Introduction: We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery.

Materials and Methods: We have studied 47 patients over period of 9 months in 2007–08. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mamp stimulus to detect the nerve. The data was compared statistically between group A and B.

Results: Average subjective pain scores in group A were reported to be 1.2 at 30 min, 1.23 at 6 hrs, 2.1 at 12 and 3 at 24 hrs. Where as in group B it was 1.2, 7.2, 8.1 and 4 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. There was statistically significant difference in pain scores at 6 and 12 hrs. There was no statistically significant difference in pain scores at 30 min and 24 hrs.

Conclusion: Popliteal block offers an effective way of pain relief in ankle and hind foot surgery. We believe that it may reduce amount of anaesthetic or anaelgesic drug requirement as well.

Background: Although bone marrow edema (BME) of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool.

Methods: 70 patients (36 female, 34 male) were investigated in this controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS).

Results: The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in nonaffected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau). Implicating a threshold value of VAS 2.0 for a tapping test to be positive in the distinction of BME affected quadrants of group 1 and all quadrants of group 2 sensitivitiy was 90.4%, specitivity 83.7%, positive predictive value 73.4% and negative predictive value 94.6%.

Conclusion: The tapping test is a good screening instrument to diagnose BME in the knee.

Hallux varus is a rare cause of pain in the foot mostly occurring after failed hallux valgus surgery. We reviewed 12 patients with unilateral hallux varus treated with soft tissue techniques (4x), arthrodesis of the first metatarso-phalangeal joint (3x) or with a distal chevron osteotomy (5x) with medial transposition of the first metatarsal head and reconstruction of the soft tissues on the lateral side of the metatarsophalangeal joint. 10 patients had previous hallux valgus surgery, in 2 cases the deformities were of unknown origin. 1 male and 11 female patients were followed up on average 26.4 months postoperatively. AOFAS hallux score improved from 46 (range 10–75) to 86 (range 72–95) points. The metatarsophalangeal angle measured with the center-head to center-base method was reduced from −16.1° (range −35° to −8°) to 5.1° (range −15° to 21°). The intermetatarsal angle increased from 5.8° (0–11°) t o 10.5° (0–19°). All patients were subjectively satisfied with the procedure. Our results indicate that joint preserving operation techniques are viable methods in the correction of mild and moderate symptomatic hallux varus deformities. Mild remaining varus deformities are well tolerated.

In case of severe varus deformity or major signs of osteoarthritis in the first metatarsophalangeal joint MTP arthrodesis provides good results.

Pain free function of the thumb carpometacarpal (CMC) joint is essential for manual work. Osteoarthrithis of the thumb saddle joint is very common. Among different conservative and operative treatment options (ergotherapy, intraarticular infiltration, ligament reconstruction, resectionarthroplasty, arthrodesis, spacer), the implantation of a prosthesis is an alternative. This prospective study reports short time results of the uncemented hydroxilapatite coated Ivory prosthesis. The mean follow up time of the 21 patients was 12.1 months (range 6 to 18 months) and the mean age 57.2 years. The patients suffered from osteoarthritis of the thumb saddle joint stage II–III according to Eaton Littler. We evaluated the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS), clinical (abduction, flexion, strength) and radiological outcome.

The clinical results showed excellent pain relief with an improvement of the VAS from 7.3 preoperative to 0.8 postoperative (p< 0.05) and a decline of the DASH score from 42.9 to 6.05 points (p< 0.5). We measured an abduction with a mean of 47.5° and a flexion with a mean of 43.2°. The power of the fist grip was in mean 31.3 kg, of the key grip 6.4 kg. Radiological there were no signs of implant loosening. As complications occurred one posttraumatic trapezium fracture with luxation and one tendovaginits De Quervain.

The advantage of a total replacement of the CMC I joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb and so better strength. Our results are encouraging, but we have to wait for long time results mainly concerning implant loosening. In the case of the trapezium fracture with luxation we could remove the prosthesis and performed a resectionarthroplasty.

Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease.

We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice.

The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11).

Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.

An unstable CMC I joint causes pain and dysfunction. Chronic subluxation can lead to cartilage damage and furthermore to rhizarthrosis. This study should evaluate the results of the Eaton Littler ligament reconstruction, in which a slip of the Flexor carpi radialis tendon (FCR) weaved through the basis of the first metacarpal and around the tendon of the Abductor pollicis longus and back to the FCR. Aftertreatment consists in 4 weeks cast, 4 weeks thermoplastic splint and physiotherapy, full opposition is allowed after 8 weeks.

We performed 10 operations in 8 patients with a mean age of 35.9 years (6 female, 2 male). In 8 times the diagnosis was a rhizarthrosis Eaton Littler stadium I and in 2 times a posttraumatic instability. The mean follow up time was 15.4 months. We evaluated subjective satisfaction with the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS) and the patients were asked, if they would undergo the operation again. Furthermore the range of motion (ROM) was examined, the strengths (key and pin grip) were measured and radiographs were made.

All patients would undergo the operation again. The mean DASH score was 17.4 points, the mean VAS in rest 0 and under stress 1.29. The mean pin grip strength was 3.98 kg and the mean key grip strength 7.14kg. The ROM was excellent with a mean anteposition of 39.5°, a mean abduction of 49.3°. The mean thumb opposition was Kapandji 9.9. Radiological there was no progression of the Eaton Littler stadium. As complications occurred 1 keloid and 1 hypaesthesia.

Our experiences with the Eaton Littler procedure for stabilisation of the hypermobile thumb saddle joint were positive. Long time results will show, if the procedure can prevent cartilage damage and progression of rhizarthrosis.

Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES.

The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES.

Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months).

The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.

Bone marrow edema (BME) is a rare cause of pain in the foot.

We reviewed 19 patients with unilateral bone marrow edema of ischemic, stress or osteoarthritic origin located in the hindfoot treated with the vasoactive prostacyclin analogue iloprost. The patients’ mean age was 61,5 years (25–76) and the duration of symptoms lasted 19 weeks before the therapy started. Bone marrow edema was located 9x in the talus, 3x in the calcaneus, 3x in the navicular bone and 2x in the cuboid. 11 cases were estimated to have a primary ischemic origin, the other 8 ones to be secondary to an activated osteoarthritis or to mechanic stress. Our therapy consisted of a series of five infusions with 20 μg (50 μg in the first six patients) of iloprost given over 6 hours on 5 consecutive days each. Mazur’s foot score was used to assess function before and 3 months after therapy.

During this time, the score improved from a mean of 54,9 (range 23–73) before to 87,8 points (47–100) 3 months after therapy, with the best results in ischemic lesions with an improvement from 56,2 to 93,9 points and inferior results in patients with osteoarthritic edema as well as edema due to stress with a change in the score from 53 to 79,3 points. Magnetic resonance imaging showed complete recovery of the bone marrow edema within 3 months in 12 patients, 3x partial regression and no change in 4 cases with bone marrow edema due to activated osteoarthritis.

We conclude that the parenteral application of the vasoactive drug iloprost might be a viable method in the treatment of bone marrow edema of different origins but especially in ischemic ones. In edema secondary to osteoarthrosis or stress, therapy effect with iloprost is of a symptomatic character depending on the grade of the basic disease.

Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool.

70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS).

The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau).

The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI.

The tapping test is a good screening instrument to diagnose BME in the knee.

For surgical treatment of hallux rigidus many different procedures have been described. Resection arthroplasty (‘Keller procedure’) is a surgical procedure mostly used for older patients suffering from severe osteoarthritis of the first metatarsophalangeal joint. As a modification of this procedure, resection arthroplasty is combined with cheilectomy and interposition of the dorsal capsule and extensor hallucis brevis tendon, which are then sutured to the flexor hallucis brevis tendon on the plantar side of the joint (capsular interposition arthroplasty, IA).

Capsular interposition arthroplasty was performed on 22 feet of 14 patients (six male, eight female) suffering from osteoarthritis of the 1st MTP-joint were included in this study (group 1). These results were compared to the outcome of 30 feet of 22 patients (12 male, 10 female) treated with resection arthroplasty (group 2). The indication for resection arthroplasty were the same as for IA. The mean age was 55.3 years (37.6 to 71.2) in group 1 and 57.8 (43.5 to 75.6) in group 2. The age distribution of our patients at surgery did not differ significantly between both groups (p=0.633). The mean follow-up period was 15.1 month, range 6 to 27 months and did not differ between both groups (group 1: 16.5 month, group 2: 14.1 month; p=0.143).

The mean follow-up period was 15 months. No statistically significant difference was found between both groups concerning patient’s satisfaction, clinical outcome and increase in range of motion of the first metatarsophalangeal joint. At follow-up, patients who had undergone interposition arthroplasty did not show statistically significant better AOFAS forefoot-scores compared to the Keller procedure group. A high rate of osteonecrosis of the first metatarsal head was found in both groups. These radiological findings did not correlate with the clinical outcome at follow-up.

There is no benefit in clinical or radiological outcome for capsular interposition arthroplasty compared to the Keller procedure.

Introduction: Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a rarely seen disease associated with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition.

Materials and Methods: We treated 4 postpartum women (6 hips) presenting with femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing.

Results: Symptoms regressed rapidly during and after therapy. After 4 weeks, all patients were asymptomatic with no limitations in ambulation. In the magnetic resonance imaging assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck was found in one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (range, 14 to 43 months).

Conclusion: The vasoactive drug iloprost has good analgesic potency in the treatment of postpartum women suffering from BMES and accelerates the natural benign course of the disease.

Introduction: Intra-articular migration of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease.

Materials and Methods: We reviewed 8 patients (4 women, 4 men) with unilateral BMES located in the knee. The patients were aged 39 to 56 years (mean 50.2). In all the patients, bone marrow edema found in the primary magnetic resonance imaging (MRI) migrated within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice.

Results: MRI showed complete restitution in 6 cases and small residual edema in one case. A final MRI control was not obtained in one painless patient. In one patient, avascular necrosis of the contralateral hip was evident after 16 months. Improvement of the MRI pattern was correlated with the clinical outcome in all patients. All patients became asymptomatic after a mean of 9 months (range, 6–11).

Conclusion: Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.

Introduction: Although bone marrow edema (BME) of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool.

Methods: Seventy patients (36 women, 34 men) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS).

Results: The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau).

Conclusion: The tapping test is a good screening instrument to diagnose BME in the knee.

Introduction: Ulnocarpale Impaction Syndrom is defined as a degenerative disease on the basis of a relative mis-proportion in lenghth ratio between ulnar and radius, caused either by posttraumatic degeneration or idiopathic history. This causes an unusual high load bearing in the ulnar carpale joint as well as in the distal radio – ulnar joint. All these factors lead to a degeneration of the triangular discus, secondary lunotriqutral instability and chondromalazia of ulna, lunate bone and the triquetral bone.

Ulnocarpale Impaction Syndrom is diagnosed by clinical evaluation as well as typical radiologic findings. If non operative treatment leads to unsatisfactory results few operative options can be considered. Ulnar shortening osteotomy is one of them.

Material and Methods: From 2003 until 2006, 10 Patients were treated. 3 female patients and 7 male patients, with an average age of 46 years and/or 42,7 years were operated on. We evaluated forearm rotation, power, DASH Score, Numeral Analogue scale and radiologic findings considering ulnar lenghth and bone consolidation.

Results: Painfree forearm rotation increased significantly postoperatively. An increase in power was seen as well as a reduction of the DASH score of 51,6 points. Also the numeral analogue scale showed a reduction of 5 points. Postoperatively the ratio of ulnar to radial lenghth was nearly equal (average of ulnar -1mm) and all osteotomies showed normal bony healing.

Conclussion: Surgical therapy of painful ulnar impaction syndrom using ulnar shortening osteotomy seems to be a very feasible and practical procedure. In comparison to resection arthroplasty and the wafer procedure, ulnar shortening osteotomy shows no significant increase of pressure in the sigmoid fossa. Therefor it is the treatment of joice in our departement.

Background: Recent studies of arthroscopic rotator cuff repairs have shown high failure. The different suture configurations were mostly tested in non degenerative animal tendon specimen. We used instead fresh-frozen degenerative human cadaver rotator cuffs. The goal of this study was to determine the biomechanical properties of commonly used arthroscopic stitches in ruptured human cuffs in comparison to intact rotator cuffs.

Method: 36 human rotator cuff tendons were harvested, documented according to size, thickness and location of rupture, and divided into a ruptured and non ruptured specimen group. We found 12 ruptured and 24 intact cuffs. Three stitch configurations (simple, horizontal, and massive cuff stitch) with a Fiber Wire 2 (Arthrex) were randomized and biomechanically tested in each set of tendon specimen. The specimen were mounted on a uniaxial load machine (ZM200, Fa Shokoohi) and loaded to failure under displacement control at a rate of 0.6 mm/sec. Ultimate tensile load, and type of failure were recorded.

Results: Ultimate tensile load was significantly higher (p < 0.05) for the massive cuff stitch (186 ± 12 N) than it was for either the simple stitch (102 ± 9 N) or the horizontal stitch (138 ± 10 N) in the intact cuff cohort. In the ruptured cuff group ultimate tensile load was significantly lower (p < 0.05) for the massive cuff stitch (115 ± 12 N), the simple stitch (77 ± 9 N), and the horizontal stitch (103 ± 10 N) in comparison to the intact cuff group. The simple and horizontal stitches failed by tissue pull-out in both groups, whereas the massive cuff failed by pull-out and once by suture breakage in the group of intact cuffs.

Conclusion: Ruptured rotator cuffs showed significant less biomechanical strength concerning all three stitches in comparison to the intact cuff group. Overall the massive cuff stitch showed superior ultimate tensile load.

Bone marrow edema is a common cause of pain of the locomotor apparatus. We reviewed 50 patients (28 male, 22 female) with bone marrow edema of the knee. The patients mean age was 56.2 12.8 years. 8 cases were estimated to have an idiopathic BME, 10 posttraumatic and the other 32 ones to be secondary to an activated osteoarthritis or to mechanic stress. Iloprost is a vasoactive prostacyclin analogue. Therapy consisted of a series of five infusions with either 20 or 50g of iloprost given over 6 hours on 5 consecutive days each. Pain at rest as well as under stress were assessed with a semi quantitative scale from before and 4 months after therapy. MRI investigations were done before and repeated 4 months after therapy.

At the clinical follow-up 4 months after therapy, pain level at rest had diminished 84% (p < 0.0001). 70% of patients referred about a reduction, 30% about no change. Pain under stress decreased 57%, (p < 0.0001). 76% of patients showed lower pain under activity, 24% no change from baseline. There was no increase of pain level in any patient. In MRI in 85% a significant reduction of the BME size or complete restitution could be observed, 15% showed no change. Response rate to iloprost infusions came to 100% in idiopathic, 100% in posttraumatic and 66% in secondary BME. A significant reduction of side effects could be reached by lowering the daily dosage from 50 to 20g.

The authors conclude that parenteral application of iloprost might be a viable method in the treatment of BME of different origins.

Introduction: Bone marrow edema (BME) is a common cause of pain in the knee with restricted treatment options. The authors performed a double-blind, randomized, active-controlled study in order to explore the clinical effects of the prostacyclin analog iloprost (Schering AG, Germany)

Materials and Methods: Forty-one patients with painful bone marrow edema associated with osteonecrosis, osteoarthritis, bone bruise or axis deformities were evaluated. Patients were randomized either to iloprost (n=21, 15 male, 6 female; mean age 53 years) or to Tramadol (n=20, 12 male, 8 female; mean age 51 years). An individual dose adjustment was allowed within the range of 100–300 μg of iloprost, and 100–300 mg of Tramadol. The treatment duration was 4 weeks. The treatment period was followed by an 8-week treatment-free follow-up. During and after treatment, full weight bearing was allowed as tolerated. Efficacy of treatment was assessed by 10 cm visual analog scales for pain at rest and on exertion, Larson’s knee score, and magnetic resonance imaging.

Results: The results are presented below.

These clinical effects were sustained over the entire follow-up. At the end of study, 53% of iloprost patients showed healing of at least one BME affected bone as compared to only 19% of Tramadol patients. Regression of subchondral lesions occurred in 4 iloprost patients. No serious adverse events occurred; however, three Tramadol patients discontinued the treatment prematurely due to adverse events.

Discussion: The authors conclude that the oral application of the vasoactive drug iloprost results in substantial treatment effects on pain relief and joint function improvement. These effects were similar for iloprost and Tramadol. Iloprost treatment was associated more often with BME regression than Tramadol. Oral iloprost may offer a new and safe treatment option for patients with painful BME.