In contrast, the key-pinch showed a similar pattern of improvement in both groups. The ability to use the operated hand as effectively as the contralateral one developed after 24 days for the endoscopic group versus 42 for the open approach (P = 0.0000). The carpal arch alteration was less important for the endoscopic group (P = 0.013), but without any correlation with the grip strength. Agee's one-portal technique only allows correct placement of a knife, not an inspection of the structures being operated upon. This is a major limitation, reducing the surgeon to a technician. Further development of this procedure demands a device that will enable a fruitful inspection of the carpal tunnel.

Carpal Tunnel Syndrome↗

PubMed1994

Plasma neuropeptide Y in the symptomatic limb of patients with causalgic pain.

The aim of this experiment was to measure the concentration of neuropeptide Y (NPY), a vasoactive transmitter which co-exists with noradrenaline in sympathetic nerve terminals, in venous blood taken from the painful and contralateral limbs of 16 patients with features of reflex sympathetic dystrophy (RSD) or causalgia. In nine patients tapping the skin of the affected limb provoked pain (allodynia). In seven of the nine patients with allodynia the concentration of NPY was lower on the painful side; similar results were obtained in only two of seven patients without widespread allodynia. In addition, the concentration of NPY was generally lower in the painful limb if it was warmer than the contralateral limb. These findings suggest that a reduction in sympathetic activity might accompany allodynia and influence vasomotor disturbances in patients with causalgic pain.

Adolescent↗

PubMed1989

Oxidative stress. Biochemistry and human disease.

The early involvement of free radicals in the evolution of life may explain their ubiquitous presence and vital physiological role. Imbalance between protection against free radicals and their generation, explains the likely association of various diseases with toxic oxygen species. An elaborate defence system against oxygen-free radicals exists. The effects of oxidative stress are manifold. Direct demonstration of oxygen radicals in intact biological systems is difficult. Frequently, effect-related measurements are used in this respect. The clinical conditions adult respiratory distress syndrome and multiple organ failure, reflex sympathetic dystrophy and sugar cataract are discussed and the role of oxygen radicals in the aetiology of these diseases are described.

Free Radicals↗

PubMed1994

Non-union of pediatric fibula fractures: easy to overlook, painful to ignore.

Fracture non-union in the pediatric population may span the age range from childhood to adolescence. Fracture non-union in children and adolescents is often due to an underlying cause such as affliction with neurofibromatosis or osteogenesis imperfecta. Although less commonly seen, non-union may occur in the otherwise healthy pediatric population. We report three cases of fracture non-union of the distal end of the fibula in the pediatric age group. All three were characterized by persistent local pain and tenderness following injury with radiographic evidence of fracture non-union. All three had undergone conservative treatment with extended periods of immobilization. Following surgery, all three had marked improvement of their local symptomatology. One patient's course was complicated by reflex sympathetic dystrophy syndrome. In two patients, resection of the un-united fragment at the distal fibula resulted in marked relief from pain without any increase in ankle instability. We postulate that the fracture non-union resulted in a fibrotic reaction that was so extensive that ankle stability was maintained even after removal of the fracture fragment.

Adolescent↗

PubMed1982

Osteonecrosis of the femoral head and pregnancy.

The authors report 7 anatomo-clinical cases of osteonecrosis of the femoral head, the clinical onset of which occurred during pregnancy or in the fortnight after delivery. On the basis of histological data obtained through core-biopsy in these 7 cases they discuss the relationship between osteonecrosis and reflex sympathetic dystrophy of the hip.

Adult↗

PubMedDate not supplied

Diagnostic and therapeutic ankle arthroscopy.

Ankle arthroscopy has grown in popularity over the past decade as a diagnostic and therapeutic procedure. We assessed 24 patients who underwent ankle arthroscopy during the two year period 1991-1993. In 18 cases a mini-arthrotomy was performed based on the arthroscopic findings. All patients were reviewed at an average of 26 months and a detailed evaluation was carried out according to an objective scoring system which grades five parameters; pain, swelling, stiffness, limp, and activity level. Twenty-two patients (92%) had good or excellent results. There were two complications transient tarsal tunnel syndrome and reflex sympathetic dystrophy. There were no neurovascular complications. This series represents an initial experience and illustrates that ankle arthroscopy provides a safe and effective method of diagnosis and treatment with few complications. Further advances in instrumentation and distraction techniques will reduce the need for open arthrotomy and should expand the indications for the procedure.

Adolescent↗

PubMed1997

[Neurophysiological aspects of pain and its consequences for the anesthetist].

Nociception is a protective system of the body which prevents it from injury and tissue damage. Human beings respond to noxious stimuli by moving away. They learn by pain to avoid these situations in future. Shortly after major injury, there is a limited analgesic period allowing the body to flee the area of danger, later on, emerging pain compels the body to rest and supports recuperation. While acute pain has a certain meaning, chronic pain does not. It induces a comprehensive suffering including loss of initiative, appetite and vigilance. It reduces life-quality, often accompanied by depressive moods. Acute pain causes changes in the central nervous system leading to an increased sensitivity of nociception (hyperalgesia). During healing, the central processing of noxious stimuli is normalised taking minutes to weeks. Sometimes, unknown factors initiate chronification of pain. Changes on a molecular level in peripheral tissue as well as in the central nervous system induce "cellular early genes", a synthesis of c-fos, c-jun and other proteins favouring the chronification of pain. All efforts have to be made to depress or interrupt such a development. One of the first steps to pain prophylaxis in a hospital is an optimal surgical technique: incision, extension, limited tissue damage and minimal invasive surgery should guarantee the smallest impairment of the nociceptive system possible. However, nociceptive input is intense and of long duration and leads to central sensibilisation. Postoperative pain has lost its function as surgery anticipates healing. Pain induces a reduction of ventilation, circulation, digestion and increases the risk of other disorders. There is need of aggressive pain treatment for humanitarian reasons and for reasons of late sequelae like permanent pain and increased reduction of function. This is of pivotal importance in patients with amputations or sympathetic reflex dystrophy (SRD). Antinociception is best provided by regional anaesthesia technique with a combination of local anaesthetics and opioids which results in better outcome. Hence, regional anaesthesia techniques are strongly indicated in those patients. Good antinociception may be even more important than it is assumed today. Anand demonstrated a lower morbidity and mortality in 45 newborns undergoing cardiothoracic surgery, when general anaesthesia was performed with high-dose sufentanil versus halothane supplementary doses of morphine. Anaesthesiologists have to reconsider the quality of general anaesthesia: the antinociception of their regimen.

Anesthesia↗

PubMed2005

Arthrodesis of the first tarsometatarsal joint for correction of the advanced splayfoot accompanied by a hallux valgus.

OBJECTIVE: Arthrodesis of the first tarsometatarsal joint for the treatment of a painful splayfoot with the aim to restore a normal weight bearing on the first ray. Correction of hallux valgus deformity. INDICATIONS: Advanced splayfoot deformity with a first intermetatarsal angle > 18 degrees. Hypermobility of the first tarsometatarsal joint with reduced weight bearing on the first ray and development of a transfer metatarsalgia. Painful, primary or secondary osteoarthritis of the first tarsometatarsal joint. Recurrence of splayfoot deformity after previous attempt at surgical correction. Elevation of the first ray such as after developmental clubfoot. Metatarsus primus varus deformity accompanied by hallux valgus in the presence of a hypermobile flatfoot. CONTRAINDICATIONS: Minimal or moderate splayfoot deformity with a first intermetatarsal angle < 17 degrees and a clinically stable first tarsometatarsal joint. Untreated hindfoot deformities such as flatfoot combined with heel valgus. Inability to use walking aids for postoperative partial weight bearing. Insufficient circulation of forefoot. SURGICAL TECHNIQUE: Dorsomedial incision overlying the first tarsometatarsal joint. Splitting of the extensor aponeurosis medial to the tendon of the extensor hallucis longus. Subperiosteal exposure of the first tarsometatarsal joint. Opening of the joint. Judicious removal of articular cartilage and resection of a laterally based bony wedge from the medial cuneiform for correction of the increased first intermetatarsal angle. Manual correction of the splayfoot with concomitant plantar displacement of the base of the first metatarsal. Selection of properly fitting fixed-angle plate and internal fixation. Soft-tissue correction at the first metatarsophalangeal joint or metatarsal neck osteotomy to realign the articular surface of the first metatarsal head. RESULTS: Clinical and radiologic results based on 56 patients (64 feet) followed up for an average of 8.2 months. COMPLICATIONS: one reflex sympathetic dystrophy, four nonunions of the first tarsometatarsal joint (6.2%). Radiologic evidence of consolidation at a mean of 9 weeks. Improvement of the first intermetatarsal angle from 20.4 degrees to 11.2 degrees. Pressure measurement showed a significantly improved load-carrying capacity of the first ray. The score of the American Orthopaedic Foot and Ankle Society improved significantly (p < 0.01) from 51 to 92 points.

Arthrodesis↗

PubMed2005

[Tibiotalocalcaneal arthrodesis using a distally introduced femur nail (DFN)].

OBJECTIVE: Simultaneous arthrodesis of ankle and subtalar joints and, at the same sitting, correction of axial malalignment of hindfoot, treatment of bony defects and of sequelae of circulatory disturbances after multiple previous interventions. Internal stabilization with a short distal femur nail. Restitution of a pain-free weight bearing. INDICATIONS: Failure of arthrodesis of ankle and subtalar joint causing pain in patients with severely altered bone structures particularly at the level of the talar dome. Malalignment of hind- and/or forefoot after previous arthrodesis of ankle and subtalar joint. Failure of conservative therapy in both above-enumerated conditions. CONTRAINDICATIONS: Poor skin or soft-tissue conditions. Reflex sympathetic dystrophy. Acute osteitis/osteomyelitis. SURGICAL TECHNIQUE: Posterolateral approach. Resection of the articular cartilage and the areas of sclerosis of the ankle and of the posterior facet of the subtalar joint. Interposition of bone grafts harvested from the iliac crest. Correction of malalignment of hind- and forefoot. Locked nailing with a short distal femur nail. POSTOPERATIVE MANAGEMENT: Fitting of a flexible custom-made arthrodesis boot; weight bearing in boot not exceeding half of body weight until the 8th week. Gait training. After 12 weeks wearing of normal shoes. Radiographs after 6 and 12 weeks. RESULTS: Between February 1, 2002 and September 1, 2003 this technique was performed on 18 feet in 17 patients (three women, 14 men, average age 53 years [38.9-73.7 years]). Average duration of follow-up: 1.2 years (0.6-2.1 years). The goal of surgery was reached in all patients. Subjective assessment: 14 times good, three times satisfactory. Four complications: one loss of nail purchase, one dislocation of locking screw, one breakage of locking bolt, one prolonged bone healing.

Adult↗

PubMed2005

[Revision of failed ankle arthrodeses].

OBJECTIVE: Ankle arthrodesis with the foot at 90 degrees with minimal as possible leg shortening. Regain of a pain-free use of the limb. INDICATIONS: Failure of arthrodesis, septic or aseptic in origin, accompanied by pain interfering with weight bearing. CONTRAINDICATIONS: General surgical or anesthesiologic risks. Acute reflex sympathetic dystrophy. Significant arterial circulatory disturbances or extensive neurologic deficits. Extensive bone or soft-tissue defects after previous surgeries. SURGICAL TECHNIQUE: Approach using existing scars. Resection of nonunion making allowance for the planned position of arthrodesis. Removal of all necrotic bony and soft tissue. Posterior translation of talus by 1 cm. Autogenous bone grafting of major defects. Temporary fixation with a Kirschner wire with the foot at 90 degrees in the sagittal plane, in 0 degrees in the frontal plane, and 10-20 degrees of external rotation. Application of an external fixator, removal of Kirschner wire and compression of resection surfaces. If needed, apposition of cancellous bone harvested from iliac crest. Suction drain. Wound closure. RESULTS: Revision of arthrodesis in 13 men and three women (average age 48 years [27-76 years]). Average follow-up 10.8 months (3-26 months). In spite of problematic preoperative conditions (local infection eight times, malposition five times) a bony consolidation occurred in 15 of 16 patients, 14 times in a perfect position. Average leg shortening 2.8 cm (1-8.5 cm). Satisfactory soft-tissue healing in twelve patients. Superficial ulceration in two patients, fistula in one. Successful repeat revision of arthrodesis in one patient on account of persisting nonunion and infection.

Adult↗

PubMed2005

[Iliac crest bone graft with vascular pedicle for treatment of fibrous ankylosis of the ankle].

THE PROBLEM: 63-year-old man with a painful fibrous ankylosis of the left ankle in spite of two surgical attempts at arthrodesis. The subtalar joint had been fused 3 years previously during a reconstruction of the posterior tibial tendon. The severe, activity-related pain was partially due to a reflex sympathetic dystrophy. Wearing of orthopedic shoes did not relieve the symptoms; a below-knee amputation had been considered. THE SOLUTION: Tibiotalar arthrodesis in functional position with a free pedicled iliac bone graft. SURGICAL TECHNIQUE: Microsurgical harvesting of a pedicled iliac bone graft. Debridement of the fibrous ankylosis and transplantation of the bone graft into an anterior tibiotalar groove. RESULT: Bony fusion within 3 months. Pain-free weight bearing. The favorable outcome persisted after 1 year.

Ankle Joint↗

PubMed2005

Dorsal double-plate fixation of the distal radius.

OBJECTIVE: Restoration of the intra- and extraarticular anatomy of the distal radius. Stable internal fixation of fragments, with the possibility of early functional rehabilitation. INDICATIONS: Distal intraarticular radius fractures with impacted articular fragments and displaced dorsoulnar fragment. Distal intraarticular radius fractures with bony or ligamentous injury of the proximal carpal row. CONTRAINDICATIONS: General medical contraindications for surgical intervention. Distal radius fractures with palmar tilt of the distal fragment. SURGICAL TECHNIQUE: Dorsal longitudinal incision. Approach to the intermediate column via the third extensor compartment by detaching the extensor pollicis longus (EPL) tendon. Arthrotomy and revision of the proximal carpal row. Reconstruction of the radiocarpal articular surface and support with a plate applied to the dorsoulnar aspect. Approach to the radial column by subcutaneous preparation between skin flaps (cave: superficial branch of the radial nerve) and retinaculum, incision of the first extensor compartment and support of the radial column with a preshaped plate, which is pushed through under the tendons of the first compartment. Cancellous bone grafting is usually not necessary. Subcutaneous displacement of the EPL tendon with the aid of a small retinacular flap. MANAGEMENT RESULTS: Application of a removable velcro cuff. Immediate functional postoperative physiotherapy, without the cuff. No straining or forcing until first radiographic examination at 6 weeks after the operation. RESULTS: 25 consecutive patients were monitored following a double-plate fixation, with a minimum follow-up of 12 months. In all cases the reduction, in accordance with the Stewart Score, was very good, a loss of reduction was not observed. The range of motion was between 100 degrees and 160 degrees for flexion/extension and between 160 degrees und 180 degrees for pronation/supination. The average DASH Score was 7.2 points, the PRWE Score 8.0 points. No relevant loss of strength (JAMAR dynamometer) was found in any of the patients in comparison with the healthy side. Complications noted were a muscle adhesion in the region of the first extensor compartment as well as a mild reflex sympathetic dystrophy, which healed without consequences. Implants were removed from six of the patients.

Adolescent↗

PubMed2003

[Recent trends in understanding and therapy of complex regional pain syndromes].

Since the term "complex regional pain syndromes" (CRPS) was introduced based on a revised taxonomy for disorders previously called reflex sympathetic dystrophy and causalgia in 1995, much knowledge grew up on the understanding and therapy of the disease. This review gives an overview on the clinical characteristics, pathophysiology, diagnostic tools and therapeutic options in CRPS. It will especially focus on recent findings on the role of the sympathetic nervous system, the central nervous system and peripheral inflammatory processes as underlying mechanisms. Although there is no diagnostic gold standard, careful clinical evaluation and additional apparative test procedures are very helpful for the diagnosis. An early and interdisciplinary approach is the basis for an optimal and successful treatment.

Causalgia↗

PubMed1999

[Complex regional pain syndrome. Clinical and autonomic disorders during acute and chronic illness stages].

In order to describe autonomic dysfunction and clinical outcome in complex regional pain syndrome (CRPS) 20 patients were followed-up. First investigation was performed in the acute stage of CRPS and the second investigation two years later after therapy (individual, not standardized). Skin temperature and sudomotor function (thermoregulatory sweating (TST) and quantitative sudomotor axon reflex (QSART)) were assessed, and a clinical follow-up was performed carefully. Skin temperature was warmer on the affected side at first investigation (p < 0.001) and colder at follow-up (p < 0.02). Sudomotor output was enhanced on the affected side both after TST (p < 0.005) and QSART (p < 0.05) at first investigation. At follow-up, however, while thermoregulatory sweating was still increased (p < 0.04) QSART was not different. While autonomic failure improves as assessed by clinical examination, therapy failed to alleviate pain significantly. But patients' self-assesment of therapy was mostly positive (16 of 20, p < 0.001). The present study has shown that the autonomic failure may be probably the result of central disturbances of thermoregulation, but secondary peripheral mechanisms also contribute to our findings. Individual based therapy seems to be efficacious for long term treatment, but for final judge controlled studies are required.

Adult↗

PubMed2001

Calcineurin-inhibitor induced pain syndrome (CIPS): a severe disabling complication after organ transplantation.

Bone pain after transplantation is a frequent complication that can be caused by several diseases. Treatment strategies depend on the correct diagnosis of the pain. Nine patients with severe pain in their feet, which was registered after transplantation, were investigated. Bone scans showed an increased tracer uptake of the foot bones. Magnetic resonance imaging demonstrated bone marrow oedema in the painful bones. Pain was not explained by other diseases causing foot pain, like reflex sympathetic dystrophy, polyneuropathy, Morton's neuralgia, gout, osteoporosis, avascular necrosis, intermittent claudication, orthopaedic foot deformities, stress fractures, and hyperparathyroidism. The reduction of cyclosporine- or tacrolimus trough levels and the administration of calcium channel blockers led to relief of pain. The Calcineurin-inhibitor Induced Pain Syndrome (CIPS) is a rare but severe side effect of cyclosporine or tacrolimus and is accurately diagnosed by its typical presentation, magnetic resonance imaging and bone scans. Incorrect diagnosis of the syndrome will lead to a significant reduction of life quality in patients suffering from CIPS.

Adult↗

PubMed1999

The contribution of bone scintigraphy in occupational health or medical insurance claims: a retrospective study.

Patients with a suspicion of bone damage following an industrial or traffic accident are often referred for bone scintigraphy as part of an occupational health or medical insurance investigation. The aim of this study was to assess the contribution and the potential role of bone scintigraphy compared with X-ray investigations in the aforementioned situation. To this end we evaluated 70 consecutive patients referred for bone scintigraphy during 1996 and 1997 by occupational health or medical insurance physicians. The most common reasons for referral were the exclusion of occult fractures of hands and feet, whiplash injuries, reflex sympathetic dystrophy or avascular necrosis, or the differentiation between an old and a recent vertebral fracture. X-rays were only available for comparative review of 53 patients, so only those were analysed. The results of bone scintigraphy were compared with X-rays, and their contribution and potential role in occupational health or medical insurance investigations assessed. In 31 out of the 53 patients investigated, bone scintigraphy findings concurred with X-rays as to the number and location of abnormalities. For 19 of the 53 patients, bone scintigraphy showed clinically relevant additional foci when compared with X-rays, predominantly involving lesions to hands/wrists and feet/ankles. Among these 19 patients, scintigraphic diagnoses were subsequently confirmed in ten cases by means of X-ray or computed tomography. In four patients, supplementary radiological investigations revealed no abnormalities, and in five patients no further investigations were undertaken. Finally, in three of the 53 patients, X-rays revealed bone damage (burst fractures) whilst the corresponding bone scintigraphy was negative, thus excluding recent injury. In conclusion, in 22 patients, representing 42% of the cases analysed, bone scintigraphy was conclusive compared with X-ray imaging in the final diagnosis and in this way in detecting occult or excluding active bone damage after a traffic or industrial accident. This makes bone scintigraphy a useful investigation in situations where a full or partial disablement claim has to be confirmed, extended or terminated.

Accidents, Occupational↗