ORTHOPEDIE

CENTRUM ORTHOPEDIE

ARTIKELS

ABSTRACT 1

High-resolution cone-beam computed tomography is a fast and promising technique to quantify bone microstructure and mechanics of the distal radius

Mys K, Varga P, Stockmans F, Vanovermeire O Calcified Tissue International, 108 (3), 2021, 314-323

ABSTRACT Het abstract is na te lezen op p.35

ABSTRACT 2

Avascular necrosis of the foot and ankle in a patient with systemic sclerosis: a case based review

Wastyn H, Leys M, Deleu A, Michels F, et al. Modern Rheumatology Journal, 2021, 15(1), 94-97

ABSTRACT This report describes a case of atraumatic avascular necrosis in the foot and ankle in a patient with systemic sclerosis who did not receive corticosteroid therapy.

Both avascular necrosis and systemic sclerosis are uncommon disease entities. This case depicts that the vasculitis and secondary vasoconstriction in the pathogenesis of systemic sclerosis are important risk factors for the development of avascular necrosis of the foot and ankle.

Therefore, if these patients develop chronic foot and ankle pain, avascular necrosis should be included in the differential diagnosis, even if they do not receive corticosteroids. MRI remains the gold standard for avascular necrosis diagnosis and follow-up. It should be used to diagnose AVN in an early stage. ABSTRACT Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus.

The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. The study consisted of 2 parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of 2 lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling.

Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8±3.0 mm (0-10.4 mm). The mean distance between both observers was 4.2±3.2 mm (0-10.3 mm). The mean distance to the sural nerve was 1.4±2 mm (0-5.8 mm). The mean distance to the peroneal tendons was 7.3±3.1 mm (1.2-12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. Lateral landmarks enabled to locate the CFL footprint.

Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity.

ABSTRACT 3

A calcaneal tunnel for CFL reconstruction should be directed to the posterior inferior medial edge of the calcaneal tuberosity

Michels F, Matricali G, Wastyn H, et al. Knee Surgery Sports Traumatology Arthroscopy, 2021, 29(4), 1325-1331 ABSTRACT 4

The intrinsic subtalar ligaments have a consistent presence, location and morphology

Michels F, Matricali G, Vereecke E, et al. Foot Ankle Surgery, 2021, 27(1), 101-109

ABSTRACT Chronic subtalar instability is a disabling complication after acute ankle sprains. Currently, the literature describing

the anatomy of the intrinsic subtalar ligaments is limited . and equivocal which causes difficulties in diagnosis and treatment of subtalar instability. The purpose of this study is to assess the anatomical characteristics of the subtalar ligaments and to clarify some points of confusion.

In 16 cadaveric feet, the dimensions and locations of the subtalar ankle ligaments were assessed and measured. CT-scans before dissection and after indication of the footprints with radio-opaque paint allowed to generate 3D models and assess the footprint characteristics. The cervical ligament (CL) had similar dimensions as the lateral ligaments: anterior length 13.9±1.5 mm, posterior length 18.5±2.9 mm, talar width 13.6±2.2 mm, calcaneal width 15.8±3.7 mm. The anterior capsular ligament (ACaL) and interosseous talocalcaneal ligament (ITCL) were found to be smaller structures with consistent dimensions and locations.

This study identified consistent characteristics of the intrinsic subtalar ligaments and clarifies the local anatomical situation. The dimensions and footprints of the intrinsic ligaments of the subtalar joint suggest a more important role of the CL and ACaL in the stability of the subtalar joint. The results of this study are relevant to improve diagnostic tools and offer some guidelines when reconstructing the injured ligaments.

PRESENTATIES/ CONGRESSEN

ABSTRACT 1

Reconstruction of the ankle ligaments using the M. Gracilis Tendon

Michels F

June 2021, Eurasion Orthopedic Forum, Moscow, Russia

ABSTRACT In the past tenodesis was used to restore the stability of the lateral part of the ankle. Since 1960 the Brostrom technique became popular. It consists of a suture or reattachment of the injured ligaments. The extensor retinaculum can be added to reinforce the repair. More recently a ligament reconstruction was described. A reconstruction can be defined as a replacement of the injured ligaments by graft tissue. In this technique often a gracilis tendon is used. The reconstruction can be performed using an open technique or an endoscopic technique. The technique of ligament reconstruction using the gracilis tendon was first described by M Takao in 2005! The technique allows to reconstruct the ATFL or both the ATFL and CFL with a strong gracilis tendon graft. This is technically more demanding than a repair however, the major advantage is that we end up with a strong new ligament.

Repair versus reconstruction. In general the ligament repair is still the golden standard. However, in many cases you can consider to perform a ligament reconstruction instead of a repair. Especially in revision cases, patients with poor ligament quality and generalized hyperlaxity but also in patients with lesions of the calcaneofibular ligament, suspected subtalar instability, major instability. Besides in patients with lateral ankle instability, a similar technique is also used to perform reconstructions in patients with medial, subtalar and midfoot instability.

Reconstruction of the ankle ligaments using the gracilis graft is a safe and reliable technique. It allows to restore the local anatomy and to obtain a stable reconstruction. The technique should be adapted according to the needs of each patient.

ABSTRACT 2

The importance of tunnels in lateral and medial ankle ligament reconstruction

Michels F

June 2021, Eurasion Orthopedic Forum, Moscow, Russia

ABSTRACT In the past we performed tenodesis and drilled curved bone tunnels. Today we aim for an anatomical reconstruction to restore the normal function of the ligaments. Bone tunnels (interference screws) offer a greater fixation strength than bone anchors. The most challenging part is the position of the bone tunnels. The entry point should be at the normal anatomical footprint insertion. The tunnels should be directed to maximize the surrounding bone and to avoid soft tissue damage. Fibular tunnel. Drill one single tunnel to fix ATFL and CFL. Look for the fibular obscure tubercle. Hold the foot in inversion. Use a slightly more medially located entrance point to avoid the digital fossa and peroneal tendons. Drill an oblique tunnel (longer tunnel, more surrounding bone). Lateral talar tunnel. A blind ended tunnel measuring 5 mm in diameter and 22 mm in depth directed to the posterior point of medial malleolus is recommended.

Alternatively, a transosseous tunnel measuring 5 mm in diameter directed to the inferior point of MM can be used. Lateral calcaneal tunnel. Use the lateral malleolus

as a landmark. A tunnel length of > 30 is easily obtained, larger diameters are possible, because of weaker bone oversizing the screw is allowed. Avoid screw protrusion. A transosseous tunnel is directed to the lower posterior edge of calcaneal tuberosity. Tibial tunnel. Start in intercollicular groove and aim in an anterolateral direction just lateral to the tibial crest. Medial talar tunnel. Aim in a an anterolateral direction to the triangular region of the talus. Medial calcaneal tunnel. Aim in a distal posterior direction to avoid the subtalar joint.

Conclusion. Interference screws in tunnels offer a good fixation. The tunnel entrance should correspond with the normal anatomical footprint to restore the normal anatomical function of the ligaments. The tunnel direction should: allow sufficient surrounding bone, allow a sufficient tunnel length, avoid neurovascular structures.

ABSTRACT 3

Percutaneous treatment of hammertoes

Michels F

June 2021, International Basic and Advanced Course of Foot MIS and Percutaneous Surgery, Barcelona, Spain

ABSTRACT The purpose of this surgical technique is to realignment of the toes and to restore the function. The percutaneous techniques should be seen as an additional toolbox to correct the different toe deformities. We distinguish 2 groups of procedures: the soft tissue procedures and the bony procedures. The different procedures are combined and adapted to correct the toe deformity.

A tenotomy of the both extensor tendons allows to correct a hyperextension of the metatarsophalangeal joint. In medial or lateral deviations the same approach can be used to do a release of the collateral ligaments. Especially in overlapping toes and subluxations this is quite useful. A tenotomy of both flexor tendons is performed by a plantar approach on the level of the proximal phalanx. An osteotomy of the proximal phalanx. Using a plantar proximal approach a burr is introduced. If needed a tenotomy of the flexor tendons is performed before. If not the tendons are pushed to the side. According to the needed correction we perform a wedge osteotomy, a complete osteotomy or a shortening osteotomy.

The percutaneous techniques offers a new toolbox to correct the different toe deformities. Adapt your surgical technique to the deformity. Cadaverlabtraining is mandatary before performing MIS in clinical situations. The postoperative care is as important as the surgical technique.

ABSTRACT 4

Toe corrections: postoperative care

Michels F

June 2021, International Basic and Advanced Course of Foot MIS and Percutaneous Surgery, Barcelona, Spain

ABSTRACT The main goal is to maintain the toe in a corrected position during healing. Adhesive wound closure strips are often used. They are very powerful and allow correction adapted to the deformity. They provide a quite semirigid fixation. Early postoperative mobilisations of the toes is recommended. Physiotherapy should be focused on plantarflexion. The osteotomy site should be protected during the healing process.

ABSTRACT 5

Surgical technique in percutaneous toe corrections

Michels F

June 2021, International Basic and Advanced Course of Foot MIS and Percutaneous Surgery, Barcelona, Spain

ABSTRACT During this presentation the different technical aspects of percutaneous toe corrections are discussed: specific recommendations, technical tips, pitfalls and tricks.

ABSTRACT 6

Dressing techniques in percutaneous foot surgery: movie session

Michels F, Malagelada F June 2021, International Basic and Advanced Course of Foot MIS and Percutaneous Surgery, Barcelona, Spain

ABSTRACT During this presentations different dressing techniques are discussed with use of movies.

ABSTRACT 7

Percutaneous foot surgery: kinesiotaping, orthoses and aftercare

Michels F

June 2021, International Basic and Advanced Course of Foot MIS and Percutaneous Surgery, Barcelona, Spain

ABSTRACT The use of elastic tapings (kinesiotape) is discussed in the postoperative care: indications, applications and results. The use of silicone orthoses is discussed in the postoperative care: indications, applications and results. The other aspects in the aftercare are discussed: physiotherapy, shoes, patient counseling.