Arthrorise
The arthrorise (synonym Arthrorhise, Arthroroesis; ancient Greek. Ἄρθρον arthron , 'joint' and ereisai , 'support, lean firmly') is an orthopedic surgical procedure by which the mobility of a joint is restricted by creating an obstacle outside the joint capsule, without opening the joint. This can be a screw or a bone chip.
The arthrorise that is most commonly performed is the subtalar arthrorise, used to treat a flexible arched foot with blockage of the lower ankle.
Subtalar arthrorise
This is by far the most common arthrorosis, all other forms are performed very rarely. In the subtalar arthroereisis a screw or a bone graft is outside under the ankle bone (talus) in the tarsal sinus introduced. This corrects the valgus position or hyperpronation of the heel bone against the ankle bone in the lower ankle , which is responsible for the buckle foot.
DS Grice originally proposed an extra-articular arthrodesis in 1952 , in which a bone block firmly connects the heel and talus bone. This procedure is still carried out in the case of severe hindfoot deformities, but leads to a complete and irreversible stiffening of the subtalar joint with loss of pronation and supination in this joint section. That is why S. Giannini developed an intervention in 1985 that does not require complete stiffening, but rather restricts mobility in hyperpronation. To do this, he inserted a Teflon plug ( Sinus tarsi spacer ) into the sinus tarsi . Later, numerous metal and absorbable screws, e.g. B. developed with polylactide . Attempts were also made to introduce bone chips, but these either led to osteoarthritis or were resorbed. On the other hand, bone dowels or screws still allow mobility and can be removed later if problems arise.
The screw or the dowel can either be inserted directly into the sinus tarsi or horizontally in the heel bone in the area of the sinus tarsi , thus blocking excessive pronation during pronation movement by pressing the dowel / screw against the ankle bone.
This procedure was modified in many ways, and in the 1990s it became a standard procedure in pediatric orthopedics, with a high market share from the manufacturers of screws and dowels. There are numerous studies with short and medium-term follow-up , but no randomized controlled trial and so far no long-term results. In particular, the comparison with a non-operated comparison group would be important, since the flexible buckle foot often shows an independent normalization after growth is complete. There are also no clinical studies that compare the various implants.
Indications
Typically, this procedure serves as a “growth control” in the case of severe, functional, unfixed knee or flat feet in 8 to 12 year old children, ie before growth is complete. The foot must be passively movable into the normal position without any problems. Before the age of 6, the procedure is only carried out in special cases, usually not after the age of 13.
In addition to the functional arched foot, the subtalar arthrorise can also occur in spastic arched arches such as infantile cerebral palsy , in malalignments due to hypotonic muscle diseases and in excess mobility, also due to connective tissue diseases such as Ehlers-Danlos syndrome , or after poliomyelitis and the like. a. can be applied. Others recommend an arthrodesis according to Grice instead of arthrorise in the case of neurological flat feet or excessive mobility.
Arthrorisis can also be performed in adults with a secondary arch malalignment due to a posterior tibial dysfunction , especially in stage II with functional and not yet fixed hindfoot malalignment.
Intervention
During the operation, a 1–2 cm long skin incision is made over the sinus tarsi . The extensor digitorum brevis muscle is held back dorsally, the extensor retinaculum is split over the cuboid , and the interosseous ligament in the tarsal sinus is located and divided. Then the sinus tarsi is opened further and expanded in the neutral position of the foot in order to insert the implant.
Occasionally, the arthrorise needs to be expanded to include other interventions. Occasionally, an equinus foot is found , which makes an Achilles tendon lengthening necessary. Or there is a painful bone prominence on the inside of the scaphoid bone , where this bone prominence or an occasional accessory bone , the os tibiale externum , is removed.
Currently u. a. Pro-Stop from Arthrex , AO cancellous screw / calcaneus stop / calcaneostop screw from Synthes , Subtalar Spacer Systems from Wright and Kalix from Newdeal used.
Postoperatively, a lower leg cast was often put on for three weeks, nowadays usually only a compression bandage is applied. Most of the time, partial weight bearing with forearm crutches is allowed, but 4–6 weeks of sports leave are prescribed. The procedure is usually carried out as a day inpatient or with an overnight stay in hospital.
Complications and results
Complications of the procedure are in particular pain in the area of the implant, which, however, can be eliminated by removing the material. The implant can loosen, migrate or break. The intervention can lead to increased stiffness in the lower ankle, and overcorrection or inadequate correction is also possible.
Osteonecrosis of the ankle bone has been described as a serious but rare complication .
In a follow-up examination, an AO cancellous bone screw was inserted on 226 feet in 152 children aged 10.6 years and on both sides in 74 children. The results were good to very good in 95%, 55 screws (24%) had to be removed after a mean 2.9 years.
Other rare arthrorise techniques
- In the past, a bone chip was used very often on the upper ankle , as a stop at the rear against increased plantar flexion (equinus foot) or at the front against increased dorsiflexion (heel foot), especially in the case of flaccid paralysis, e.g. B. after poliomyelitis . The "front stop lock", in which an inclined tibial chip was bolted from the front edge of the shin into the ankle, was first described by Putti. A tibial span was also used as a rear stop, and numerous surgical techniques have been described, as suggested by Lange, Campbell, Gill or Nové Josserand.
- A stop lock can be inserted at the front of the knee joint to limit the genu recurvatum in the case of flaccid paralysis . This procedure was often used for polio in the past, but is no longer used. In the Wollenberg technique, the tibial tuberosity was detached with the front edge of the tibia and moved proximally towards the knee joint. This arthrorise is actually intra-articular.
- On the forearm near the wrist , Manfrini described a radio - ulnar arthrorise for the treatment of the supination deformity in children with plexus paralysis .
- For the metatarsophalangeal joints of the fingers, there is a method of dorsal arthrorise in ulnar paralysis and claw hand malalignment, which is also used in claw hand position caused by leprosy .
Individual evidence
- ↑ a b c Fritz Hefti: Children's orthopedics in the practice Springer-Verlag Berlin 1997, ISBN 3-540-61480-X
- ^ A b S. Giannini, F. Ceccarelli, M. Mosca: Flat foot in children: Treatment with an endo-orthotic implant , Chapter 34, pages 253-258, in: Tomás Epeldegui Torre, Nikolaus Wülker (ed.): Surgical techniques in Orthopedics and Traumatology - Lower Leg, Ankle and Foot , Volume 8 of the EFORT series (Ed. Jacques Duparc), Urban & Fischer-Verlag Munich 2005, ISBN 3-437-22576-6
- ↑ a b John Corrigan: The buckled-sagging foot of the adult , Chapter 23 (pp. 152–161) in: Nikolaus Wülker, Michael M. Stephens, Andrea Cracchiolo III. (Ed.): Operations atlas foot and ankle, Thieme-Verlag Stuttgart 2007, 2nd edition, ISBN 978-3-13-142592-8
- ↑ TE Siff, WM Granberry: Avascular necrosis of the talus following subtalar arthrorisis with a polyethylene endoprosthesis: a case report Foot Ankle Int. 2000, Volume 21, Issue 3 of March 2000, pages 247-249
- ↑ M. De Pellegrin: 15 years of experience with subtalar screw arthrorise in children’s flat foot foot & ankle 2007, Volume 5, Issue 1 of February 2007, pages 12-20, doi: 10.1007 / s10302-007-0265-1
- ^ Pschyrembel : Clinical Dictionary , 256th edition, Walter de Gruyter Verlag Berlin 1990, page 132, ISBN 3-11-010881-X
- ^ A b Max Lange : Orthopedic-surgical operation theory 2nd edition, Springer-Verlag Berlin 1962, page 797, link
- ↑ Martin Kirschner: General and special surgical operations teaching , 2nd edition, Springer-Verlag Berlin 1956, 10th volume, part II, link
- ↑ M. Manfrini, L. Valdiserri: Proximal radio-ulnar arthrorisis in the treatment of supination deformity resulting from obstetrical paralysis Italian Journal of Orthopedics and Traumatology 1985, Volume 11, Issue 3 of September 1985, pages 309-313
- ^ L. Cornet: Posterior metacarpo-phalangeal arthrorisis. New corrective operation for claw-hand Journal de Chirurgie 1965, Volume 90, Issue 1, pages 45-50
