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We growth disturbances are less likely to occur in the lower do not take the growth plate into consideration in chil- extremity compared to the forearm in connection with dren of 10 years or older as the distal femoral epiphyseal multiple osteochondromas artane 2mg free shipping, they are still encountered plate contributes to subsequent growth by no more than fairly often quality artane 2 mg. Depending on the patient’s expected only occur sporadically generic artane 2mg free shipping, whereas axial deviations are final height we perform surgical closure of the contra- more common 2mg artane. As mentioned above, non-ossifying bone lateral epiphyseal plate concurrently with the resec- fibromas do not require treatment. Growth disturbances tion or we schedule a lengthening procedure at a later arise particularly in connection with enchondromatosis date. Malig- length discrepancy can become considerable, but here too nant degeneration is less likely to occur in enchondromas the resection must naturally include a margin of healthy around the knee than in those close to the torso, for tissue. One alternative to amputation is rotationplasty , example in the pelvis or the torso itself [4, 18]. Chon- as first described by Borggreve and later by Van Nes droblastomas, chondromyxoid fibromas, giant cell tumors, for the treatment of congenital defects. In this pro- osteoblastomas and aneurysmal bone cysts should be com- cedure the knee is resected and the lower leg with the pletely resected with a margin of healthy tissue if pos- foot – rotated through 180° – is anchored to the femur. Since they usually grow in the vicinity of the joint As a consequence of this operation the upper part of the cartilage or epiphyseal plate en-bloc resection is rarely ankle functions as the knee ( Chapter 4. Careful curettage is required in such cases (see the rotated foot is difficult for the parents and child to chapter 4. The recurrence rate of accept psychologically, the functional advantages these tumors can be reduced from over 50% to less than over amputation are so great that the esthetic disadvan- 10% with effective curettage [15, 26]. If the fibular head tages usually become well tolerated with time [17,18, 23, needs to be resected because of a tumor, a corresponding 46] ( Chapter 4. A rotationplasty is also a suitable replacement must be constructed in order to provide an »salvage operation« in cases of infection or the failure of anchoring point for the lateral collateral ligament and the prostheses or allografts. AP MRI and lateral x-ray (a) of the left knee of a 15- year old boy with a giant cell tumor in the area of the fibular head. The patient’s knee is very stable for the complete distal femur or proximal tibia is feasible (⊡ Fig. The advantage of the allograft over a joint prosthesis is the possibility of preserving the part of the joint opposite the tumor. At the proximal tibia this provides a better anchoring option, compared to a b prosthesis, for the patellar tendon (and thus the complete extensor apparatus). Although considerable experience – up to 36 years – has been accumulated with the use of such large allografts, certain disadvantages should be Reconstruction options mentioned: for example, joint function is not usually very The treatment of malignant tumors of the distal femur good, the mechanical strength is inferior to that of metal or proximal tibia is usually associated with the loss of all implants, and the complication rate is very high (40% or part of the joint surface. Only those tumors located fractures, 15% infections) [9, 12, 19, 30, 36]. The recon- become a standard method of treating malignant tumors structive measures in this case are limited to the anchor- in the knee area. These are modular prosthesis with resec- ing of the lateral ligamentous apparatus of the knee. The fem- many cases, however, the peroneal nerve also needs to oral and tibial sections are firmly linked by a hinge joint. The most widely-used surface must be removed as well then reconstruction will prostheses in Europe are the implant developed by Kotz be required ( Chapter 4. We In our experience, the use of allografts in the knee routinely use such prostheses particularly for tumors of area has not proved effective particularly in those cases the distal femur (⊡ Fig. Since the anchoring point in which only a part of the joint surface of the femur or of the extensor apparatus can be preserved, the functional tibia has to be removed. The short- and medi- as the anchorage for the patellar tendon is inadequate on um-term results of treatment with tumor prostheses are the tumor prosthesis. With an allograft however, the fixed very good, although long-term results, for example tendon can integrate with the allograft, which is not pos- over a period of 50 years and more after the implantation sible with a metal implant (⊡ Fig. The soft tissue covering occasionally represents a We have not had much experience with the combination critical problem, hence the frequent use of gastrocne- of a homogenous osteocartilaginous graft (allograft) 3 b ⊡ Fig.
The fixation of the deformity must be pre- risk of recurrences buy discount artane 2mg on-line, consistent follow-up orthotic manage- vented by bringing the foot into an anatomically correct ment is required buy 2mg artane with visa. The foot position can also be corrected position order artane 2mg online, otherwise a progressive clubfoot deformity will with a muscle transfer with the aim of balancing the mus- result in a deterioration in walking ability generic 2 mg artane amex. If the spasticity is strongest in the tibialis anteri- pinated during the swing phase and strikes the ground in or, the best option is to transfer the whole muscle distally this position, resulting in instability in the stance phase. Since, in addition to the clubfoot position, a bone tunnel and then sutured back on itself. However, an equinus foot is also usually present at the same time, the tibialis posterior should not be transferred completely, both deformities can be corrected with the one orthosis. The increased supination of the foot is generally based A more suitable procedure is the split transfer: The on tibialis posterior muscle hyperfunction. Provided no tendon is exposed at its distal end and divided, and the bone deformities have developed, the injection of botu- lateral half is pulled laterally behind the tibia and sutured linum toxin is an elegant method of inactivating this to the peroneus brevis tendon. Since this muscle is located deep in if the muscle has already become contracted by this stage: the tissues and is relatively thin, we prefer to perform this In this case, one half of the tendon would need to be injection under ultrasound control. But since the is also producing a deforming effect then this muscle can tendon of the tibialis posterior muscle is usually too thin be included in the injection treatment. While good results are re- and may also be indicated in those who cannot walk in ported in the literature for both muscle transfers, our own order to alleviate pain, resolve major problems or possibly experience has dampened our expectations of this opera- to simplify the provision of footwear. Nevertheless we have also used the tendon transfers all contracted muscles is a simple surgical option. If bone deformities already exist, an improvement, but not a full correction, can be achieved with purely soft tissue procedures. The arches are flattened out, the heel is in a valgus position and the forefoot is abducted. This foot position progressively leads to subluxation and a b eventually to dislocation between the talus and navicu- lar or between the navicular and the distal tarsal bones, ⊡ Fig. Schematic view of the direction of traction exerted by the Achilles tendon in the anatomical position (a) and with subluxation as well as subluxation in the lower ankle. F Direction of the Achilles tendon which, in the position of the calcaneus progresses, the 5th ray is pulled case of subluxation in the lower ankle, exerts a force in line with the laterally, in turn pulling the 1st ray as well. The triceps su- lower leg Fk and a dislocated force component Fi rae muscle becomes contracted since the deviation of the calcaneus into the valgus position brings the origin and insertion of the triceps surae muscle closer together. The contracture of the triceps surae muscle leads, in turn, to a direction, resulting in an internal rotation of the leg. This progressive valgus position, since the muscle is evidently internal rotation combined with a flexed knee simulates a not as extensible as the joint capsules in the tarsal bones pronounced valgus position. As a result, although the whole foot (including the control is good enough to benefit from mobility, a spring heel) may strike the ground, the triceps surae muscle orthosis may be used as this is less irksome. Otherwise a can, in severe abducted pes planovalgus, be greatly con- rigid orthosis is indicated. If the plantarflexed foot is placed in maximum If there is minimal or no spasticity and adequate dor- supination and adduction (thereby reducing the tarsal siflexion in the upper ankle, a good insert in a shoe with bones) and then dorsiflexed, the extent of the shorten- medial and lateral stabilization will suffice. If must incorporate a medial, plateau-shaped support whose this deviant position of the foot is present permanently dorsal section rests under the medial part of the calcaneus or for most of the time, the foot skeleton will grow into so that the calcaneus is placed in a sufficiently varus posi- this abnormal shape (with shortening of the 5th ray and tion that it remains under the talus even during weight- an excessively lengthened 1st ray). This reduction of the calcaneus will also correct dislocation in the rearfoot will become fixed. In extreme the abnormal posture of the forefoot, the flattening of the cases the patient will be standing on the talus and the foot longitudinal arch and the abduction. Instead of shoe adaptation, we have started a result of the flattening of the foot arch and partly as a employing foot orthoses consisting of an insert and sta- result of the outward rotation. This loss of stability leads bilizer, and which cover the hindfoot up to the malleoli, to a functional pes calcaneus position with increased flex- as these provide greater stability and fit in normal shoes. At the same time, the foot skeleton twists If a slight contracture of the triceps surae muscle is also as the talus slides down off the calcaneus in a medial present, it can be lengthened by means of a spring orthosis 433 3 3. The patient is able to stand in a plan- tigrade position on the ground, but only on the talus (a). Same foot in maximum dor- siflexion after reduction in the lower ankle (b). To this end, the orthosis is adapted according to the existing muscle contracture and the equinus foot position is progressively reduced over several months.
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