2010 : 30th YEAR OF ORTHOMED READ FOR YOU IN THE PROFESSIONAL PRESS Here are the various articles read for you in the professional press. Endoscopic treatment of the tarsal tunnel syndrome: a preliminary report 23 cases of use of beta-tricalcium phosphate for filling bone defects in the foot Treatment of 5th metatarsal base fractures in adults Use of bone substitutes to maintain the internal opening of a tibial valgus osteotomy.
ENDOSCOPIC TREATMENT OF THE TARSAL TUNNEL SYNDROME: A PRELIMINARY REPORT
A. VANNINEUSE, J.L. RAMANDROSOMANA
Médecine et chirurgie du pied, June 2002,Volume 18-Number 2, pages 93-98
The tarsal tunnel syndrome is caused by compression of the tibial nerve behind the medial malleolus. Surgical release of this nerve is sometimes proposed. Considering the interest of the endoscopic treatment of the carpal tunnel syndrome, it was very tempting to transpose this technique to the foot. However, it was necessary to ascertain the safety of the surgery in cadavers.
Material and method
Five tarsal tunnels were investigated in cadavers. Each time, the ORTHOMED instrumentation for treatment of the carpal tunnel syndrome was used.
To ensure reproducibility of the technique, anatomical landmarks had to be found and operative methods had to be defined. During the first dissection, the anatomical landmarks and contents of the tarsal tunnel were explored by targeted dissection gradually reconstituting the various steps of the endoscopic treatment. Then, four operations were performed under these conditions and checked for safety.
Results: the operative technique
1 ) Identification of anatomical landmarks: the medial malleolus and its posterior edge, the Achilles tendon, the upper edge of calcaneus, and the tibial artery by Doppler examination.
2) A longitudinal incision 2cm behind and above the medial malleolus, halfway to the Achilles tendon, above the upper edge of the calcaneus.
3 ) Separation of the deeper plane of the retinaculum with a spatula.
4 ) Bougie dilation up to a distal abutment.
5 ) Placement of the ORTHOMED instrument sheath.
6 ) Sectioning using a 3 mm knife under arthroscopy to avoid damaging the skin.
Indications and precautions
This surgery is reserved for patients resistant to conservative treatment (anti-inflammatories, infiltrations, rest). Formal contraindications are:
23 cases of use of beta-tricalcium phosphate for filling bone defects in the foot
L. GALOIS , D. MAINARD , P. COHEN , J.P. DELAGOUTTE
Médecine et Chirurgie du Pied , March 2001 , Vol.17 , Number 1 , pages 44 to 53
Calcium phosphate ceramics were initially used in odontology and maxillofacial surgery, then, commonly, in orthopaedic and traumatological surgery.
1) Their advantages:
full biocompatibility.
bioactivity, i.e. the ability to induce specific biological reactions.
porosity, which promotes cell and bone ingrowth, thereby supporting osteogenesis.
synthetic origin, which avoids immune intolerance problems and risks of virus transmission (sterilization by gamma irradiation).
2) The main disadvantage:
low mechanical properties due to porosity.
In this study, the product used was synthetic beta-tricalcium phosphate (PTCb) with the chemical formula Ca3(PO4)2 marketed under the name of BIOSORB.
3) The indications were the following:
5 benign bone tumours.
1 talus necrosis.
3 osteochondrites (talus and medial malleolus).
4 cases of trauma (fractures of tibial pilons, talus, fracture-dislocation of the tarso-metatarsal joint).
10 arthrodeses (subtalus, talonavicular, tibiotalal, hallux interphalangeal, Lisfranc).
4) Substitutes used:
granules (2 times)
blocks (21 times)
In 6 cases, an autograft has been associated.
5) Results:
a) The trauma conditions, osteonecroses and osteochondrites give the best results (100% with excellent and good integration), before arthrodeses (80%) and benign tumours (80%). There was no case of sepsis nor fibrous encapsulation.
Some results should be qualified:
There was only one case of osteonecrosis with a long integration time (60 months). No conclusion can be drawn from a single case.
In all cases of osteochondritis, an autograft has been associated. This has changed local conditions.
b) It takes a minimum of six months before the radiograph shows a significant change.
c) Full resorption of the implants requires an average of two years.
6) Discussion:
a) For benign tumours, osseous integration is slower in cortical bone than in cancellous bone. The results, however, are good in both cases.
b) The determining factors of osseous integration of tricalcium phosphate are:
well vascularized bone.
stable and intimate contact.
good initial stabilization of the operative site.
c) The osseous integration of ceramics in arthrodeses is generally satisfactory.
d) The indication in traumatology can be reconsidered if the loss of substance is limited.
e) The beta-tricalcium phosphate has greater solubility and resorption than hydroxyapatite.
f) Although there was no infection, this complication remains possible. There is an interesting research direction with trial incorporation of antibiotics into the ceramics.
g) The results appear better for small losses of substance. Large losses of substance do not lend themselves to the use of ceramics, probably because of the deficiency in osteogenic cells at the receptor site, due to the fact that tissue containing them is far.
7) Conclusion:
The main indication is the filling of moderate substance losses in benign to moderate trauma conditions. For arthrodeses, ceramics replace more and more the autograft.
The implantation specifications must be complied with:
strict asepsis
intimate contact
immediate good stability.
TREATMENT OF 5TH METATARSAL BASE FRACTURES IN ADULTS Médecine et Chirurgie du Pied, September 2001, Vol.17-Number 3, pp. 131-135
The base of the 5th metatarsus includes 3 distinct anatomical areas to which correspond 3 types of fractures:
1 ) The extra-articular styloid process.
The avulsion fracture of this process is probably due to tearing not by the peroneus brevis, as was long thought, but rather by the lateral band of the plantar aponeurosis. In fact, interfragmentary gaps are rare, whereas a pull by a strong muscle should be a contributing factor to displacement.
a) In the injured person capable of walking easily with crutches, undisplaced fractures will be treated by immobilization in a moulded plaster or resin cast for 3 weeks. For the others, a functional method will be chosen: elastic bandage, and shoes providing good support for the hindfoot and ankle.
b) Fractures with interfragmentary gaps will be treated surgically by reinsertion of the avulsed fragment using an anchor.
2) The proximal portion of the tuberosity, articulated to the cuboid.
A fracture at this site may displace secondarily, probably because of the pull exerted by the peroneus brevis.
a) Undisplaced fractures should therefore be strictly immobilized in a moulded plaster or resin cast for at least six weeks because the consolidation time is longer.
b) Primarily or secondarily displaced fractures will be treated by osteosynthesis providing interfragmentary compression: figure-of-eight cerclage or compression screwing.
3) The distal area of the base, at the level of the fourth-fifth intermetatarsal joint
Fractures at this site are called Jones’ fractures and are characterized by long consolidation times – 3 months in many cases – and frequent pseudarthroses.
a) Undisplaced fractures should be strictly immobilized for a prolonged period with no weight bearing allowed until consolidation.
b) Surgery is not reserved for displaced fractures. Even undisplaced fractures can be treated operatively when quicker return to work or sport is desired. Osteosynthesis requires fracture site compression. This is difficult with intramedullary screw fixation because of the curvature of the bone. The technique of choice is compression stapling, possibly using shape memory staples.
Use of bone substitutes to maintain the internal opening of a tibial valgus osteotomy.
Two papers on this subject were published simultaneously in Number 5 of Volume 88 (2002) of the Revue de Chirurgie Orthopédique.
The first paper is by J.-C. Bové: “Utilization of a porous alumina ceramic spacer in tibial valgus open-wedge osteotomy. ” (pp 480–485).
The author uses the spacer to maintain the opening during bone reconstruction. Stability is provided by internal plate osteosynthesis. The rectangular parallelepiped spacers maintain a tibial opening of 5 to 17 mm. They have a high mechanical strength and can withstand compressive forces up to 60 MPa (600 kg/cm2). With controlled porosity (about 60%), bone ingrowth can be expected.
A series of fifty cases is presented. Bone healing was achieved at 3 months on the average. Throughout the bone healing period, the ceramic spacer had the expected mechanical strength. There was no sign of intolerance, which corresponds to bio-inertia. If it is true that rehabilitation is correlated with the absence of radiolucent lines, the interest of porosity is confirmed by the paucity of radiolucent lines and their tendency to disappear.
The qualities of the ceramic suggest that the spacer could be left in place for later arthroplasty.
The second paper, by P.Bonnevialle, A.Abid, P.Mansat, L.Verhaeghe, D.Clement, M.Mansat, is entitled: “Tibial valgus osteotomy using a tricalcium phosphate medial wedge” (pp 486–492).
The wedges were shaped to rhomboid parallelepideds with medial heights of 6 to 15 mm. The porosity is 30% by volume. The ultimate compressive strength is greater than 80 MPa.
The operative technique is described. It is a minimally invasive technique using staples for osteosynthesis.
The series comprises fifty-five patients. Bone healing was achieved at 3 months in 42 osteotomies, and at 6 months in all cases. There was no loss of the osteotomy angle. The degradation rate of the substitute was constant and favoured by the broad contact surface, compression, and the cancellous site. The bone stock is restored in a few years. Degradation, however, seems to fail beyond 5 years.
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