Custom-made wrist prothesis (UNI-2™) in a patient with giant cell tumor of the distal radius: 10-year follow-up

Wrist endoprosthesis is still an exceptional indication compared to the prosthesis of large joints, especially when a rescue surgery procedure of the wrist is no longer possible and the complete wrist arthrodesis is to be considered the ultima ratio. However, a suspended function in the wrist is accompanied by a significant restriction in the patient`s daily life. Using the fourth-generation endoprosthesis, the situation regarding long-term results for the hand has already improved. This means that a durability of more than 6 years is no longer a rarity. Defect situations in joints, in particular those which occur after tumor, still pose a greater challenge. If autologous reconstructions cannot be performed, custom-made prostheses can be considered as very rare indications for joint reconstruction. While these have been used for years on large joints such as shoulder, elbow, knee and hip, they have only been described on the hand in particular cases. We report the 10-year follow-up of implantation of a custom-made wrist prothesis (UNI-2™, KMI, Germany) in a 36-year-old patient with tumorous destruction of the distal radius by a giant cell tumor.

[Revision surgery after total wrist arthroplasty]

BACKGROUND

Wrist arthroplasty is still an exceptional indication in the field of hand surgery. In recent years, it has become increasingly accepted as an alternative to wrist arthrodesis as the ultima ratio for panarthrosis or similar destruction of the wrist. In particular, the patient's desire for functional integrity also plays an important role.

COMPLICATIONS

While there were often complications with earlier prosthesis designs of the older generations and only a short survival rate could be achieved, this has improved, if the indication of the so-called fourth generation prostheses is done properly. Survival rates of over 10 years are no longer uncommon, even without revision operations. Currently, the indication for hemiarthroplasty has been increasing, particularly in the case of post-traumatic destruction. Those who are seriously interested in endoprosthesis should also be able to treat the associated complications. The present article is intended to provide an overview of common or potential complications in the context of wrist arthroplasty and to demonstrate possible solutions by presenting case studies. The basics of primary implantation are, therefore, not discussed. Reference is made to further literature.

[Plastic reconstructive options for chronic pilonidal disease]

INTRODUCTION

Chronic pilonidal disease represents an infectious disease of the gluteal cleft that often requires surgical resection.

AIM

In this article, several plastic-surgical reconstructions are presented.

METHODS AND RESULTS

Based on our experience and the current literature, different plastic surgical reconstructive methods are presented and discussed. Thorough debridement including sinus tracts and follicles represents an important step in the treatment algorithm. Subsequently, wide defects may remain that can require reconstructive surgery with local flaps. These may include a Karydakis procedure, Limberg transposition flap, V-Y advancement or rotation flap.

CONCLUSION

After thorough debridement and adherence to plastic surgical principles, sufficient reconstructions can be obtained with the presented methods.

[Therapeutic options for pressure ulcers]

The aim of this overview is based on remarks on the pathogenesis of and therapy for pressure ulcers and selected but representative cases to demonstrate current options of plastic coverage. As a consequence of the demographic developments, in particular, with regard to the increasing proportion of older patients as well as the advances in modern medicine, the number of multimorbid, geriatric and bedridden patients and of those with prolonged sickbed periods has been steadily growing. Therefore, partly severe manifestations of pressure ulcers at various exposed body regions can be observed in spite of the best preventive intention of care. While in the early stages rather conservative treatment is adequate, surgical intervention might become important and indispensable for a sufficient treatment in advanced stages. To facilitate basic care and to appropriately treat the infectious focus, the methods and procedures of plastic surgery can become relevant. Although there are several options and approaches existing to sanitise and cover defects of pressure ulcers, which are described within the article based on representative cases, preventive measures can still be considered the best approach.

[Plastic-surgical treatment options in necrotising fasciitis]

Necrotising fasciitis (NF) is considered a rare and possibly life-threatening infection of the subcutaneous tissue and of the fascia. A specific characteristic is the rapid progress of the disease associated with considerable local pain. Since laboratory parameters as well as imaging are only unspecific, diagnosis is set up clinically. Even in the case of a serious suspicion, an immediate and radical debridement has to be initiated, accompanied by intensive care and adequate antibiotic treatment. Only after stabilisation of the general physical condition and local - sometimes extensive - wound debridement, can coverage and reconstruction of soft tissue defects be appropriately performed by the measures and procedures of plastic surgery.

The importance of genetic susceptibility in Dupuytren's disease

Dupuytren's disease (DD) is a progressive fibromatosis that causes the formation of nodules and cords in the palmar aponeurosis leading to flexion contracture of affected fingers. The etiopathogenesis is multifactorial with a strong genetic predisposition. It is the most frequent genetic disorder of connective tissues. We have collected clinical data from 736 unrelated individuals with DD who underwent surgical treatment from Germany and Switzerland. We evaluated a standardised questionnaire, assessed the importance of different risk factors and compared subgroups with and without positive family history. We found that family history clearly had the strongest influence on the age at first surgery compared to environmental factors, followed by male sex. Participants with a positive family history were on average 55.9 years of age at the first surgical intervention, 5.2 years younger than probands without known family history (p = 6.7 × 10(-8) ). The percentage of familial cases decreased with age of onset from 55% in the 40-49 years old to 17% at age 80 years or older. Further risk factors analysed were cigarettes, alcohol, diabetes, hypertension, and epilepsy. Our data pinpoint the importance of genetic susceptibility for DD, which has long been underestimated.

[What do general, abdominal and vascular surgeons need to know on plastic surgery - aspects of plastic surgery in the field of general, abdominal and vascular surgery]

There is overlap between general, abdominal and vascular surgery on one hand and plastic surgery on the other hand, e.g., in hernia surgery, in particular, recurrent hernia, reconstruction of the abdominal wall or defect closure after abdominal or vascular surgery. Bariatric operations involve both special fields too. Plastic surgeons sometimes use skin and muscle compartments of the abdominal wall for reconstruction at other regions of the body. This article aims to i) give an overview about functional, anatomic and clinical aspects as well as the potential of surgical interventions in plastic surgery. General/abdominal/vascular surgeons can benefit from this in their surgical planning and competent execution of their own surgical interventions with limited morbidity/lethality and an optimal, in particular, functional as well as aesthetic outcome, ii) support the interdisciplinary work of general/abdominal/vascular and plastic surgery, and iii) provide a better understanding of plastic surgery and its profile of surgical interventions and options.

[The plastic coverage of soft-tissue defects after endoprosthesis on the lower limb]

BACKGROUND

The implantation of endoprostheses is an established procedure in orthopaedic and trauma surgery. However, the techniques are often associated with a high risk of post-interventional infections and wound healing disorders that can result in loss of the prosthesis or the limb--most likely based on an insufficient debridement and poor soft-tissue coverage. The purpose of this study was to evaluate the efficacy of the coverage methods in our patient population.

PATIENTS

In the past 10 years 38 patients with exposed knee prostheses and 14 patients following an ankle endoprosthesis were included in this retrospective study over the period from 2001 to 2011. Soft-tissue reconstructions around the knee were mostly performed by unilateral or bilateral gastrocnemius flaps combined with split-skin grafts. One defect was covered with a free flap. 57% of the soft-tissue defects around the ankle are often problematic and were closed by a pedicled peroneus brevis muscle flap and 35% by a free flap (3 with a latissimus dorsi muscle flap, 2 with a free lateral upper arm flap and one with an anterolateral tight flap).

RESULTS

In our patient population we achieved stable soft-tissue coverage in most of the cases using the above-mentioned flaps. Due to multiple preexisting comorbidities, it was observed that the course was frequently prolonged and wound healing difficulties occurred. These, however, could be controlled by conservative means or small secondary procedures.

CONCLUSION

A radical debridement and an early appropriate defect coverage of the exposed prosthesis is crucial in the reconstruction process. Through a close interdisciplinary collaboration a stable soft-tissue covering can be achieved. Consequently it is possible to avoid a loss of the endoprosthesis, marked functional deficits or even amputations.

An isolated hand tumour as primary manifestation of sarcoidosis

BACKGROUND

Sarcoidosis is a systemic disorder with unknown etiology, characterized by non-caseating granulomas in numerous organs and tissues. In 90% of patients lung and lymph nodes are involved. The incidence of sarcoidal granulomas in the upper extremities is low. Here we present the case of a primary hand manifestation of sarcoidosis without clinical systemic involvement.

OBJECTIVES

A young woman presented with a painful swelling in her right hand. There were no signs of inflammation. Normal perfusion, mobility and sensibility were found. Magnetic resonance imaging (MRI) revealed a tumour infiltrating the muscles and flexor tendons of the third digit around the metacarpal bone and with pathological signal enhancement after administration of contrast medium.

RESULTS

Intraoperatively, nodular masses and fat tissue were seen. Histological examination after radical tumour resection showed sarcoidal granulomas. Postoperative staging diagnostics with computed tomography (CT) demonstrated multiple thoracic lymph node swellings in the mediastinum and bilateral hill. Follow-up after one year we saw normal scars in the palmar hand. There was no sign of local recurrence. The pulmological care is still going on.

CONCLUSIONS

Sarcoidosis is a rare, often asymptomatic disease. Patients present with dyspnoe and cough caused by the inflammation of the lung. The first clinical manifestation of sarcoidosis as a tumor in the palmar hand is unusual. Extrapulmonary systemic or progressive sarcoidosis is regarded as an indication for therapy with glucocorticosteroids. This case demonstrates that surgical excision enabled complete local cure without necessity of systemic and/or local treatment with steroids.

[Soft-tissue defects on the dorsum of the hand by extravasation of the cytostatic agents: surgical options of treatment]

Systemic treatment with chemotherapeutic agents is often applied by infusions over peripheral vein cannulae located on the hands and lower arms. Dislocation of the cannulae or vein perforation causes an extravasation of the cytostatic agent. This complication occurs in approximately 0.1 - 6 % of intravenous treatments and is rarely noticed before administration of greater volumes. Depending on the tissue toxicity of the administered substances, the extravasation results in tissue damage of different extents. In a few cases, only conservative therapy is required. The majority of patients, however, needs immediate surgical therapy. The reason for this is the severe tissue damage caused by the chemotherapeutic agent that accumulates in the subcutaneous fat where it destroys the connective and fat tissue, nerves, vessels, tendons and muscles, impairing the functionality of the entire hand and arm. In very severe cases, partial or complete amputation of the extremity is the only treatment. The application of antidotes has been discussed controversially and is not a standard procedure. In the past 11 years, 18 patients with extravasations of chemotherapeutics on the dorsum of the hand were admitted to our department. After radical debridement no primary closure of the resulting defect was advisable in the first operation. In all cases we could later perform a stable wound closure. In our opinion, this two-step procedure with primary radical debridement, temporary wound coverage and later wound closure should be performed regularly.

[The potential of high-resolution sonography in the follow-up of surgically treated flexor tendons]

Sonography of the hand is frequently used for diagnostics of hand diseases. Advantages are the lack of side effects (e. g., X-ray contamination) and easy accessibility. Soft tissues of the hand are easily examined using a linear-array transducer with a high frequency (7.5 to 15 MHz) and, in some cases, a pre-positioned device (water or gel). Also there is the possibility to record functional motility of ligaments or joints non-invasively. The beneficial use of sonography is demonstrated on patients with injured flexor tendons of the hand or fingers. Ultrasound was used to examine ligaments after suture, for the diagnosis of suspected re-ruptures and in cases of fibrotic adhesions. In this study, the sonomorphology of previously injured flexor tendons with consecutive surgical reconstruction was examined in 47 patients. The average observation period was eight months post-operatively. 15 patients were submitted to a second operation. In 86.5 % of the cases, the sonographic results acquired prior to surgery were in agreement with macroscopic morphology seen during the operation.