Orthogeriatrics – considerations in caring for older orthopaedic patient

Patients over the age of 65 are the fastest growing segment of the population, and it is estimated that it comprises 12.5% of the entire population in the developed countries. Advances in medicine, science and healthy lifestyles have promoted substantially increased lifespans, aswell as better quality of life with more physical activity. On the other hand, aging is associated with a variety of physiologic changes that affect orthopedic care. Due to natural involution processes older adults may not have the physiologic reserves necessary to promote healing or to prevent or recover fromcomplications. Degenerative diseases and injuries sustained from trauma in combination with physiologic changes and comorbidity in the aged pose a significant health problem in older adults and a major treatment challenge for an orthopaedic surgeon. This review summarizes some of these unique challenges in care for older orthopaedic patient

Disekantni osteohondritis na koljenu adolescenta iz starohrvatskoga groblja Gluvine kuće (deveto stoljeće n.e.)

Although osteochondritis dissecans of the knee has been known for a long time, we still do not fully understand why it develops. This prompted us to present and describe an example of osteochondritis dissecans identified in the Osteological Collection of the Croatian Academy of Sciences and Arts. The case of osteochondritis dissecans described in this report was recovered from the Gluvine kuće cemetery in the Dalmatian hinterland, approximately 28 km north-east of Split. A total of 77 graves were excavated and the individual exhibiting osteochondritis dissecans was recovered from grave number 16 that belongs to the younger phase of the cemetery that lasted during the second half of the 9th century A.D. Osteochondritis dissecans was noted in a subadult individual. The pathological changes consistent with osteochondritis dissecans are present on both medial femoral condyles. The lesion on the right femoral condyle is an oval crater-like defect with well defined margins and a porous floor of rough trabecular bone. The lesion on the left femoral condyle is basically, with two small provisions, identical to the one on the right side. The first is that it is slightly smaller, while the second is that unlike its antimere, it has a well preserved bone fragment that fits perfectly into the ostechondritic pit. Radiographic analyses of the femoral condyles support a diagnosis of osteochondritis dissecans and show a well-demarcated radiolucent defect in the articular surfaces of both joints surrounded by a thin sclerotic repair zone. According to the classification systems this degree of change corresponds to stage 3 or grade 3 osteochondritis dissecans – a detached but non-displaced fragment. Returning, for a second, to the opinion that prompted us to present this case, it is clear that during the last 1100 years there have been no significant morphological or radiological changes in the characteristics of osteochondritis dissecans.Disekantni osteohondritis, osobito onaj u području femoralnih kondila, poznat je stoljećima, ali se još uvijek raspravlja o uzrocima njegova nastanka. To nas je potaknulo da prikažemo slučaj osteohondritisa u području kondila femura iz Osteološke zbirke Zavoda za arheologiju Hrvatske akademije znanosti i umjetnosti. Kostur na kojem je nađen disekantni osteohondritis otkopan je na arheološkom nalazištu Gluvine kuće u Dalmatinskom zaleđu oko 28 kilometara sjeveroistočno od Splita. Na nalazištu je ukupno otkopano 77 grobova, a kostur s patološkim nalazom nađen je u grobu broj 16 koji se vremenski datira u drugu polovinu 9. stoljeća poslije Krista. Disekantni osteohondritis je nađen na kosturu osobe koja je u trenutku smrti imala 13,5 do 15 godina. Kostur je dobro očuvan, sa svijetlo smeđim kostima čiji je korteks imao relativno malo post-mortalnih oštećenja. Patološke promjene u smislu nalaza disekantnog osteohondritisa prisutne su na medijalnim kondilima obaju koljena. Lezija na desnom medijalnom kondilu femura imala je jasno omeđene rubove, a dno mu je činila gruba trabekularna kost. Gotovo jednaka lezija nađena je i na lijevom medijalnom kondilu, samo što je ova bila nešto manjeg promjera i, što je naročito zanimljivo, posjedovala je slobodni fragment kosti koji je točno odgovarao defektu na kondilu femura. Radiografska analiza medijalnih kondila obaju femura pokazala je karakterističnu radiolucentnu demarkacijsku liniju na zglobnoj ploštini obaju kondila okruženu sklerotičnom zonom kosti, što je tipičan radiološki nalaz kao i kod današnjih nativnih rendgenograma. U skladu s postojećim klasifikacijama u stupnjeve patoloških promjena pri postojanju disekantnog osteohondritisa u prikazanom slučaju radilo se o 3. stupnju, tj. stupnju s demarkiranim fragmentom. Na temelju našeg prikazanog slučaja može se zaključiti da u proteklih 1100 godina nije došlo do morfoloških i radioloških promjena u slici disekantnog osteohondritisa u području koljena

Simultaneous surgical correction of hallux valgus and lesser toes deformity

Svrha rada je prikazati rezultate istovremenog kirurškog liječenja haluksa valgusa i deformacije ostalih prstiju stopala. U Službi za ortopediju Opće bolnice Karlovac u razdoblju od 2000. do 2009. godine trodimenzionalnom (3-D) osteotomijom za haluks valgus (metoda po Lucijaniću), kombiniranoj s operacijom ostalih prstiju stopala, operirana su 74 pacijenta (87 stopala). Ispravljanje deformacija prstiju uključivalo je proksimalnu interfalangealnu resekcijsku artroplastiku, produživanje tetive dugog ekstenzora, resekciju baze drugog i trećeg prsta sa subtotalnom sindaktilizacijom. Weilova osteotomija je primijenjena u bolesnika s predugim drugim metatarzalnim kostima. Klinička i radiološka evaluacija operiranih bolesnika provedena je nakon prosječno 60,5 mjeseci (raspon 12-127 mjeseci). Prosječna dob pacijenata u vrijeme operacije bila je 56,5 godina (27-70 godina), a 97,3% su bile žene. Prosječni postoperacijski haluks valgus kut je značajno smanjen s 33,5° +- 8 na 11,4° +- 6,8, dok je intermetatarzalni kut značajno smanjen sa 14,3° +- 3,6 na 6,1° +- 3,2. Prosječno smanjenje prve metatarzalne kosti od 7,1 milimetara kompenzirano je plantarnim pomakom glave prve metatarzalne kosti u zoni osteotomije. Klinički parametri su značajno poboljšani prema AOFAS ljestvici s prosječno 37,1 +- 11,2 prijeoperativno na 87,8 +- 9,5 poslijeoperativno (p < 0,001). Rezultat je ocijenjen kao odličan i dobar u 85% slučajeva, uz 10 zadovoljavajućih i 3 loša ishoda. Komplikacije su uključivale recidiv deformacije u šest slučajeva. Jedan slučaj luksacije drugog metatarzofalangealnog zgloba je izazvao pogoršanje već prije prisutne metatarzalgije. Bio je jedan slučaj površne infekcije i jedan venske tromboze, dva tjedna nakon operacije. Rezultat ove studije potvrdio je Lucijanićevu metodu kao vrlo uspješnu u kirurškom liječenju umjerene do teške deformacije haluksa valgusa, a u kombinaciji s različitim postupcima kirurškoga liječenja deformacija ostalih prstiju, osigurava se potpuno ispravljanje glavnine poremećaja prednjega dijela stopala.The purpose of this study was to present results of simultaneous correction of hallux valgus and lesser toes deformity. In the Department of Orthopaedic Surgery, Karlovac General Hospital, between 2000 and 2009, 74 patients (87 feet) underwent new three-dimensional (3-D) osteotomy for hallux valgus (Lucijanić\u27s method) combined with lesser toes surgery or lesser metatarsal osteotomy. Correction deformities included proximal interphalangeal resection arthroplasty, extensor tendon lengthening, resection of both bases of the second and third toes with a subtotal webbing of toes two and three (syndactylisation).The Weil osteotomy on the lesser metatarsal was performed in 11 cases with excess of the lesser metatarsal length. Clinical and radiological evaluation was performed with an average follow up of 60.5 months (range: 12-127 months). The average patient age at the time of surgical treatment was 56.5 years (27-70), 97.3% were women. The average hallux valgus angle significantly decreased from 33.5 +- 8 to 11.4 +- 6.8 while the intermetatarsal angle significantly decreased from 14.3 +- 3.6 to 6.1 +- 3.2. The first metatarsal distal articular surface angle was reduced in average from 16.8 +- 6.7 to -1.4 +- 7.4. The first metatarsophalangeal joint congruence of average 1.3 +- 0.9 grade was corrected to 0.2 +- 0.5. The sesamoid position was corrected from an average preoperative grade of 2.5 +- 0.7 to a grade of 0.4 +- 1.2 at final follow-up. The first metatarsal declination angle was increased from 22.6 +- 3.7 to 28.5 -+ 4.6. The first metatarsal pronation angle was corrected from 7.2 +- 6.9 to 0.2 -+- 5.6. The relative length of the first and the second metatarsals was reduced from 2.4 +- 3.7 to -4.7 +- 3.7 millimetres. The first metatarsal shortened an average of 7.1 millimetres compensated with plantar displacement of the metatarsal head at the osteotomy site. The preoperative AOFAS\u27 hallux-metatarsophalangeal-interfhalangeal score averaged 37.1 +- 11.2 which increased significantly to 87.8 +- 9.4 postoperatively (p < 0.001). The overall outcome was rated as excellent and good in 85% of cases (10 fair, 3 poor). Complication included recurrence of deformity in six cases. Prolonged swelling was found in three cases. There were one case of superficial infection and one case of vein thrombosis two weeks after surgery. The results of this study confirmed the author\u27s procedure as very useful surgical technique for correction of a moderate to sever hallux valgus deformity. Its combination with various procedures for lesser toes ensures complete correction of main forefoot disorders

SURGICAL TREATMENT OF HALLUX VALGUS WITH NEW METHOD: OPERATIVE TECHNIQUE AND REVIEW OF 100 CASES

Prikazujemo operacijsku tehniku i rezultate liječenja za novu, trodimenzionalnu metodu korekcije haluksa valgusa razvijenu u OB Karlovac koju je uveo dr. Ivica Lucijanić. Bolesnici obuhvaćeni istraživanjem liječeni su od 2001. do 2008. godine. Klinički i radiološki evaluirani su prije i prosječno 4,5 godina poslije liječenja. Po bodovnoj ljestvici American Orthopaedic Foot and Ankle Society stanje je poboljšano s 48,56 na 92,34 boda. Vrijeme oporavka do povratka na posao bilo je prosječno 7,7 tjedana. Rezultat je bio odličan i dobar u 93%, zadovoljavajući u 5% i loš u 2% stopala. Kut haluksa valgusa smanjen je nakon operacije s prosječno 29,7° na 9,3°. Prvi intermetatarzalni kut smanjen je prosječno s 12,5° na 5,2°. Kut nagiba prve metatarzalne kosti u sagitalnoj ravnini povećan je prosječno za 5,3°. Kongruencija prvog metatarzofalangealnog zgloba i položaj medijalne sezamoidne kosti su ispravljeni. Nova metoda omogućuje korekciju haluksa valgusa u sve tri ravnine u prostoru te rješava problem metatarzalgije.We present the operative technique and treatment results for a new three-dimensional method for hallux valgus correction. Lucijanić procedure was developed at the Department of Orthopaedic Surgery, General Hospital Karlovac, where patients enrolled in this study were treated from 2001 to 2008. Clinical and radiological evaluation was performed in 100 cases with a mean follow-up of 4.5 years. Mean American Orthopaedic Foot and Ankle Society score improved from 48.56 preoperatively to 92.34 points postoperatively. Average recovery time and return to work was 7.7 weeks. Result was excellent or good in 93%, fair in 5% and poor in 2% of feet. On the average hallux valgus angle decreased from 29.7° to 9.3° and on the average intermetatarsal angle decreased from 12.5° to 5.2°. First metatarsal inclination angle on average increased 5.3°. First metatarsophalangeal joint congruence and tibial sesamoid position were corrected. The new method allows for correction of hallux valgus deformity in all three planes and for metatarsalgia attenuatio

SURGICAL TREATMENT OF HALLUX LIMITUS/RIGIDUS IN YOUNG FEMALE ATHLETE

Hallux limitus/ rigidus određuje ograničenje dorzalne fleksije metatarzofalangealnog zgloba palca usljed stvaranja osteofita uokolo dorzalnog ruba glave prve metatarzalne kosti. Navode se mnogi uzroci nastanka uključujući i traumu. Liječenje je konzervativno ili kirurško, a primjenjuje se više vrsta kirurškog liječenja. Autori prikazuju sportašicu s hallux limitusom (drugi stupanj bolesti) operiranu u njezinoj 19. godini života s postoperativnim praćenjem od 10 godina. Bolesnica je operirana metodom po Lucijaniću izvorno opisanom za kirurško liječenje hallux valgusa.Uosnovi primjenjenog kirurškog postupka je 3D distalna osteotomija prve metatarzalne kosti, njeno skraćivanje i plantarizacija glave te osteosinteza kompresivnim vijkom. Opisana je klinička i radiološka slika te nalaz podobarografije prije i nakon operacije. Dorzalna fleksija u prvom metatarzofalangealnom zglobu je prije operacije iznosila 20°. Deset godina nakon operacije pacijentica se bavi rekreacijskim trčanjem i uglavnom je bez bola i s dobrim opsegom kretnji u prvom metatarzofalangealnom zglobu, tj. dorzalna fleksija u zglobu iznosi 55 stupnjeva.Hallux limitus/rigidus is defined as the limitation of dorsiflection in the first metatarsophalangeal joint of the big toe due to the formation of osteophytes around the dorsal aspect of the articular margin of the head of the first metatarsal. Many ethiologies have been proposed including trauma. More types of the conservative and surgical treatment are practised. The autors report a case of the 19 years female sportist with hallux limitus (grade -2 disease) proceeded to open surgery with postoperative follow-up of ten years. The surgical procedure had been described before by Lucijanić originaly for treatment of hallux valgus. In the base of applied procedure is 3D distal osteotomy of the first metatarsal, shortening and plantar displacement of the metatarsal head and osteosynthesis using a compression screw. The clinical, radiological and pedobarography feature before and after surgery is described.The preoperative first metatarsophalangeal joint dorsiflexion was 20°. Ten years after surgery the patient is mainly pain-free and with good range of motion of the first metatarsophalangeal joint and dorsiflexion is 55 degrees. She is capable for recreational long running

Osteoporotic Fractures in the Elderly

Epidemiologija ozljeda u starijih ljudi bitan je čimbenik u strukturi udjela mortaliteta i uzroka hospitalizacija tih ljudi. Epidemiološki, u starijih su ljudi vrlo naglašene posljedice ozljeđivanja, odnosno komplikacije, od smanjene pokretljivosti, dekubitusa, kontraktura, infekcija pa do smrtnosti zbog hipostatske pneumonije. U Hrvatskoj je 2005. godine bilo preko 17 % populacije starije od 65 godina, a 27 % starije od 60 godina. U ljudi odmakle životne dobi česti su osteoporotični prijelomi kosti te je u Hrvatskoj 2005. godine registrirano 5489 ljudi s prijelomom u području zgloba kuka, a zbog komplikacija nakon prijeloma umrlo je 382 bolesnika. Među umrlim bolesnicima bilo je 97,38 % starijih od 65 godina. Osim prijeloma u području kuka značajni su osteoporotični prijelomi kralježaka, distalnog dijela palčane kosti, nadlaktične kosti, kosti zdjelice, itd. Bez obzira na odabir konzervativnog ili kirurškog načina liječenja osteoporotičnih prijeloma kosti, bitno je naglasiti da po zbrinjavanju prijeloma kosti treba provesti primjerene dijagnostičke pretrage i odrediti farmakološko liječenje osteoporoze. Ortopedi i traumatolozi diljem svijeta moraju shvatiti da je konzervativno ili kirurško liječenje osteoporotičnog prijeloma bilo koje lokalizacije samo jedna karika u zamršenom lancu liječenja bolesti – osteoporosis.The epidemiology of injuries is a significant factor in the structure of mortality and causes of hospitalization of elderly people. Epidemiologically, consequences of injury, i.e. their complications, from reduced mobility, sores, contractures, infections, all over to mortality from hypostatic pneumonia, are strongly emphasized in the elderly. In 2005, more than 17.0 % of Croatian population were older than 65 years of age, and 27.0 % of the population were over 60. Osteoporotic bone fractures are frequent among the elderly; 5,489 hip fracture cases were registered in Croatia during 2005, and 382 of them died from fracture complications. In total, 97.38 % of the dead patients were over 65 years of age. Besides hip fractures, other typical osteoporotic fractures are fractures of vertebral bodies, distal part of the radius, humerus, pelvic bones, etc. Regardless of conservative or surgical treatment for osteoporotic fracture, it is essential to stress out that after the care of fractured bone has been provided, appropriate diagnostic examinations and pharmacological treatment of osteoporosis should also be done. Orthopedic and traumatic surgeons all over the world have to understand that conservative or surgical treatment of osteoporotic fracture of any localization is just one link in this complex chain of managing the disease – osteoporotic treatment

TARSAL TUNNEL SYNDROME IN ATHLETES

Sindrom kompresije nervus tibialisa ili njegovih ogranaka n.plantaris medialis et lateralis u području tarzalnog kanala (tunela) poznat je od 1962. godine kao sindrom tarzalnog kanala (tunela). Tarzalni kanal je koštano-vezivni kanal (tunel) smješten ispod medijalnog gležnja (maleola) stopala, a koji kanal se naziva i „hilus stopala“, jer kroz taj tunel na taban dolaze sve anatomske strukture od tetiva do živaca i krvnih žila. Kanal se dijeli na dva dijela, tj. na lacuna tendinum za prolaz tetiva m.tibialis posterior, m.flexor hallucis longus i m. flexor digitorum longus i na lacuna vasonervorum za prolaz neurovaskularnog snopa. Lacuna vasonervorum dijeli se opet u dva kanala i to medijalni (gornji) za prolaz n. plantaris medialis i istoimene arterije i vena te lateralni (donji) za prolaz n.plantaris lateralis te arterije i vena. Medijalni (gornji) kanal je u neposrednom odnosu s lacuna tendinum što je i jedan od uzroka češće kompresije n.plantaris medialis. Uzroci nastanka sindroma tarzalnog kanala su zauzimanje prostora u kanalu (ganglion, anomalni mišić i sl.) ili zbog izvanjskog pritiska na strukture u kanalu. Postoje i idiopatski oblici sindroma tarzalnog kanala kada se ne može otkriti izravni uzrok nastanka karakterističnih simptoma u smislu žarenja, pečenja, bockanja i smanjene osjetljivosti osobito u prva tri prsta tabana. Uz kliničku dijagnostiku nove mogućnosti MRI i ultrazvučne dijagnostike smanjuju broj tzv. idiopatskih oblika sindroma tarzalnog kanala, a korisne su i za evaluiranje eventualnog neuspješnog kirurškog liječenja . Sindrom tarzalnog kanala u športaša opisuje se relativno rijetko, a češće se javlja u sportovima gdje su prisutni sprintanje, skokovi ili neki specifični pokreti (judo), a pojava simptoma povezana je i s biomehaničkim promjenama u području gležnja i stopala. Idiopatske oblike sindroma tarzalnog kanala koji se češće nalaze u športaša može se objasniti učestalim ponavljajućim istezanjima (trakcijom) živaca ili tendinitisima u području lacuna tendinum, a što se sve može svrstati u sindrome prenaprezanja. Iako se nešto rjeđe opisuje nego u općoj populaciji potrebno je misliti na mogućnost pojave sindroma tarzalnog kanala u športaša, a ne postojeće tegobe pripisivati spuštenom stopalu ili proširenim venama.Tibial nerve compression syndrome or its affiliate\u27s branches n. plantaris medialis and lateralis in the fragment of tarsal canal (tunnel) are known since 1962. as tarsal tunnel syndrome. Tarsal channel is bone-connective tissue tunnel located under medial part of the ankle, and that channel is called the "hilum foot", because through that tunnel all the anatomical structures from tendon to the nerves and blood vessels are coming to the sole. The tunnel is divided into two parts – on lacuna tendinum for passage of m. tibialis posterior tendon, m. flexor hallucis longus and m. flexor digitorum longus and on lacuna vasonervorum for passage of the neurovascular bundle. Lacuna vasonervorum is divided again into two parts – into medial (upper tunnel) for the passage of n. plantaris medialis and homonymous artery and veins and to lateral (lower tunnel) for passage of n. plantaris lateralis, artery and veins. Medial (upper) tunnel is in direct relation with lacuna tendinum, which is one of the most common causes of compression of n. plantaris medialis. Causes of tarsal tunnel syndrome onset are found in possible space engagement in the tunnel (by ganglion, anomalous muscle or similar) or due to external pressure on the structures in the tunnel. There are also idiopathic forms of the tarsal tunnel syndrome, when you cannot detect a direct cause of the characteristic symptoms in terms of firing, burning, picking and reduced sensitivity especially in the first three fingers of the feet. Besides the clinical diagnosis, new opportunities of MRI and ultrasound diagnosis procedures reduce the number of so-called idiopathic forms of tarsal tunnel syndrome, and are useful for the evaluation and for eventual failure of surgical treatment. Tarsal tunnel syndrome is relatively rare described in athletes and does occur more often in sports where sprinting, jumping, or some specific movements (like in judo) are present. The occurrence of symptoms is also associated with biomechanical changes in the ankle and foot. Idiopathic forms of tarsal tunnel syndrome, which are more often found in athletes, may be explained by frequent repetitive stretching (traction) of the nerve or by tendinitis in the lacuna tendinum and can be classified as overuse injuries. Although less frequently described than in the general population, it is necessary to think of the possibility of tarsal tunnel syndrome in athletes, and not attribute present symptoms to the foot deformities or varicose veins

Sezamoiditis - radiološka dijagnostika i konzervativno liječenje

Sesamoid bones play an essential role in first metatarsophalangeal (MTP) joint biomechanics, together with other articular surfaces, joint capsule, plantar fascia, ligaments and tendons. They are prone to different acute and chronic injuries, such as acute fracture, stress fractures, chondromalacia, avascular necrosis, bursitis degenerative changes, inflammation etc., all of which clinically manifest as a painful condition and are often diagnosed under a broad term called sesamoiditis. The mechanism of injury is most commonly associated with overuse of the anterior part of the sole of the foot accompanied by excessive dorsiflexion of the great toe. Sesamoiditis presents with pain and localized swelling in the projection of the tibial sesamoid bone, which is affected more frequently than the fibular one. Diagnostic radiology plays a key role in determination of etiology of the disease, as well as in planning of it’s treatment. Typical radiological examination includes weight-bearing dorsoplantar, lateral, oblique medial and oblique lateral radiographs of the foot, together with a direct axial radiograph of sesamoid bones. Computerized tomography is used for distinction of acute fractures and early stage of stress fractures from other pathological conditions. Magnetic resonance imaging allows differentiation between bony pathology and soft tissue conditions. Sesamoiditis management is primarily conservative and it depends on duration and severity of the condition. Orthotic insoles customized according to pedobarographic findings may be useful for solving biomechanical deformities that could have led to development of sesamoiditis. Specific pads placed under the first MTP joint in order to prevent the great toe from dorsiflexion proved to be a very effective conservative treatment option. Surgical treatment is considered if conservative methods fail to provide sufficient management of the condition.Sezamske kosti u području metatarzofalangealnog zgloba nožnog palca (hallux) dio su anatomsko-biomehaničkog kompleksa kojeg čine zglobna tijela, čahura, plantarna fascija, sveze i tetive mišića. U sklopu navedenog komplek- sa sezamske kosti podložne su raznim akutnim i kroničnim oštećenjima u smislu prijeloma, stres prijeloma, hon- dromalacije, avaskularne nekroze, burzitisa, degenerativnih promjena, upala itd., a što se sve klinički očituje kao bolno stanje i sve se podvodi pod široki pojam sesamoiditisa. Mehanizam koji dovodi do sesamoiditisa najčešće je vezan uz prenaprezanje prednjeg dijela stopala praćenog ekscesivnom dorzifleksijom nožnog palca. U kliničkoj sli- ci sesamoiditisa najčešći simptom je bol i lokalizirana oteklina i to u području tibijalne sezamske kosti koja je dale- ko češće zahvaćena u odnosu na fibularnu sezamsku kost. Radiološka dijagnostika je značajna kako u otkrivanju etiologije tako i u planiranju liječenja sesamoiditisa. Standardna radiološka pretraga obuhvaća antero-posteriornu snimku pod opterećenjem stopala, lateralnu snimku, kose snimke te aksijalnu snimku sezamskih kostiju. Komp- juterizirana tomografija pokazala se korisnom za razlikovanje akutnog prijeloma i ranog stadija stres prijeloma sezamske kosti od drugih patologija koje mogu zahvatiti sezamske kosti. MRI omogućuje diferencijaciju između koštanih promjena i promjena na mekom tkivu. Liječenje sezamoiditisa je prvenstveno konzervativno i uvelike ovisno o uznapredovalosti promjena u području cijelog metatarzofalangealnog kompleksa. Ortopedski ulošci nakon pedobarografske analize opterećenja stopala mogu otkloniti biomehaničke deformacije koje su potencijalno pridonijele razvoju sesamoiditisa. Posebni podlošci ispod metatarzofalangealnog zgloba palca u smislu sprečavanja dorzifleksije palca su vrlo korisni i efikasni u konzervativnom liječenju sesamoiditisa. Kirurško liječenje može biti preporučeno nakon neuspjelog konzervativnog liječenja

PLANTAR FASCIITIS

Plantarni fascitis spada u sindrome prenaprezanja,a oèituje se pojavom boli u području medijalne kvrge petne kosti i / ili uzduž medijalnog uzdužnog svoda stopala. Nastaje zbog dugotrajnih ponavljajućih opterećenja (stress) na plantarnu fasciju te dolazi do mikroruptura ili u završnoj fazi i do djelomične i/ili potpune rupture fascije blizu njenog polazišta na petnoj kosti. Plantarna fascija ima veliki značaj u biomehanici stopala i ona tijekom hoda ublažava mehaničke udare na stopalo i odrazuje stopalo prema naprijed po sistemu dizalice. Ukoliko doðe do poremećaja biomehanike stopala osobito naglašene pronacije stopala, zatim ako postoji udubljeno stopalo, skraćena Ahilova teiva, izrazito spušteno stopalo, itd. dolazi do pojačanih rastezanja plantarne fascije,a zbog same graðe fascije izrazito je mala mogućnost prilagodbe na ta povećana rastezanja. U sportaša plantarni fascitis češće se javlja kod trkača na duge pruge, a veća incidencija nalazi se i kod tenisaèa, košarkaša te plesača. Obično je unilateralan a u 15% pacijenata pojavljuje se obostrano. Klinička manifestacija plantarnog fascitisa je bolno stopalo, odnosno bolnost plantarnog dijela petne kosti.Dijagnoza plantarnog fascitisa se kod većine pacijenata postavlja na osnovi anamneze i klinièkog pregleda. Točka najjače bolne osjetljivosti je medijalni nastavak petne kvrge a bol se pojaèava pasivnim rastezanjem fascije. U dijagnostici plantarnog fascitisa koriste se radiološke pretrage koje često otkrivaju postojanje koštanog trna (calcar calcanei), ultrazvučna dijagnostika i danas sve više i MRI otkrivaju zadebljanje fascije, burze i rupture a uz scintigrafsku pretragu MRI je koristan i u diferncijalnoj dijagnozi prijeloma zamora petne kosti. U lijeèenju plantarnog fascitisa pogotovo u sportaša prvenstveno treba primjenom individualno izraðenih ortotskih pomagala korigirati poremećenu biomehaniku stopala, što treba provoditi i u preventivne svrhe. U konzervativno liječenje spadaju i svi inače uobičajeni postupci fizikalne medicine od krioterapije,vježbi rastezanja , primjene noćne udlage, lokalne primjene ultrazvuka ili u novije vrijeme udarnih valova velike energije do posebnih bandaža stopala. Kirurško liječenje otvorenom ili endoskopskom metodom sastoji se u opuštanju,presijecanju ili/i djelomiènom odstranjenju promijenjene plantarne fascije.Kirurško liječenje poduzima se najčešće upravo u sportaša nakon 6-12 mjeseci neuspješnog konzervativnog liječenja.Plantar fasciitis is an overuse injury characterized by pain at the medial tubercle of the calcaneus and/or along the medial longitudinal arch of the foot. It usually develops when repetitive and prolonged stress is placed on plantar fascia, which may cause microtears and/or partial or total tears of the fascia near its insertion to the calcaneus. Plantar fascia plays significant role in the foot biomechanics. It absorbs mechanical forces placed on the foot and propels foot forward by utilizing the windlass effect. In deranged foot biomechanics, like in pronation of the foot, pes cavus, shortened Achilles tendon, extreme pes planus, etc., additional stress and elongation of plantar fascia is observed, which the fascia, because of its anatomy, is unable to compensate. In athletes, plantar fasciitis is more common in long distance runners and increased incidence is observed in tennis players, basketball players and in dancers. It is usually unilateral whereas in 15% of patients it is bilateral. Clinical findings include painful foot with pain across the plantar aspect of the calcaneus. Diagnosis is usually made after anamnesis and clinical examination. The most painful spot is located at the medial tubercle of the calcaneus and pain is aggravated by passive stretching of the fascia. X-rays could be useful for diagnosing bony spur (calcar calcanei) and ultrasound and MRI are useful for diagnosing thickened fascia, bursa or rupture. MRI and scintigraphy are also useful for differentiating plantar fasciitis and stress fracture of the calcaneus. For the treatment of the plantar fasciitis, especially in athletes, custom made orthothic devices are used for correction of the deranged foot biomechanics, even for prevention. For conservative treatment all usual methods are used (physiotherapy, cryotherapy, stretching exercises, orthoses through the night, local ultrasound and shock wave therapy and foot taping). Surgical treatment with endoscopic or open methods includes release and complete or partial removal of deranged plantar fascia. Surgical treatment is most commonly performed in athletes after 6-12 months of unsuccessful conservative treatment