[Diagnostics and classification of distal radius fractures]

Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X‑ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

Biomechanical considerations on a CT-based treatment-oriented classification in radius fractures

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

[Treatment of the ulnar impingement syndrome in the distal radioulnar joint]

Ligamentous stability and joint congruity are prerequisites for a physiological function of the distal radioulnar joint (DRUJ). Impingement of the ulnar head may be caused by a congenital ulna-minus variance or by an iatrogenically excessive ulna shortening osteotomy. This impingement is detected by a positive compression test at the DRUJ. Radius correction osteotomy with shortening and correction of the radial inclination to restore the sigmoid notch may solve the problem by reducing the pressure between both joint partners and by promoting the remodelling of the DRUJ. This technique may restore the distal radioulnar joint and thus prevent the necessity of salvage procedures.

[Distal radius fracture of the adult : Diagnostics and therapy]

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

Scaphotrapeziotrapezoid (STT)-Arthrodesis in Kienböck’s Disease

This study reviews the results of 59 of 84 patients with severe Kienböck’s disease who were treated with STT fusion. The average follow-up period was 4 (ranges: 2–8) years.

The average arc of wrist extension and flexion was 67° (60% of the contralateral side, 81% of pre-operative range) and that of ulnar and radial deviation was 31° (52% of the contralateral side, 56% of pre-operative range). Pre-operative pain values (VAS) were 56 (non-stress) and 87 (stress) and were significantly higher than the postoperative values of 12 (non-stress) and 41 (stress). Grip strength improved from 45 kPa pre-operatively to 52 kPa postoperatively. The mean modified Mayo wrist score was 63 points. The patients reported low disability in the DASH scores, with an average of 28 points.

Our data show that STT fusion is a reliable and effective treatment for pain relief and offers a good functional result in advanced stages of Kienböck’s disease. However the long-term effect of this procedure on radioscaphoid and other intercarpal joints is yet to be determined.

The distal radial decompression osteotomy for ulnar impingement syndrome

INTRODUCTION

The decompression of the distal radioulnar joint (DRUJ) is performed by ulnar translation of the radial shaft proximal to the sigmoid notch, i.e. detensioning of the distal part of the interosseous membrane (DIOM) while containment of the DRUJ is achieved by closed wedge osteotomy of the radius. The osteotomy shortens the radius which entails detensioning of the triangular fibrocartilage complex (TFCC).

SURGICAL TECHNIQUE

Facilitating the modified Henry approach to the distal palmar radius a radial based wedge osteotomy is applied. The proximal osteotomy is proximal to the ulnar head and distal osteotomy is proximal to the sigmoid notch to prevent iatrogenic impingement. Ulnar translation of the radial shaft is performed to loosen the DIOM. The closed wedge osteotomy reduces radial inclination which will foster containment of the DRUJ.

CONCLUSION

Distal radial decompression osteotomy of the DRUJ preserves DRUJ function while relieving painful impingement. Further surgical interventions are not compromised in case of failure.

Gadolinium-enhanced preoperative MRI scans as a prognostic parameter in scaphoid nonunion

The purpose of this prospective study was to correlate preoperative gadolinium-enhanced MRI scans with intraoperative bleeding of the proximal fragment and postoperative union in a series of consecutive patients with established scaphoid nonunions. In 60 patients (6 females, 54 males) with a mean age of 29 years, scaphoid perfusion was judged preoperatively as normal, impaired or absent using a gadolinium-enhanced MRI scan. Scaphoid reconstruction was performed using a nonvascularized bone graft and screw fixation. Perfusion of the proximal fragment was assessed intraoperatively in 49 of 60 patients; compromised or absent vascularity was predicted with a specificity of 90% by contrast-enhanced MRI. However, there was no significant correlation between preoperative MRI assessment of vascularity and subsequent union of the scaphoid.

Avascular necrosis (AVN) of the proximal fragment in scaphoid nonunion: is intravenous contrast agent necessary in MRI?

PURPOSE

The purpose of this prospective study is to assess the diagnostic value of intravenously applied contrast agent for diagnosing osteonecrosis of the proximal fragment in scaphoid nonunion, and to compare the imaging results with intraoperative findings.

MATERIALS AND METHODS

In 88 patients (7 women, 81 men) suffering from symptomatic scaphoid nonunion, preoperative MRI was performed (coronal PD-w FSE fs, sagittal-oblique T1-w SE nonenhanced and T1-w SE fs contrast-enhanced, sagittal T2*-w GRE). MRI interpretation was based on the intensity of contrast enhancement: 0 = none, 1 = focal, 2 = diffuse. Intraoperatively, the osseous viability was scored by means of bleeding points on the osteotomy site of the proximal scaphoid fragment: 0=absent, 1 = moderate, 2 = good.

RESULTS

Intraoperatively, 17 necrotic, 29 compromised, and 42 normal proximal fragments were found. In nonenhanced MRI, bone viability was judged necrotic in 1 patient, compromised in 20 patients, and unaffected in 67 patients. Contrast-enhanced MRI revealed 14 necrotic, 21 compromised, and 53 normal proximal fragments. Judging surgical findings as the standard of reference, statistical analysis for nonenhanced MRI was: sensitivity 6.3%, specificity 100%, positive PV 100%, negative PV 82.6%, and accuracy 82.9%; statistics for contrast-enhanced MRI was: sensitivity 76.5%, specificity 98.6%, positive PV 92.9%, negative PV 94.6%, and accuracy 94.3%. Sensitivity for detecting avascular proximal fragments was significantly better (p<0.001) in contrast-enhanced MRI in comparison to nonenhanced MRI.

CONCLUSION

Viability of the proximal fragment in scaphoid nonunion can be significantly better assessed with the use of contrast-enhanced MRI as compared to nonenhanced MRI. Bone marrow edema is an inferior indicator of osteonecrosis. Application of intravenous gadolinium is recommended for imaging scaphoid nonunion.

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND

Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out.

METHODS

We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system.

RESULTS

All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation.

CONCLUSION

Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.

[Ulna shortening osteotomy using a new 7 hole gliding plate. Results from 73 cases]

BACKGROUND

Ulna shortening osteotomy is a common procedure for the surgical treatment of ulna impaction syndrome, but it is still associated with complications such as rotation malalignment, and delayed or non-union due to of incomplete closure of the osteotomy gap.

METHODS

We have developed a 7-hole titanium compression plate that provides fixation of the ulna before the osteotomy is carried out. With this plate, which has been in use for 4 years, a shortening of up to 10 mm is possible using two gliding holes, with the compression holes enabling the closure of the osteotomy gap. We report the results of 70 patients undergoing 70 ulna shortening procedures, with a follow-up of between 5 and 18 months. Two patient groups underwent follow-up clinical examination as well as completing the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for evaluation.

RESULTS AND CONCLUSIONS

There was no occurrence of delayed or non-union. The DASH score averaged 19 points in the prospective and 23 points in the retrospective group, representing a good functional result with only minor impairment. This study indicates that ulnar shortening using this gliding compression plate and performing an oblique osteotomy is associated with a minimal complication rate and highly satisfactory clinical outcome.

Der Fingermittelgelenkersatz mit Pyrocarbonprothesen

OBJECTIVE

Prosthetic joint replacement to reduce pain and maintain function of the proximal interphalangeal joint.

INDICATIONS

Symptomatic arthritis of the proximal interphalangeal joint with preservation of the collateral ligaments, sufficient bone support, and intact or at least reconstructable extensor tendons.

CONTRAINDICATIONS

Lack of stability, e. g., as a result of rheumatoid arthritis or destruction of the ligaments caused by an accident. Nonreconstructable extensor tendons. Florid or chronic infection. Lack of patient compliance.

SURGICAL TECHNIQUE

Dorsal approach to the proximal interphalangeal joint. A triangular tendinous flap with pedicle, based distally on the insertion of the medial band, is lifted up, leaving the lateral bands intact. The joint surfaces are resected while maintaining the palmar plate and the collateral ligaments. The trial prosthesis is fitted, its position is checked, and the final unconstrained prosthetic components are inserted using a press-fit technique. The dorsal aponeurosis is reapproximated.

RESULTS

20 patients were treated for posttraumatic or idiopathic arthritis with 24 pyrolytic carbon PIP prostheses, and a follow-up examination was carried out after an average of 15 months (6-30 months). Surgical management was changed from arthroplasty to arthrodesis in three cases. For the remaining prostheses, an average range of motion of 50 degrees was achieved for the proximal interphalangeal joint. On the visual analog scale (VAS; 0: no pain, 10: incapacitating pain), the patients suffered few symptoms (VAS: 0-3). 80% of patients said they were satisfied with the outcome of the operation. In three cases (one infection, two dislocations) the prostheses had to be removed and arthrodesis performed. Migration of the distal components was observed on the radiographs in five cases, and of the proximal components in four cases, although this did not have any effect on the functional parameters. The development of a painless noise ("squeaking") was noticed in nine out of 21 prostheses. However, as with prosthetic migration, this did not cause any functional deficits.

Multidirektionale winkelstabile Versorgung der instabilen distalen Radiusfraktur

PURPOSE/BACKGROUND

Open reduction and internal fixation with plates is a valid treatment of displaced extra- and intra-articular distal radius fractures. This report presents our experience treating unstable distal radius fractures by using a multidirectional palmar fixed-angle plate system (Aptus(R) Radius 2.5 by Medartis). The subchondral support of the articular surface by fixed angle screws prevents secondary dislocation allowing early mobilisation.

PATIENTS AND METHOD

61 patients with distal radius fractures were treated during 6/2003 and 10/2004 using this palmar fixed-angle plate fixation without bonegraft. Postoperative X-rays showed anatomical reduction in all cases. 55 patients could be evaluated postoperatively. The follow-up examination included the patient's history, physical and radiographic examination as well as the DASH questionnaire and the Krimmer's modified Cooney wrist score.

RESULTS

The average follow-up time was 9.6 +/- 5.2 months. The mean age of the examined patients was 53.9 +/- 17.8 years. The fractures were classified according to AO. There were eleven A3, four B2 and five B3 fractures, ten C1, 16 C2 and nine C3 fractures. All fractures united without complications. Just two cases showed a loss of length. At follow-up the average palmar angulation was 8 degrees , ulnar inclination 21 degrees and ulnar variance + 0.2 mm. Wrist motion averaged a decrease for extension and flexion of 12 %, for ulnar and radial deviation of 9 % and for pronation and supination only of 2 % in comparison to the uninjured side. Grip strength reached an average of 85 % of the contralateral side. Patients regained good function as represented in a mean DASH score of 14 points and a Krimmer score of 82 points.

CONCLUSIONS

The treatment of unstable distal radius fractures with this plate fixation provided stable internal fixation and allowed early function. Due to multidirectional angle fixation and two lines of cortical screws it is possible to achieve an optimal restoration. The fixation of the central articular surface is guaranteed by the distal line, the dorsal subchondral support by the proximal line.

[The reamer--a new instrument for simplified harvesting of donor bone from the iliac crest]

Harvesting donor bone from the iliac crest site to fill gaps in bone defects is a simple operation but there are still reports of many complications occurring in the bone harvesting process. We now describe a procedure that significantly decreases the morbidity of the donor site. Reports on the iliac crest miller modified according to Krimmer that was applied on 40 patients (average age: 68 years) afforded results that were compared with data collected from the use conventional methods (average age: 65 years). The average length of the skin incision of 41 mm was significantly shorter than the incision length recorded in connection with the conventional methods, namely 79 mm. The harvesting time was limited to 7.6 minutes instead of 18 minutes und thus was also significantly shorter. The postoperative pain as measured on the basis of a visual analogue scale (0 to 100 points) was as follows: pain records were lower than those of the control group by 29 points on the second day following the operation, by 25 points on the fourth day, and by 17 points on the 12th day following the operation. No complications were observed. In the control group there were three haematomas, two cicatricial dehiscences, one cicatricial keloid and one loss of sensibility. This new procedure fulfils the demands for a minimally invasive technique.

[Long-term results after resection arthroplasty in patients with arthrosis of the thumb carpometacarpal joint: comparison of abductor pollicis longus and flexor carpi radialis tendon suspension]

PURPOSE/BACKGROUND

This retrospective analysis focused on a comparison of long-term results in patients who underwent resection of the trapezium with subsequent arthroplasty and tendon suspension using either the abductor pollicis longus (APL) or the flexor carpi radialis (FCR) tendon.

METHOD AND MATERIAL

Based upon a positive history along with a clinical and radiological examination, 20 patients underwent suspension arthroplasty using the APL tendon (APL group) and 21 patients suspension arthroplasty using the FCR tendon (FCR group) after trapeziectomy. In both groups mean age (APL group: 60.4 +/- 5.3; FCR group: 61.7 +/- 6.8 years), pain severity according to the Visual Analogue Scale (VAS; APL group: 6.7 +/- 1.9; FCR group: 6.9 +/- 1.7), severity of arthrosis in the thumb carpometacarpal joint according to the Eaton-Littler classification (APL group: 3 +/- 0.7; FCR group: 3.2 +/- 0.6) and time interval from onset of symptoms to surgery (APL group: 27 +/- 8.1; FCR group: 41.5 +/- 14.1 months) did not significantly differ. Each patient of both groups was treated surgically and reviewed by one experienced hand surgeon. Both groups received the same standardized postoperative treatment.

RESULTS

In the APL group the mean operative time was significantly shorter (31.7 +/- 9.5 min) than in the FCR group (48.7 +/- 7.9 min). The follow-up period from surgery to the final examination was similar in both groups (APL group: 23.1 +/- 12.2; FCR group: 31 +/- 17.6 months). At the time of the final examinations, no statistically significant differences were found when analyzing the results of the DASH score (APL group: 20.1 +/- 15.1; FCR group: 29.3 +/- 15.7), the self-administered hand ability score (APL group: 1.7 +/- 0.6; FCR group: 2.1 +/- 0.6) and the VAS (APL group: 1.1 +/- 1.6; FCR group: 0.8 +/- 1.5). The time period from surgery to the offset of postoperative pain was also comparable in both groups (APL group: 5 +/- 1.8; FCR group: 5.3 +/- 2.5 months). The range of abduction in the first carpometacarpal joint after arthroplasty, parallel and perpendicular to the dorsum of the hand, was also similar in both groups (APL group: 63.4 +/- 14.3 degrees /62.1 +/- 11 degrees ; FCR group: 67.8 +/- 12.7 degrees /66 +/- 12.1 degrees ). However, patients enrolled in the APL group revealed significantly better results compared to patients in the FCR group regarding grip-strength, key and pinch grip (APL group: 23.9 +/- 9.7/6.6 +/- 2.4/6.2 +/- 2.8 kg; FCR group: 17 +/- 7.2/4.5 +/- 1.5/3.6 +/- 1.5 kg).

CONCLUSION

Both techniques led to highly satisfactory results as seen in DASH and VAS data together with a near normal range of abduction in the first carpometacarpal joint in all enrolled patients. However, in direct comparison the APL procedure is technically easier to perform with significantly shorter surgery time recorded and significantly higher values in all force parameters compared to the FCR procedure.

Ulnar shortening osteotomy with a new sliding-hole plate

Ulnar shortening osteotomy represents a common procedure for surgical treatment of the ulnar impaction syndrome but is still associated with complications like malrotation, angulation, or malunion because of incomplete closure of the osteotomy gap. Therefore, the authors developed a special 7-hole compression plate that allows fixation of the ulna before the osteotomy is carried out to prevent rotation. With this plate, a shortening of up to 10 mm is possible and the compression holes allow closure of the osteotomy gap. The plate has been used in 23 ulnar shortening cases at their center with good results. The authors describe the technique and report their results of ulnar shortening with this device.

[Pyrocarbon prosthesis for finger interphalangeal joint replacement. Experience after one year]

The long-term results of finger joint replacement, particularly the proximal interphalangeal (PIP) joint, have mostly been disappointing according to a review of the international literature and our own experiences. The recently developed pyrolytic carbon implants (Ascension Orthopedics, Austin, Texas) for replacing the PIP joint were evaluated retrospectively regarding range of motion, functionality, and relief of pain. In our hospital 17 PIP joints were replaced with pyrolytic carbon implants in 16 patients by an offset stem technique inserted without cement. This study included 13 patients; we excluded three patients because of follow-up <3 months. Prerequisites were adequate collateral ligaments, bone stability, and sufficient or at least reconstructable extensor tendons. The purpose of this study was to evaluate the 1-year outcome (minimum 270, maximum 360 days) regarding range of motion, implant stability based on radiological and clinical parameters, and relief of pain using a pre- and postoperative visual and verbal analogue scale.There was an improved range of motion of the PIP joint from 0-28-51 preoperatively to 0-22-77 postoperatively (average value). On the visual analogue scale (0 no pain, 10 incapacitating pain) we achieved pain relief at rest and in motion of 80%. On the verbal analogue scale there was an improvement of 62%. The results of this study demonstrate that pyrolytic carbon implants reduce pain and are functionally superior to arthrodesis. A precise and individual postoperative protocol is necessary for beneficial results.

[Mid-term results after proximal row carpectomy and review of the literature]

PURPOSE

The aim of this study is to evaluate the results after proximal row carpectomy and to compare them with results in the literature.

METHOD

Between 1994 and 2001, 37 patients underwent proximal row carpectomy. 30 patients were available for follow-up. In all cases the proximal row carpectomy was performed through a dorsal approach. Clinical parameters were evaluated by using the conventional wrist score (Krimmer score) as well as the DASH-score.

RESULTS

Follow-up examination shows a range of motion (ROM) for wrist extension and flexion of 46 % of the contralateral side. ROM for ulnar and radial deviation is 42 % of the other side, ROM for pronation and supination is equal to the other side. Mean grip strength is determined to be 58 % of the contralateral side. 90 % of the patients are satisfied with the result of the operation. The Krimmer score amounts to 58 and the DASH score to 39 points.

CONCLUSION

We consider proximal row carpectomy to be a good therapeutic option for lunate necrosis stage IIIB or IV or carpal collapse stage II (SNAC or SLAC wrist) with a concomitant lesion of extrinsic ligaments with ulnar translocation. Another indication is the acute, non-reconstructable or the chronic perilunar luxation with arthrosis.

Intraoperative 3D-Bildgebung am Handgelenk mit einem mobilen isozentrischen C-Bogen

In addition to conventional radiological C-arm image amplifiers used for intraoperative imaging, now a new mobile C-arm image amplifier with an option for three dimensional imaging (Iso-C 3D) is available to visualize reduction of fractures and position of implants. In a wrist-model three titanium pins were placed and three holes of different length were drilled. Distances between the pins and the depths of the drilled holes were calculated in conventional computer tomographic scans and Iso-C 3D scans in perpendicular, 30 degree and 90 degree position of the gantry and compared to actual distances and depths. There were no significant differences between the actual measured distances and those measured by CT scans and Iso-C 3D scans. Furthermore, gantry position had no significant effect upon the results. Iso-C 3D scans are as reliable as conventional CT scans for intraoperative controlling of implant positioning.

Kahnbeinfrakturen - wann operativ, wann konservativ? CT-basierte Klassifikation

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

[Bilateral carpal tunnel syndrome with familial accumulation]

We report on a six-year-old girl with bilateral carpal tunnel syndrome with familial accumulation. Parents and one grandmother had positive history for CTS, treated by surgical decompression. Following neurologic and radiologic evaluation and after failed conservative treatment in a plaster cast, open carpal tunnel release was performed in a two-stage procedure. Postoperatively symptoms diminished and now six months after surgery, all complaints disappeared completely.

Die Kraftübertragung am Handgelenk nach Skaphoid-, Trapezium- und Trapezoideumfusion

Scaphotrapeziotrapezoid (STT) arthrodesis has been proposed to stabilise the radial column and to redirect the load away from the lunate. Midterm effects on force transmission are still unclear. Six patients who were treated with triscaphe arthrodesis were examined after an average of 5 years using CT osteoabsorptiometry of both wrists. STT arthrodesis had been performed in four cases with Kienböck's disease type IIIb and in two cases of scaphotrapeziotrapezoid arthritis. At all contralateral wrists peak mineralisations were found beyond the lunate fossa and in the scaphoid fossa of the distal radius. At the side with STT arthrodesis there was only one peak. In five cases this density maximum was beyond the scaphoid fossa and in one case half beyond the lunate and half beyond the scaphoid fossa. Triscaphe arthrodesis allows load transmission from the lunate to the radial column.

Handgelenkläsionen in der direkten MR-Arthrographie im Vergleich zur Arthroskopie des Handgelenks

BACKGROUND

Wrist arthroscopy is routinely used for diagnosis of ligamentous lesions to the wrist. Although it is very sensitive and specific, it is also more invasive than other available diagnostic techniques.

METHOD

In a prospective trial, 125 patients (80 men, 45 women) 37 years old (+/- 12) with clinical evidence of wrist lesions were evaluated with direct wrist arthro MRI. Within 24 hours following direct arthro MRI wrist arthroscopy was performed. The surgeons and radiologists were not aware of the other results until completion of their investigation. Specificity, sensitivity, positive predictive value, negative predictive value and accuracy were determined.

RESULTS

According to the MRI findings, lesions of the TFCC were suggested in 70 patients (56 % of all patients). In 65 cases this was confirmed by wrist arthroscopy. In the remaining 55 patients no TFCC lesions were detected by MRI. However in three cases TFCC lesions were found by arthroscopy. In the remaining 52 patients MRI accurately excluded TFCC lesions. There was a correlation of MRI and arthroscopy in detecting TFCC lesions in 93.6 %. Sensitivity was 94 %, specificity 89 %, positive predictive value 91 % and negative predictive value 93 %. Complete scapholunate ligament tears were detected by MRI in 12 (9.6 %) cases. Correlation with wrist arthroscopy was 99 %, sensitivity 92 %, specificity 100 %, positive and negative predictive value 100 % and 99 %, respectively. Accuracy for incomplete scapholunate lesions (n = 17, 13.6 %) and lunotriquetral tears (n = 4, 3.2 %) was poor (sensitivity 59 % and 25 %, specificity 100 % and 99 %).

CONCLUSION

Though sensitivity of MRI arthrography approaches that of arthroscopy, it cannot replace it at the moment. However, it is a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate diagnosis and indications for surgery of the wrist. It may make arthroscopic and more invasive interventions for diagnostic purposes avoidable in future.

Frühe Ergebnisse der Fingermittelgelenkendoprothetik mit der Pyrocarbonprothese (Ascension®) bei idiopathischen und posttraumatischen Arthrosen

Surgical treatment of painful idiopathic and post-traumatic arthritis with joint replacement of the proximal interphalangeal joint has become increasingly important. Due to shortcomings of former constrained and partially constrained prostheses with regard to abrasion and durability we have been using an unconstrained prosthesis since April 2002. This model is an almost abrasion free, biocompatible 2-component prosthesis. The surface is shaped like the condyles and the position is secured in a press-fit technique. During October 2004 we reviewed the results of 20 out of 29 patients with idiopathic or post-traumatic arthritis who had been treated with a pyrolytic carbon proximal interphalangeal joint prosthesis from April 2002 to April 2004 retrospectively. Clinical, subjective and radiological parameters were studied. On follow-up after 0.5 to 2.5 years the patients were satisfied with the pain relief. The range of motion varied. However, with an average ROM of 50 degree it was equivalent to the results in literature. Signs of periprosthetic cysts, osteophytes and loosening of the proximal as well as of the distal component could be seen in the radiograms of some patients. There was no correlation between these radiological observations and range of motion, pain or grip strength. In three cases the joint prosthesis had to be converted to an arthrodesis of the proximal interphalangeal joint. Bearing in mind the correct indications (intact collateral ligaments, stable bone stock and sufficient extensor and flexor tendons), pyrocarbon prosthesis are a treatment option for idiopathic and posttraumatic arthritis preserving motion and reducing pain. Radiological results seem to indicate an absence of osteointegration and tension forces at the prosthesis/bone interface. Further investigation will be necessary to improve surface and design to increase radiological results in long-term follow-up. Additional surveys are required to improve indications, surgical approach and intraoperative control of correct component positioning.

Zur Differenzialdiagnostik des „signalkompromittierten” Os lunatum in der MR-Tomographie

PURPOSE

To define both the underlying pathology and diagnostic criteria in lunates presenting with conspicuous signal pattern in MRI.

MATERIALS AND METHODS

The retrospective evaluation of 2940 MRI examinations revealed 203 patients with signal alterations of the lunate. All MRI examinations were performed on 1.5-Tesla platforms using dedicated surface coils and an intravenous contrast agent. To establish a definitive diagnosis, a total of 252 MRI examinations (49 follow-ups), 22 CT examinations and 4 arthroscopic studies were obtained in addition to the obligatory conventional radiographs.

RESULTS

Incorporating all clinical data, radiographs and MRI examinations succeeded in assigning a diagnosis in 136 signal-compromised lunates (67.0 %), whereas additional diagnostic procedures or follow-up examinations were required for the definitive diagnosis in 57 cases (33.0 %). The most frequent entities were 51 cases of Kienbock's disease (25.1 %), 47 cases of ulnolunate-(triquetral) impaction syndromes (23.2 %) and 44 cases of intra-osseous ganglion cysts (21.7 %). Other pathologies included 23 degenerative, 19 traumatic and 10 inflammatory changes as well as 9 congenital conditions. For MRI assessment of the altered lunate, the most important parameters were location and morphology as well as involvement of the articular and osseous structures of the carpus.

CONCLUSION

The lunate may be affected by different pathological states of the wrist. In total, only one quarter of the signal-compromised lunate represented Kienboeck's disease.

Special aspects of wrist arthritis management for SLAC and SNAC wrists using midcarpal arthrodesis: results of bilateral operations and conversion to total arthrodesis

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilateral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis experienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: I to 4). A mean arc of wrist extension and flexion of 53 degrees on the right and 49 of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed partial arthrodesis at rest and by 46% at stress on the visual analog scale andfrom intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain activities, 55%felt considerably and 15% strongly limited in daily life. However, all but two patients were satisfied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and preserved valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.

Palmare winkelstabile Plattenosteosynthese der instabilen distalen Radiusfraktur

Internal fixation of distal radius fractures often shows the problem of secondary dislocation due to dorsal comminution and osteoporosis. Although dorsal plating systems provide good stabilization, the intraoperative control of reduction is difficult in the comminuted area with high incidence for the need of cancellous bone graft. Occurrence of extensor tendon complications including tendonitis and rupture is not uncommon. The use of fixed angle devices by a palmar approach has demonstrated the advantage of better visualization and control at the fracture side. The subchondrale support of the articular surface by fixed angle pegs or screws prevents secondary dislocation allowing early mobilization. Better soft tissue coverage is associated with a low complication rate. 62 patients (average age 55 years) were treated with different fixed angel devices according to the fracture type and underwent retrospective evaluation with mean follow-up of 11 months (6-23 months). According to the AO Classification there were 3 A2, 24 A3, 7 B3, 14 C1, 9 C2 und 5 C3 fractures. The majority beside the B3 types and one C3 fracture were dorsally displaced. All of them showed healing without relevant secondary loss of reduction. Mean DASH score reached 19 points.

[Ulnar head prosthesis]

The ulnar head prosthesis has been the subject of a prospective multicenter-study since 1995. Until 2000, it has been used in 57 patients by the study group. In 35 patients, the indication was painful instability of the distal end of the ulna following previous resection arthroplasties, and in 22 patients it was painful arthritis of the distal radioulnar joint (DRUJ). The mean follow-up was 38 months. Pronation increased from a preoperative mean of 63 degrees to a postoperative value of 78 degrees, while supination increased from 43 degrees to 76 degrees. Grip strength improved from a preoperative mean of 51% to a postoperative mean of 77% of the opposite limb. Pain, measured on the verbal pain scale (1-4), was reduced remarkably from a preoperative mean level of 3.6 to a postoperative mean of 1.7. Patient' satisfaction was evaluated using the visual analog scale (0-10) and improved from a preoperative mean of 2.1 to a postoperative mean of 7.9. With one exception of loosening, we consistently found bony integration of the shaft of the prosthesis. Stability of the DRUJ was achieved in all but three patients. This method has given reliable and excellent results as a salvage procedure for failed resection arthroplasties of the DRUJ with painful instability of the distal end of the ulna. We consider the method an alternative treatment option for the arthritically destroyed DRUJ. Sufficient soft tissue to stabilise the prosthesis is needed to successfully reconstruct the DRUJ.

Minimal invasive treatment for scaphoid fractures using the cannulated herbert screw system

Internal fixation of scaphoid fractures avoids the problems associated with prolonged plaster immobilization and, at the same time, allows an early return to activity for these mostly young patients.Internal fixation of the scaphoid is greatly facilitated by the use of specially designed headless bone screws, such as the Herbert bone screw, originally developed specifically for internal fixation of the scaphoid; furthermore, the advent of cannulated scaphoid screws has made closed (percutaneous fixation) stabilization of the scaphoid a reality. Indeed, this method has now become the treatment of choice for the majority of acute scaphoid fracture, bringing with it all the advantages of internal fixation without the disadvantages of open surgery.However, the success of closed treatment is also dependent on an accurate assessment of the fracture, and for this reason, we now advocate the routine use of computed tomography preoperatively. Because of the complex, 3-dimensional shape of the scaphoid, simple x-rays alone are inadequate, whereas computed tomography, parallel to the long axis of the scaphoid, allows excellent visualization of the fracture and any associated deformity, which must be corrected at the time of surgery.We describe here our method of treating acute scaphoid fractures, and we report the outcome of minimally invasive fixation.

Bildgebende Verfahren am Handgelenk

Injuries of the wrist are difficult to diagnose because of the complex and narrow anatomic structures. Based on precise clinical examination, X-rays, CT, and MRI are valuable additional tools that can be used. If a fracture is suspected a CT scan is preferable. In the case of a suspected soft tissue or ligamentous injury and non-vital fragments or necrosis MRI is suitable. Other diagnostic tools are presently of minor importance for the wrist. Technical innovations allow better visualization and classification of lesions. However, exact knowledge of the tools is important.

Teil-Arthrodesen von Skaphoid, Trapezium und Trapezoideum (STT-Fusion)

BACKGROUND

Scapho-trapezio-trapezoid (STT)/triscaphe fusion is used to stabilize the radial column of the wrist. However the reported results are controversial.

MATERIAL AND METHODS

111 patients were treated with STT fusion from 1992 to 1997. Indications were chronic dissociation of the scapholunate joint (n = 15), idiopathic arthrosis of the scaphotrapeziotrapezoid joint (n = 11), Kienböck's disease in advanced stage (n = 84) and dislocation of the trapezium (n = 1). This study reviews the results after an average follow-up period of four years (range, two to eight years).

RESULTS

Patients showed an average wrist motion (ROM) in extension and flexion of 81 % of the preoperative range and in radial and ulnar deviation of 68 % of the preoperative range. Preoperative pain values (VAS) were reduced 76 % (non-stress) and 55 % (stress). The average grip strength improved to 65 % of the contra-lateral side. Good results were reached according to the modified Mayo wrist score with a score of 66 points (71 points in arthritis of the STT joint; 62 points in Kienböck's disease, 60 points in SL-dissociation). The patients described low disability in the DASH scores, with an average of 27 points.

CONCLUSIONS

Our data show that STT fusion is reliable and effective for treatment and pain relief and offers reasonable functional results in the above mentioned indications.

Der posttraumatische karpale Kollaps

PURPOSE

Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid.

METHOD AND MATERIAL

37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically.

RESULTS

The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain.

CONCLUSION

Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

[Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients]

OBJECTIVE

In literature the diagnostic value of MRI for detecting lesions of the carpal ligaments and the TFCC is judged controversially. The aim of the following study is to determine the diagnostic accuracy of direct MR arthrography for depicting and staging of intraarticular lesions of the wrist.

MATERIAL AND METHODS

One day before undergoing arthroscopy, 125 patients suffering from wrist pain were examined with direct MR arthrography in a prospective and blinded study. A mixture of contrast medium (iodine-containing contrast medium and gadopentetate in relation 200 : 1) was injected into both radiocarpal and midcarpal joints. The following sequences were acquired on a 1.5T scanner: coronal T1-weighted SE, coronal fat-saturated T1-weighted SE, coronal T1-/T2*-DESS-3D, and sagittal T2*-weighted MEDIC. MRI results were compared with arthroscopic findings using statistical analysis (SEN = sensitivity, SPE = specificity, PPV = positive predictive value, NPV = negative predictive value, ACC = accuracy).

RESULTS

In comparison to arthroscopy as the accepted diagnostic gold standard, the following results were found for MR arthrography. Detection of TFCC lesions: SEN 97.1 %, SPE 96.4 %, PPV 97.1 %, NPV 96.4 %, ACC 96.8 %. Detection of complete tears of the scapholunate ligament: SEN 91.7 %, SPE 100 %, PPV 100 %, NPV 99.1%, ACC 99.2%. Detection of partial tears: SEN 62.5 %, SPE 100 %, PPV 100 %, NPV 94.8 %, ACC 95.2 %. Detection of cartilage defects: SEN 84.2 %, SPE 96.2 %, PPV 80 %, NPV 97.1 %, ACC 94.4 %. In total, only three lesions of the lunotriquetral ligament were present.

CONCLUSION

Direct MR arthrographic imaging is well suited for detecting intraarticular lesions of the wrist. The presented diagnostic results of MR arthrography are superior to the results of unenhanced MRI reported in the literature. Direct MR arthrography as a reliable diagnostic tool is strongly recommended if lesions of the scapholunate ligament and the triangular fibrocartilage complex are suspected. In contrast, an attitude of caution must be adopted in diagnosing lesions of the articular cartilage of the wrist.

[Standardised operation technique for ulna-shortening with a new sliding-hole plate]

Ulna-shortening is a widely accepted procedure for the treatment of ulna-impaction syndrome. High rates of non-unions however necessitate improving the operation technique. The new device introduced in this study is a 7-hole plate in which two proximal holes are sliding-holes. By correct placement of two distal screws and two screws in the sliding-holes, rotational stability is guaranteed. The osteotomy is performed while the plate is loosely fixed to the ulna. After fixation of the two distal screws, the sliding-holes facilitate reposition with a good closure of the osteotomy gap. Excentric placement of two more screws and placement of a lag screw across the oblique osteotomy leads to further compression at the osteotomy site. Ulna-variance can be adjusted exactly. So far the plate has been implanted in 15 patients. Ulna-variance was reduced from + 2 to - 2.2 mm. The clinical results are comparable to those of ulna-shortenings in the literature. The sliding-hole plate allows an exact connection with good closure of the osteotomy without malrotation. With this simplified technique, the risk of non-union can be reduced.

[Treatment of hand surgery patients in chronic pain]

The treatment of hand surgery patients suffering from chronic pain requires an interdisciplinary procedure. An imbalance between nociception and antinociception can be seen as a reason for the chronification of pain. The complexity of the problem of chronic pain patients is marked by a wide variety of symptoms. Full diagnostic assessment to detect or to exclude other organic diseases is required. Rehabilitation to improve function and reduce pain intensity has priority. Our therapeutic strategy consists of intensive physiotherapy and analgesic drugs as well as a series of blockades with buprenorphine (Temgesic) of the ganglion stellatum (GLOA). This specific therapy achieved an improvement of the function of the upper extremity and a reduction of pain intensity. The majority of patients were satisfied with the outcome.

[TFCC-lesion. MR arthrography vs. arthroscopy of the wrist]

In a blinded study from January to July 2000, 125 patients suffering from specific complaints of the wrist were examined with direct MR arthrography prospectively. Within 24 hours an arthroscopy of the wrist was performed. With the MR arthrography in 70 patients or 56% of all patients injury of the TFCC was diagnosed. In 65 patients this could be verified arthroscopically. In the remaining 55 patients no TFCC lesion was diagnosed with the MR arthrography. However lesions were found via arthroscopy in three cases,were MRI findings expected an intact TFCC. In the remaining 52 cases the MRT could exclude a lesion of the TFCC correctly. An agreement of the MRT and arthroscopic results could be determined in 93.6% of the cases (correlation). The diagnosis of a TFCC lesion by means of MRI was correct in 94% of the cases (sensitivity), the exclusion of such lesion in 89% (specificity). Positive or negative predictive values of 91% or 93% were achieved. Since neither a specificity nor a sensitivity of 100% can be reached at the moment, the MR arthrography cannot replace the arthroscopy. However it could be a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate the diagnostics and the indication for surgery at the ulnocarpal wrist and help to reduce arthroscopic interventions that are only for diagnostic purposes and without any therapeutic consequences. With improvement of the technique of magnet resonance tomography we can expect further increase of accuracy and the clinical use of the MR arthrography in the diagnostic workup at the ulnocarpal wrist.

[Scapholunate ligament tears in MR arthrography compared with wrist arthroscopy]

In a blinded study from January to July 2000, 125 patients suffering from specific complaints of the wrist were prospectively examined with direct MR arthrography. Within 24 hours an arthroscopy of the wrist was performed. With MR arthrography in 21 patients or 17 % of all patients, injury of the scapho-lunate ligament was diagnosed. In all patients this could be verified arthroscopically. In the remaining 104 patients, no SL-ligament lesions were diagnosed with the MR arthrography. However, partial lesions were found via arthroscopy in seven cases and complete lesions of the ligament were found in one case, where MRI findings expected an intact SL ligament. In the remaining 96 cases, the MRI could correctly exclude a lesion of the SL-ligament. The diagnosis of a SL-ligament lesion by means of MRI was correct in 100 % of the cases (specificity), the exclusion of such lesions in 72 % (sensitivity). Positive or negative predictive values of 100 % or 92 % were achieved. Since a sensitivity of 100 % cannot be reached at the moment, MR arthrography cannot replace arthroscopy. However, it could be a potent additional tool for wrist diagnosis if intraarticular contrast is used. It can facilitate the diagnostics and the indication for surgery of the wrist and help to reduce arthroscopic interventions for purely diagnostic purposes and without any therapeutic consequences. With improvement of the technique of magnet resonance tomography we can expect a further increase of accuracy in the clinical use of the MR arthrography in the diagnostic workup of the wrist.