Soccer above all? Analysis of academic and vocational education among female soccer players in the German women's Bundesliga and 2nd women's Bundesliga

Introduction

Career-related (financial) reasons as well as advantages in terms of expanding social support systems, promoting a balanced lifestyle and personal development suggest that female soccer players should pursue academic or vocational education in parallel to elite sport. However, dual careers are fraught with challenges, mainly due to simultaneity in time and the associated conflicting goals. The aim of this article is to analyze the vocational or academic educational careers of professional female soccer players.

Methods

To generate the data, an online survey was conducted among soccer players in the German Women's Bundesliga and 2nd Women's Bundesliga. A total of n = 200 questionnaires (German: n = 191; English: n = 9) were included in the analysis, which corresponds to approx. 29.6% of the population addressed.

Results

90.6% of the players are pursuing or have already completed academic or vocational education. The majority (71.2%) of female soccer players choose to study. 81.8% of players report no impact or even a positive impact of soccer on their performance in academic or vocational education. Willingness to pursue and complete academic or vocational education is influenced by membership of the A-National Team, time spent playing soccer, form of school-leaving qualification, nationality and age.

Discussion

This study increases the visibility of professional women's soccer as an object of analysis in sports science research, follows up on demands for a more athlete-centered approach and generates further insights for research and practice with regard to the success of dual careers in elite sport.

[Selective Neurectomy in Spastic Paralysis of the Upper Extremity]

Selective neurectomy refers to the targeted transection of motor nerve fibres at their entry into the muscle in order to reduce the increased muscle tone in cases of spastic paralysis. This procedure has regained popularity in recent years, especially in the upper extremity. First and foremost, it requires an exact knowledge of the topographical anatomy of muscle innervation. To be able to control the extent and localisation of the denervation, the terminal nerve branches must be visualized precisely during the procedure. For a meaningful reduction of muscle tone, 2/3 to 4/5 of nerve fibres must be resected. This article presents the historical development, principles and operative details of this technique as well as clinical results.

Clinical evaluation of augmented reality-based 3D navigation system for brachial plexus tumor surgery

BACKGROUND

Augmented reality (AR), a form of 3D imaging technology, has been preliminarily applied in tumor surgery of the head and spine, both are rigid bodies. However, there is a lack of research evaluating the clinical value of AR in tumor surgery of the brachial plexus, a non-rigid body, where the anatomical position varies with patient posture.

METHODS

Prior to surgery in 8 patients diagnosed with brachial plexus tumors, conventional MRI scans were performed to obtain conventional 2D MRI images. The MRI data were then differentiated automatically and converted into AR-based 3D models. After point-to-point relocation and registration, the 3D models were projected onto the patient's body using a head-mounted display for navigation. To evaluate the clinical value of AR-based 3D models compared to the conventional 2D MRI images, 2 senior hand surgeons completed questionnaires on the evaluation of anatomical structures (tumor, arteries, veins, nerves, bones, and muscles), ranging from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

Surgeons rated AR-based 3D models as superior to conventional MRI images for all anatomical structures, including tumors. Furthermore, AR-based 3D models were preferred for preoperative planning and intraoperative navigation, demonstrating their added value. The mean positional error between the 3D models and intraoperative findings was approximately 1 cm.

CONCLUSIONS

This study evaluated, for the first time, the clinical value of an AR-based 3D navigation system in preoperative planning and intraoperative navigation for brachial plexus tumor surgery. By providing more direct spatial visualization, compared with conventional 2D MRI images, this 3D navigation system significantly improved the clinical accuracy and safety of tumor surgery in non-rigid bodies.

Nerve transfer reversal to treat co-contraction after anatomic brachial plexus reconstruction and Oberlin transfer: A case report

Distal nerve transfers to restore elbow flexion have become standard of care in brachial plexus reconstruction. The purpose of this report is to draw attention to intractable co-contraction as a rare but significant adverse event of distal nerve transfers. Here we report of treatment of a disabling co-contraction of the brachialis muscle and wrist/finger flexors after median to brachialis fascicular transfer in a 61-year-old male patient. The primary injury was an postganglionic lesion of roots C5/C6 and a preganglionic injury of C7/C8 with intact root Th1 after a motor bicycle accident. After upper brachial plexus reconstruction (C5/C6 to suprascapular nerve and superior trunk) active mobility in the shoulder joint (supraspinatus, deltoid) could be restored. However, due to lacking motor recovery of elbow flexion the patient underwent additional median to brachialis nerve transfer. Shortly after, active elbow flexion commenced with rapid recovery to M4 at 9 months postoperatively. However, despite intensive EMG triggered physiotherapy the patient could not dissociate hand from elbow function and was debilitated by this iatrogenic co-contraction. After preoperative ultrasound-guided block resulted in preserved biceps function, the previously transferred median nerve fascicle was reversed. This was done by dissecting the previous nerve transfer of the median nerve fascicle to the brachialis muscle branch and adapting the fascicles to their original nerve. Postoperatively, the patient was followed up for 10 months without a complication and maintained M4 elbow flexion with independent strong finger flexion. Distal nerve transfers are an excellent option to restore function, however, in some patients cognitive limitations may prevent cortical reorganization and lead to disturbing co-contractions.

The Surgical Restoration of Arm and Hand Function in Tetraplegic Patients

BACKGROUND

There are approximately 140 000 people in Germany with spinal cord injury, with approximately 2400 new patients each year. Cervical spinal cord injuries cause, to varying degrees, weakness and impairment of everyday activities of the limbs (tetraparesis, tetraplegia).

METHODS

This review is based on relevant publications retrieved by a selective search of the literature.

RESULTS

From among 330 initially screened publications, 40 were included and analyzed. Muscle and tendon transfers, tenodeses, and joint stabilizations yielded reliable functional improvement of the upper limb. Tendon transfers improved the strength of elbow extension from M0 to an average of M3.3 (BMRC) and grip strength to approximately 2 kg. In the long term, 17-20% of strength is lost after active tendon transfers and slightly more after passive ones. Nerve transfers improved strength to M3 or M4 in over 80% of cases, with the best results overall in patients under 25 years of age who underwent early surgery (within 6 months of the accident). Combined procedures in a single operation have been found to be advantageous compared to the traditional multistep approach. Nerve transfers from intact fascicles at segmental levels above that of the spinal cord lesion have been found to be a valuable addition to the established varieties of muscle and tendon transfer. The reported long-term patient satisfaction is generally high.

CONCLUSION

Modern techniques of hand surgery can help suitably selected tetraparetic and tetraplegic patients regain the use of their upper limbs. Competent interdisciplinary counseling about these surgical options should be offered as early as possible to all affected persons as an integral part of their treatment plan.

Axonal mapping of the motor cranial nerves

Basic behaviors, such as swallowing, speech, and emotional expressions are the result of a highly coordinated interplay between multiple muscles of the head. Control mechanisms of such highly tuned movements remain poorly understood. Here, we investigated the neural components responsible for motor control of the facial, masticatory, and tongue muscles in humans using specific molecular markers (ChAT, MBP, NF, TH). Our findings showed that a higher number of motor axonal population is responsible for facial expressions and tongue movements, compared to muscles in the upper extremity. Sensory axons appear to be responsible for neural feedback from cutaneous mechanoreceptors to control the movement of facial muscles and the tongue. The newly discovered sympathetic axonal population in the facial nerve is hypothesized to be responsible for involuntary control of the muscle tone. These findings shed light on the pivotal role of high efferent input and rich somatosensory feedback in neuromuscular control of finely adjusted cranial systems.

Nerve Transfers for Brachial Plexus Reconstruction in Patients over 60 Years

Negative expectations regarding nerve reconstruction in the elderly prevail in the literature, but little is known about the effectiveness of nerve transfers in patients with brachial plexus injuries aged over 60 years. We present a series of five patients (1 female, 4 male) aged between 60 and 81 years (median 62.0 years) who underwent nerve reconstruction using multiple nerve transfers in brachial plexopathies. The etiology of brachial plexus injury was trauma (n = 2), or iatrogenic, secondary to spinal surgical laminectomy, tumor excision and radiation for breast cancer (n = 3). All but one patient underwent a one-stage reconstruction including neurolysis and extra-anatomical nerve transfer alone (n = 2) or combined with anatomical reconstruction by sural nerve grafts (n = 2). One patient underwent a two-stage reconstruction, which involved a first stage anatomical brachial plexus reconstruction followed by a second stage nerve transfer. Neurotizations were performed as double (n = 3), triple (n = 1) or quadruple (n = 1) nerve or fascicular transfers. Overall, at least one year postoperatively, successful results, characterized by a muscle strength of M3 or more, were restored in all cases, two patients even achieving M4 grading in the elbow flexion. This patient series challenges the widely held dogma that brachial plexus reconstruction in older patients will produce poor outcomes. Distal nerve transfers are advantageous as they shorten the reinnervation distance. Healthy, more elderly patients should be judiciously offered the whole spectrum of reconstructive methods and postoperative rehabilitation concepts to regain useful arm and hand function and thus preserve independence after a traumatic or nontraumatic brachial plexus injury.

Early Postoperative Recovery after Modified Ultra-Minimally Invasive Sonography-Guided Thread Carpal Tunnel Release

Thread carpal tunnel release (TCTR) has been reported to be safe and effective for the treatment of carpal tunnel syndrome. The aim of this study is to evaluate the modified TCTR for safety, efficacy, and postoperative recovery. Seventy-six extremities in 67 patients undergoing TCTR were analyzed pre- and postoperatively using clinical parameters and patient-reported outcome measures. Twenty-nine men and 38 women with a mean age of 59.9 ± 18.9 years underwent TCTR. The mean postoperative time to resume activities of daily living was 5.5 ± 5.5 days, analgesia was completed after 3.7 ± 4.6 days, and return to work was achieved after a mean of 32.6 ± 15.6 days for blue-collar workers and 4.6 ± 4.3 days for white-collar workers. The Boston Carpal Tunnel Questionnaire (BCTQ) and Disability of Arm, Shoulder, and Hand (DASH) scores were comparable with previous studies. Overall, two persistent compressions and one recurrence required open reoperation (3.9%). All three had been operated in the initial phase, and none required reoperation after an additional safety step was introduced. No other complications occurred. TCTR surgery appears to be a safe and reliable technique with almost no wound and scarring and a potentially faster recovery time than open techniques. Although our technical modifications may reduce the risk of incomplete release, TCTR requires both ultrasound and surgical skills and has a considerable learning curve.

[Plastic-surgical reconstruction of the lower extremity in senior patients]

The proportion of patients in the population beyond the 7th decade of life is increasing worldwide, especially in highly developed countries. Consequently, there is also an increasing need for complex lower extremity reconstructions after trauma, tumors, or infections in this age group. The reconstruction of soft tissue defects of the lower extremity should be performed according to the principle of the plastic-reconstructive ladder or elevator. The goal of reconstruction is to restore anatomy and function of the lower extremity to enable pain-free and stable standing and walking; however, for older patients in particular, a careful preoperative multidisciplinary planning, detailed preoperative assessment and optimization of comorbidities, such as diabetes, malnutrition or pathological vascular alterations, as well an age-adapted perioperative management are necessary. By implementing these principles, older and very old patients can maintain their mobility and autonomy, which are crucial for a high quality of life.

Knochenrekonstruktion an der oberen Extremität mittels eines freien vaskularisierten Knochentransplantates aus der medialen Femurkondyle ohne Berücksichtigung des Skaphoids

Ziel Diese Studie untersucht, ob das vaskularisierte Knochentransplantat aus der medialen Femurkondyle (MFC) auch erfolgreich bei kleinen (< 4 cm) Knochendefekten an der oberen Extremität eingesetzt werden kann, die nicht das Skaphoid betreffen.

Patienten und Methoden Achtmal wurde bei 7 Patienten mit einem Alter zwischen 28 und 66 Jahren ein vaskularisiertes Knochentransplantat aus der MFC zur Rekonstruktion von Knochendefekten, die nicht das Kahnbein betrafen, an der oberen Extremität eingesetzt. Knochenheilung, Komplikationen, Hebemorbidität und die Patientenzufriedenheit wurden erfasst. Die Nachuntersuchungszeit betrug 3 bis 40 Monate. Die Indikationen für die Rekonstruktion mittels freier MFC waren 2 trotz mehrerer Voroperationen nicht geheilte distale Radiusfrakturen, ein ossärer Defekt am distalen Radius nach Fraktur mit radioskaphoidaler Arthrose, ein akutes, komplexes Trauma mit Verlust von Anteilen des Karpus und des distalen Radius bei Explosionsverletzung, eine Rekonstruktion des ersten Mittelhandknochens (MHK) nach Resektion eines Riesenzelltumors und 3 Arthrodesen zwischen dem 1. und 2. MHK als Rettungsoperation nach mehrfachen Operationen bei Daumensattelgelenksarthrose.

Ergebnisse Vier der 8 Knochentransplantate zeigten eine regelrechte Heilung; 3-mal war sie mit 7, 8 und 9 Monaten verzögert. Einmal zeigte sich nur eine partielle Knochenheilung. Zweimal kam es zu einem revisionsbedürftigen Hämatom an der Entnahmestelle. Die Patientenzufriedenheit war mit Schmerzfreiheit in 7 der 8 Fälle in Anbetracht der Komplexität der Fälle zufriedenstellend.

Schlussfolgerung Das freie vaskularisierte Knochentransplantat aus der MFC kann erfolgreich ohne Längenverlust zur Rekonstruktion bei Knochendefekten an der oberen Extremität eingesetzt werden, die nicht das Kahnbein betreffen und kleiner als 4 cm sind.

[Bone Reconstruction in the Upper Extremity other than the Scaphoid with the free vascularized Medial Femoral Condyle]

PURPOSE

To evaluate whether a vascularized bone graft from the medial femur condyle (MFC) can successfully be used to reconstruct small bone defects (< 4 cm) on the upper extremity other than the scaphoid.

PATIENTS AND METHODS

In 7 patients at the age of 28 to 66 years 8 vascularized bone grafts from the MFC were used to reconstruct bone defects on the upper extremity other than the scaphoid. Bone healing, complications, donor side morbidity, and patient´s satisfaction were evaluated. Follow-up was 3 to 40 months. Indications were: two nonunion of the distal radius in spite of several surgical procedures, one defect of the distal radius following a radius fracture with osteoarthritis of the radiocarpal joint, one acute trauma with partial loss of the carpus and radius due to an explosion injury, reconstruction of the first metacarpal (MC) following resection of a giant cell tumour, and three fusions between the 1^st and 2^nd MC as a salvage procedure after several surgical procedures at the saddle joint.

RESULTS

There was a regular bony healing in 4 of the 8 cases; delayed bony healing was seen in three cases after 7, 8, and 9 months. In one case there was only a partial bony healing. Two donor side haematomas required surgical revision. Patient's satisfaction was high with 7 painless cases.

CONCLUSION

Free vascularized bone grafts from the medial femur condyle can successfully be used to reconstruct bone defects up to 4 cm of the upper extremity other than the scaphoid.

Autologous rib cartilage as implanted stiffener of phalloplasty: comparing three different methods

BACKGROUND

Maintaining the length, rigidity, and appearance of a reconstructed phallus in the long term has been challenging for phalloplasty and may depend on choosing the optimal implanted stiffener. The aim of this study was to determine the best type of stiffener for a reconstructed phallus regarding aesthetic and functional parameters.

METHODS

From 1987 to 2018, 376 individuals underwent phalloplasty at a single institution of which 81 met the following inclusion criteria: biological male gender, age between 18 and 60 years, radial forearm flap for tube-within-a-tube phalloplasty with rib cartilage and secondary glans sculpting and unimpaired urination preoperatively. Those were divided into three groups with regard to different types of autologous rib cartilage stiffener. A group with a cartilage strip, T-shaped cartilage, and mushroom-shaped cartilage group were evaluated regarding preserved length and aesthetic features of the phallus during a minimum period of 12 months. The rib cartilage length in the phallus was 10.5 cm in all groups.

RESULTS

The length of the phallus was 10.8 ± 0.5 cm in the cartilage strip group, 11.3 ± 0.3 cm in the T-shaped cartilage group and 11.3 ± 0.3 cm in the mushroom-shaped cartilage group at 1-year postoperatively. The aesthetic appearance score of mushroom-shaped cartilage group was 1.67 ± 0.48, significantly higher than the cartilage strip group (1.38 ± 0.50, p = 0.03) at 1 year after surgery.

CONCLUSIONS

The mushroom-shaped autologous rib cartilage group showed superior length preservation and aesthetic appearance and appeared as the best type of stiffener for one-phase phalloplasty.

[Nerve transposition (nerve transfer): development and principles]

This review article presents the history, indications and techniques for the usual nerve transpositions in the upper extremities. By means of nerve transposition paralyzed muscles are reinnervated using dispensable donor motor axons. Many standard operations on the upper extremities are attributable to concepts of German-speaking surgeons and orthopedists. The reliable return of function by the short-range and selective motor reinnervation using nerve transfer results in a renaissance of these techniques. The spectrum of applications has been substantially extended in recent years. In order to achieve an optimal result, a subtle microsurgical technique is necessary. In this way excellent results can be achieved even for complex proximal nerve injuries.

Breast reconstruction during the COVID-19 pandemic in resource-limited settings

The coronavirus disease 2019 (COVID-19) is a novel, rapidly changing pandemic. It has affected specialized medical services in unprecedented ways. Surgical decision making, always the most important aspect of care has taken on an added layer of complexity in the face of the COVID-19 pandemic. Therefore, recommendations for breast reconstruction during COVID-19 remain challenging and unclear. This article reviews the impact of the COVID-19 pandemic and suggests potential approaches that could be considered in the absence of validated strategies in breast reconstruction.

Nerve transfers in tetraplegia: a review and practical guide

INTRODUCTION

Spinal cord injury (SCI) may lead to tetraplegia. Several nerve transfers have been successfully used for the restoration of the upper limb in tetraplegia. Reconstruction of an upper limb is individualized based on the functional level. In this study, the authors reviewed nerve transfers based on the injury level for the restoration of upper limb function in tetraplegia.

EVIDENCE ACQUISITION

We performed this study to review nerve transfers in tetraplegia by searching MEDLINE and EMBASE databases to identify relevant articles published through December 2020. We selected studies that reported cases in tetraplegia and extracted information on demographic data, clinical characteristics, operative details, and strength outcomes based on each injury level after surgery.

EVIDENCE SYNTHESIS

Total of 29 journal articles reporting on 275 nerve transfers in 172 upper limbs of 121 patients were included in the review. The mean time between SCI and nerve transfer surgery was 21.37 months (range: 4-156 months), and the follow-up time was 21.34 months (range: 3-38 months). The best outcomes were achieved for the restoration of wrist/finger extension and elbow extension.

CONCLUSIONS

Nerve transfer can provide a new function in tetraplegic patients' upper limbs to improve daily living activities. The type of surgical procedure should be performed based on the functional level of SCI and the individual's needs. Functional recovery occurs more in extensor muscles than flexors. Nerve transfer is a promising option in the reconstruction of upper limb function in tetraplegia.

Microsurgical Reconstruction of the Lower Extremity in the Elderly

Demand has increased for complex lower-extremity reconstruction in the steadily growing elderly patient group in many highly developed countries. Microsurgery is indispensable for soft tissue reconstruction and osseous consolidation salvaging leg function and preventing amputation, with its devastating consequences. Microvascular reconstruction can be performed successfully in specialized centers with low donor-site morbidity, minimal operative time, and comparably low complication rates. However, this requires thorough multidisciplinary planning, preoperative optimization of risk factors, such as diabetes and malnutrition, and individually adapted intraoperative management. Implementing these principles can reliably restore ambulation and mobility, maintaining autonomy in this population.

[A short History of Handsurgery with link to video]

Hand surgery is a combination of microsurgery, osteosynthesis, nerve and tendon surgery focusing on the most essential organ in daily life and in societal interactions: the human hand. A discipline as important and highly specialized as hand surgery must be based on scientific studies and milestones from the past. Our work accompanies the video with english subtitles that was displayed in part during the opening ceremony of the 58th Congress of the Deutsche Gesellschaft für Handchirurgie (DGH, German Society of Hand Surgery) in Munich (President of the conference, Univ.-Prof. Dr. R. Giunta). This paper presents the development of hand surgery from its historical origins, focusing on and introducing important characters from the times of Hippokrates, the Middle Ages, the Renaissance, the 18th and 19th centuries, as well as the two World Wars. In summary, progress of hand surgery is linked to the advances in anatomy, tendon surgery, nerve surgery and closely connected to the necessity of specialized care for upper limb injuries during and after World War II. A well-founded understanding of history and an insight into the development of our specialization underlines the importance of our daily work as hand surgeons and creates new incentives for the future development of hand surgery.This contribution is published in honor of Ulrich Lanz on occasion of his 80th birthday in november 2020.

Availability Of Covid-19 Information From National And International Burn Society Websites

National and international burn society websites are an important source of information for patients and burn care professionals. The current COVID-19 pandemic represents an unprecedented global health crisis. The aim of this study was to assess the information available on national and international burns society websites on the current pandemic of COVID-19. National and international burns society websites were assessed with regard to COVID-19 information. Five percent of nations had a burn care society website. Forty percent of these national society websites mentioned COVID-19. None provided their state's guidelines, nor advised to provide only urgent or emergent care. None recommended following WHO guidelines. One-third (33%) of the international societies documented the decision to postpone its congress and provided links to two articles describing burn care during the COVID-19 pandemic. The availability of COVID-19 clinical guidelines and information on national and international burn care society websites is lacking. Burn care society websites must develop relevant COVID-19 information to support burn care professionals on the frontline of care.

Bladder Pain Syndome/Interstitial Cystitis due to Pudendal Nerve Compression: Described in 1915-A Reminder for Treating Pelvic Pain a Century Later

Background  Interstitial cystitis (IC) or bladder pain syndrome (BPS) is highly painful and disabling and probably the most misdiagnosed urologic condition. Its classic symptoms of perineal pain, urinary urgency, and frequency despite sterile urine cultures were already described more than a century ago in a report on soldiers during World War (WW) I due to chronic pudendal nerve compression. Objectives  This article translates a report from 1915 on pudendal neuropathy and discusses its author Georg Zülzer (1870-1949). Methods  An English translation of the German original is provided with the biography and work of Zülzer, his clinical observations are discussed regarding modern diagnosis and therapy of pudendal nerve compression. Results  In his article entitled "Irritation of the Pudendal Nerve (Neuralgia). A Frequent Clinical Picture during War Feigning Bladder Catarrh," Zülzer describes his observation of soldiers during WW I, presenting with a triad of perineal pain, urinary urgency, and frequency despite sterile urine cultures excluding urinary infections. He also documented a characteristic skin hypersensibility of the perineum in a rhomboid shape which corresponds to the innervation area of the pudendal nerve with its two branches deriving from the "pudendal plexus." He regards this symptomology as rare during peace, but as disease of trench warfare which can be easily diagnosed regarding clear urine and a painful skin island overlying the area of the pudendal nerve as tested by simple needle examination. Zülzer, born in Germany, was forced to emigrate to the United States in 1934, was also an important pioneer of diabetes research using pancreas extracts from dogs as early as 1907. Conclusion  In this historical description, dating from about a century ago, Georg Zülzer probably gave the first exact clinical description of symptoms due to pudendal nerve compression. Pudendal nerve compression should always be taken into account when examining and treating patients with symptoms of IC/BPS.

Management of Spinal Cord Injury-Induced Upper Extremity Spasticity

Spasticity affects more than 80% of patients with spinal cord injury. Neural mechanisms and musculotendinous alterations lead to typical upper extremity features including shoulder adduction/internal rotation, forearm pronation, and elbow, wrist, and finger flexion. Long-standing spasticity may lead to soft tissue and joint contractures and further impairment of upper extremity function. Surgical management involves tendon lengthening, release, and transfer, as well as selective neurotomy, in an effort to reduce spastic muscle hypertonicity, restore balance, prevent further contracture, and improve posture and function. This article summarizes surgical strategies to improve function of the upper extremity in patients with tetraplegia.

Nikolaus Rüdinger (1832-1896), His Description of Joint Innervation in 1857, and the History of Surgical Joint Denervation

BACKGROUND

 Selective joint denervation has become a reliable palliative treatment, especially for painful joints in the upper and lower extremity.

METHODS

 This article highlights the life and work of Nikolaus Rüdinger (1832-1896) who first described joint innervation which became the basis of later techniques of surgical joint denervation. The historical evolution of this method is outlined.

RESULTS

 Rüdinger made a unique career from apprentice barber to military surgeon and anatomy professor in Munich, Germany. His first description of articular innervation of temporomandibular, shoulder, elbow, wrist, finger, sacroiliac, hip, knee, ankle, foot, and toe joints in 1857 stimulated the subsequent history of surgical joint denervation. Comparing his investigations with modern joint denervation methods, developed by pioneers like Albrecht Wilhelm or A. Lee Dellon, shows his great exactitude and anatomical correspondence despite different current terminology. Clinical series of modern surgical joint denervations reveal success rates of up to 80% with reliable long-term results.

CONCLUSION

 The history of joint denervation with Rüdinger as its important protagonist offers inspiring insights into the evolution of surgical techniques and exemplifies the value of descriptive functional anatomy, even if surgical application may not have been realized until a century later.

Revision Surgery after Carpal Tunnel Release –Analysis of the Pathology in 200 Cases during a 2 Year Period

Carpal tunnel release (CTR) is regarded as a common and successful operative procedure in hand surgery. However, an increasing number of patients with complications have been referred to our hospital. This retrospective investigation was undertaken to clarify the reasons for persisting or recurrent symptoms in 200 patients who underwent secondary exploration during a 26 month period at a single institution. In 108 cases, the flexor retinaculum was found to have been released incompletely. In 12 patients, a nerve laceration had occurred during the primary intervention. In 46 patients, symptoms were due to the nerve being tethered in scar tissue. The re-exploration revealed circumferential fibrosis around and within the median nerve in 17 patients and a tumour in the carpal tunnel in four patients. In 13 patients, no specific reason was found for recurrence of symptoms. We conclude that CTR seems to be a widely underestimated procedure and revision surgery could be largely avoided by reducing technical errors during the primary operation.

Launching a new national tetraplegia upper extremity surgery service

OBJECTIVE

Surgical restoration of upper extremity function in tetraplegia is acknowledged as beneficial, yet in many countries it is underused or absent. This study describes a 10-year review of a project to implement a tetraplegia upper extremity surgery service in Hungary. The main aims were to increase awareness among patients, the medical community and the public about the benefits of this rehabilitation. The process of implementing a national tetraplegia hand surgery service is described, together with a retrospective outcome study of upper extremity function after surgical reconstruction in this service.

METHODS

A total of 141 tetraplegic patients were assessed. Of these, 57 (40%) underwent a total of 126 reconstructions, including 366 procedures, between 2002 and 2012. Clinical parameters and patient-perceived results demonstrated improved functions and abilities. Considerable media attention and scientific presentations facilitated making this service permanent. In 2009, surgical rehabilitation in tetraplegia became a recognized part of the rehabilitation protocol in Hungary.

RESULTS

These results suggest that the success of starting a national tetraplegia hand service relies on convincing postoperative outcomes, patient-to-patient contacts, and co- operation between rehabilitation specialists, therapists, health authorities and surgeons.

DISCUSSION

The leadership of dedicated hand surgeons is necessary to provide and disseminate scientific support for the concept of tetraplegia hand surgery and to stimulate interdisciplinary communication and educational programmes.

Tetraplegia Management Update

Tetraplegia is a profound impairment of mobility manifesting as a paralysis of all 4 extremities owing to cervical spinal cord injury. The purpose of this article is to provide an update and analyze current management, treatment options, and outcomes of surgical reconstruction of arm and hand function. Surgical restoration of elbow and wrist extension or handgrip has tremendous potential to improve autonomy, mobility, and critical abilities, for example, eating, personal care, and self-catheterization and productive work in at least 70% of tetraplegic patients. Tendon and nerve transfers, tenodeses, and joint stabilizations reliably enable improved arm and hand usability, reduce muscle imbalance and pain in spasticity, and prevent joint contractures. One-stage combined procedures have proven considerable advantages over traditional multistage approaches. Immediate activation of transferred muscles reduces the risk of adhesions, facilitates relearning, avoids adverse effects of immobilization, and enhances functional recovery. Transfer of axillary, musculocutaneous, and radial nerve fascicles from above the spinal cord injury are effective and promising options to enhance motor outcome and sensory protection, especially in groups with limited resources. Improved communication between medical disciplines, therapists, patients, and their relatives should help that more individuals can benefit from these advances and could empower many thousands tetraplegic individuals "to take life into their own hands" and live more independently.

Review of Upper Extremity Nerve Transfer in Cervical Spinal Cord Injury

OBJECTIVE

 Several nerve transfers have now been successfully performed for upper limb reanimation in tetraplegia. This study was performed to review the use of nerve transfers for upper limb reanimation in tetraplegia.

METHODS

 Medline and Embase (1950 to February 11, 2015) were searched using a search strategy designed to include any studies that reported cases of nerve transfer in persons with cervical spinal cord injury (SCI).

RESULTS

 A total of 103 manuscripts were selected initially and full-text analysis produced 13 studies with extractable data. Of these manuscripts, 10 reported single cases and 3 reported case series. Eighty-nine nerve transfers have been performed in 57 males and 2 females with a mean age of 34 years. The mean SCI level was C6 (range: C5-7), time to surgery post-SCI was 19.9 months (range: 4.1-156 months), and follow-up time was 18.2 months (range: 3-60 months). All case reports recorded a Medical Research Council (MRC) score of 3 or 4 for recipient muscle power, but two early case series reported more variable results.

CONCLUSION

 This review documents the current status of nerve transfer surgery for upper limb reanimation in tetraplegia and summarizes the functional results in 59 cases with 89 nerve transfers performed, including 15 cases of double-nerve transfer and 1 case of triple-nerve transfer.

The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb interphalangeal joint

Hyperflexion of the thumb interphalangeal (IP) joint interferes significantly with pinching between the thumb and the index finger in a paralyzed hand. The extensor pollicis longus-loop-knot (ELK) procedure was used successfully in 7 tetraplegic patients to balance the IP joint between strong restored flexor function and lacking or weak antagonism of the thumb extensors. A V-shaped incision was made over the extensor hood at the level of the IP joint, the extensor pollicis longus (EPL) tendon was elevated, a loop was formed, secured by sutures, and then turned proximally onto the EPL tendon itself and fixed on both sides. The operation reliably limited the maximum range of IP flexion at 20 to 30 degrees from neutral. Postoperative problems did not occur. The ELK procedure is easy and quick and secures the optimal setting of IP flexion with limited flexibility, which is advantageous compared with rigid bony arthrodesis. It also avoids certain disadvantages of the commonly used flexor pollicis longus split tenodesis and is therefore a valuable alternative for the correction of Froment's sign due to intrinsic or extrinsic paralysis of the thumb.

Joint denervation and neuroma surgery as joint-preserving therapy for ankle pain

Partial joint denervation or surgical neuroma therapy are alternative concepts to treat pain around the ankle joint that preserve joint function and relieve pain by interrupting neural pathways that transmit pain impulses from the joint to the brain. This review article summarizes the indication, anatomic background, operative techniques, and clinical results of joint denervation or neuroma surgery, which, although rarely reported and used, may provide a valuable alternative treatment in selected patients with neurogenous problems around the ankle.

[Restoration of knee extension with biceps femoris muscle transfer after resection of the quadriceps femoris muscle]

OBJECTIVE

Improvement of gait and ability to stand by reconstruction of functional knee extension.

INDICATIONS

Loss of function of the quadriceps femoris muscle due to tumour resection or traumatic damage of the muscle with loss of active knee extension.

CONTRAINDICATIONS

Inadequate strength of the biceps femoris muscle. Recurrent tumour or ankylosis of the knee joint.

SURGICAL TECHNIQUE

The tendon of the biceps femoris is dissected near the knee at the head of the fibula and is mobilized proximally. The underlying common peroneal nerve and the neurovascular supply of the biceps muscle must be spared. Through a ventral approach at the thigh the lateral intermuscular septum is opened and the biceps tendon is pulled through and sutured to the quadriceps tendon and periost of the patella.

POSTOPERATIVE MANAGEMENT

The knee is immobilized in extension with a cast followed by a knee orthosis for 6 weeks, which is followed by intensive physiotherapy; however, the patient should not be forced to flex the knee extensively. The orthosis can be worn for another 3-4 weeks to stabilize the knee joint, while the muscles are intensively trained.

RESULTS

Reliable reconstruction of functionally useful, active knee extension without an orthosis of a previously unstable knee joint in the sagittal plane, even if full extension is not to be expected.

Otfrid Foerster (1873-1941)--self-taught neurosurgeon and innovator of reconstructive peripheral nerve surgery

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

Restoration of active palmar abduction of the thumb in tetraplegia by tendon transfer of the extensor digiti minimi to abductor pollicis brevis

We describe a method to restore active palmar abduction of the thumb and report its functional impact in tetraplegia. At 54.2 (SD 42.8) months after cervical spinal cord injury (12 traumatic, 3 nontraumatic), the extensor digiti minimi (EDM) tendon was transferred to the abductor pollicis brevis (APB) through the interosseous membrane in 15 tetraplegic patients (age range 19-70 years) in addition to a mean 3.2 procedures to restore key pinch. According to International Classification, the operated upper extremities were in the OCu4 to OCu8 (1 patient X) group. The maximum distance between thumb and index finger tips during active or passive opening of the hand, maximum angle of palmar abduction, grip and key pinch strength, and active finger range of motion were measured. All patients were re-examined after 38.4 (SD 22.7) months. The active thumb-index opening increased significantly from 2.5 (SEM 1.0) cm before to 9.0 (SEM 0.8) cm after surgery. Nine patients without previous active opening of the first web space recovered a mean thumb-index opening of 9.1 (SEM 1.7) cm, whereas this distance increased by an average of 2.9 (SEM 0.8) cm in six patients who had active thumb index distance of 6.3 (SEM 1.6) cm before surgery. All but one patient were able to direct and coordinate key pinch and perform tasks using the restored APB function, including five patients whose EDM strength was rated as grade 3 before transfer. This EDM-to-APB transfer meets the theoretical requirements of architecture matching between donor and recipient muscles, the principles of tendon transfer, and our surgical expectations. We strongly recommend that an active EDM is transferred to the APB to restore opening of the hand and help in key pinch control in patients with tetraplegia.

Brachialis-to-extensor carpi radialis longus selective nerve transfer to restore wrist extension in tetraplegia: case report

Active wrist extension allowing tenodesis grip is the key function in high-level tetraplegic patients. It is absent and cannot be restored by traditional tendon transfer in patients who have no transferable muscle below the elbow. We present a 36-year-old man with high-level tetraplegia treated 12 months after injury who regained active wrist extension after transfer of the brachialis muscle branch of the musculocutaneous nerve to the extensor carpi radialis longus muscle branch of the radial nerve. No functional deficit of elbow flexion occurred after reconstruction.

Carpal tunnel syndrome caused by supernumerous lumbrical muscle in hemihyperplasia of the upper extremity

INTRODUCTION

Hemihyperplasia of the upper extremity is a rare pathology that occurs in 1/86,000 births. Carpal tunnel syndrome may be associated with this disease.

CLINICAL PRESENTATION

We describe the case of a 74-year-old male who has hemihyperplasia of both upper extremities since birth. At the age of 73, he started experiencing continuous, progressive and high intensity pain that occurred more frequently at night and was localized in the right hand. It was associated with paresthesia and hypoesthesia predominantly of the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to diagnosis of carpal tunnel syndrome.

RESULTS

The patient underwent surgical carpal tunnel release to treat the disease. The enlarged nerve was compressed by a supernumerous lumbrical muscle, which was resected intraoperatively. After six months of follow-up the patient has normal sensitivity and grip strength in the right hand.

CONCLUSION

Hemihyperplasia should be clearly distinguished from other complex pathologies that may also entail CTS. Since significant variation in the anatomy of the hemihyperplasic extremities is the rule rather than the exception, a conventional open approach should be taken to localize and treat the compression.

Simultaneous powering of forearm pronation and key pinch in tetraplegia using a single muscle-tendon unit

This study clinically assessed the concept that both thumb flexion and forearm pronation can be restored by brachioradialis (BR)-to-flexor pollicis longus (FPL) tendon transfer if the BR is passed dorsal to the radius. Six patients [two women and four men, mean age 32.3 years (SD 4.9, range 23-56)] underwent BR-to-FPL transfer dorsal to the radius and through the interosseous membrane (IOM). Lateral key pinch strength and pronation range of motion (ROM) were measured 1 year after surgery. A group of six patients [two women and four men, mean age 31.2 years (SD 5.0, range 19-52)] who underwent traditional palmar BR-to-FPL was included for comparison. Postoperative active pronation was significantly greater in the dorsal transfer group compared to the palmar group [149 (SD 6) and 75 (SD 3), respectively] and pinch strength was similar in the two groups [1.28 (SD 0.16) kg and 1.20 (SD0.21) kg, respectively]. We conclude that it is feasible to reconstruct lateral key pinch and forearm pronation simultaneously using only the BR motor.

Otto Hilgenfeldt (1900-1983): tribute to an important pioneer of European hand surgery

The German surgeon Otto Hilgenfeldt (1900-1983) was a great innovator in European hand surgery in the 20th century, particularly in respect of the tactile (sensate) thumb and grip reconstruction in amputation injuries. His experience, beginning in the 1930s, helped him to treat hundreds of soldiers with mutilating hand injuries from 1941 to 1945 during World War II. While totally isolated and without any access to international publications, he devised many innovative ideas such as a neurovascular middle finger transposition for pollicization (first case done in July 1943) and a sensory dorsoradial first metacarpal flap for thumb resurfacing. His book Operative thumb replacement and substitution of finger losses published in 1950 is regarded as one of the most important German contributions to modern hand surgery. Hilgenfeldt's life and work remain fascinating and exemplary from a historical and surgical point of view. Many of his pragmatic surgical solutions remain valid despite the advent of microsurgery.

A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

Reconstruction of nasal deformity in Wegener's granulomatosis: contraindication or benefit?

BACKGROUND

Saddle-nose deformity is a well-recognized stigma of patients affected by Wegener granulomatosis (WG). However, plastic surgical repair is seldom performed. In this study, the authors aimed to evaluate their own patients exclusively reconstructed by costal cartilage L-strut of the nose for this specific deformity.

METHODS

During a 5-year-period, four women with an average age of 33 years underwent reconstructive rhinoplasty of their saddle-nose deformity caused by WG, which in every case was in remission regarding the nose at the time of surgery. Restoration of the nasal framework was performed by an L-shaped rib cartilage graft.

RESULTS

The external form and function of the newly reconstructed nose was preserved during an average follow-up period of 42 months for all the patients. No resorption of the rib cartilage graft was observed. A review of the literature found a total of 22 nasal reconstructions for patients affected by WG.

CONCLUSION

According to this patient series and a review of the literature, external nasal reconstruction for patients affected by WG appears to be safe and effective if the disease is in remission before any operation. Despite concern that high-dose immune suppression therapy may increase the risk of failure in primary nasal dorsal repair, this could not be observed in the patients of this series, all of whom were receiving immunosuppressive medication. Therefore, nasal reconstruction to improve the physical appearance and thus the psychological well-being of these chronically ill patients seems to be justified.