[Treatment reality of distal radius fractures in a center]

Distal radius fractures are the third most common type of fracture in Germany after fractures of the femoral neck and peritrochanteric femoral fractures. In 2019 a total of 72,087 cases were registered with an incidence of 106 cases per 100,000 inhabitants (81,570 fractures of the femoral neck, 73,785 peritrochanteric fractures). Many of these fractures are surgically treated also in this hospital but with controversial views on the optimal treatment. Against the background of the coronavirus disease 2019 (COVID-19) pandemic, disappearing personnel resources and the political pressure to form centers and a switch to outpatient treatment, the authors ask the question what the treatment reality in this hospital looks like and whether the general changes in the framework conditions also have an affect in this context. This is not a strictly scientific study but a stocktaking without any claims of completeness and the retrospective evaluation of a larger data pool with all its weaknesses. On the contrary, the data provide interesting aspects that are explained in detail in the individual sections.

[Physiolysis with Resection of Vickers' Ligament in Adolescent Patients with Madelung's Deformity]

BACKGROUND

Madelung's deformity is a congenital or acquired growth disorder of the forearm that can lead to significant impairments in the quality of life of affected patients. Various surgical treatment options for the condition have been described in the literature. This study aimed to investigate whether physiolysis with resection of the Vickers ligament can successfully halt the progression of the disease in a cohort of young patients, as would be expected based on existing literature on this topic.

MATERIAL AND METHODS

An analysis was performed on the records of all patients with Madelung's deformity who were primarily treated with physiolysis with resection of the Vickers ligament between January 2001 and June 2017. Patients were invited for follow-up examinations, and surgical outcome was assessed. Parameters evaluated included pain at rest and under load, range of motion of the wrists, and activity level. Additionally, standard X-rays and radiological measurements were performed for each operated wrist. The collected data was compared with the preoperative data from patient records.

RESULTS

Nine wrists were included in the study. The average age at the time of surgery was 13.2 years, and the average follow-up period was five years. Extension and ulnar abduction showed a slight decrease from preoperative to follow-up, while flexion improved minimally, and radial abduction and forearm rotation showed noticeable improvement. The visual analogue scale score for pain at rest increased from preoperative 0.25 points to 1.88 points at follow-up. Under load, the average pain score increased from 2.00 to 4.25 points. The mean DASH score increased from 6.04 points before the surgical procedure to 12.20 points at follow-up. The average values of two out of the five measured McCarroll parameters increased, the increase being statistically significant for lunate subsidence. A follow-up procedure was required in one wrist.

CONCLUSION

In our cohort, the progression of Madelung's deformity was only partially halted by physiolysis with resection of the Vickers ligament, and a significant increase in pain symptoms during the study period could not be avoided. Therefore, this procedure should be used cautiously in skeletally immature patients.

[Protracted Course with Finger Amputation Following Stonefish Envenomation]

Eine 53-jährige Frau stellte sich 2,5 Wochen, nachdem sie sich auf Mauritius eine Steinfischstichverletzung am rechten Kleinfinger zugezogen hatte, in unserer Notfallambulanz vor. Sie hatte im Urlaub beim Schwimmen am Meeresufer versehentlich auf einen im Sand vergrabenen Steinfisch gegriffen (Abb. 1). Sofort war es neben massiven Schmerzen am gesamten Arm zu einer Rötung am Kleinfinger und einer Schwellung der Hand gekommen. Nach notfallmäßigem Transport in das nächste Krankenhaus wurde der Patientin dort aufgrund einer starken systemischen Reaktion ein Antidot im Rahmen eines kurzzeitigen intensivmedizinischen Aufenthaltes verabreicht. Bei Blasenbildung wurde eine oberflächliche Wundrevision und eine Kompartmentspaltung palmar an der rechten Hand am Folgetag durchgeführt. Die Narben ließen allerdings auf eine nur minimale Eröffnung der Stichwunde und der Intermetakarpalräume schließen. Eine Antibiotikatherapie erfolgte während des 4-tägigen Krankenhausaufenthaltes mittels Ampicillin/Sulbactam intravenös, welche bei Entlassung oralisiert und bis zur Vorstellung in unserer Klinik fortgesetzt wurde.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries

OBJECTIVES

The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique.

METHODS

Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists.

RESULTS

Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds.

CONCLUSIONS

Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC.

CLINICAL RELEVANCE STATEMENT

MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries.

KEY POINTS

• Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

[The complexity of hand-surgical procedures in the context of cross-sector care concepts: a consensus recommendation of the German Society of Hand Surgery]

Overboarding politcal influence in Germany concerning medical issues has come to a new peak. The report by the IGES Institute published in 2022 made an important contribution in this regard. Unfortunately, only that part of the recommendations of this report were implemented in a new version of the contract for outpatient surgery according to Section 115b SGB V (AOP contract), that called for an expansion of outpatient surgery. In particular, those aspects that are important from a medical point of view for a patient-specific adjustment of outpatient surgery (e. g. old age, frailty, comorbidities) as well as the important structural requirements for outpatient postoperative care were included in the new AOP contract at best in a rudimentary manner. For this reason, the German Society for Hand Surgery felt compelled to give its members a recommendation as to which medical aspects must be taken into account, especially when performing hand surgery operations, in order to ensure the highest level of safety for the patients entrusted to us while performing outpatient surgery. An expert group of experienced hand surgeons and hand therapists who work in hospitals of all levels of care as well as resident surgeons was formed in order to formulate mutually agreed recommendations for action.

[Operative Approaches to the distal radioulnar Joint and distal Ulna]

At the distal radioulnar joint (DRUJ) and the ulnocarpal joint several anatomical structures are in a limited space. Therefore, the operative approach has to consider the pathology to be treated. The DRUJ may be approached from the dorsal or the palmar side. Procedures to treat the arthrotically destroyed DRUJ involving bone resection of the ulnar head and destabilizing ligamentous injuries of the triangular fibrocartilage complex (TFCC) are best approached from the dorsal side. This approach allows excellent visualization of the ulnar head and the ulnar and radial attachment of the TFCC. The arthroscopic, half open refixation of the ulnar avulsion of the TFCC may be performed using a variety of limited and small approaches over the dorsal or lateral ulnar head. Pathologies with an origin at the palmar aspect of the DRUJ as the palmar dislocation of the ulnar head in the DRUJ or the shrinkage and scaring of the palmar capsule with consecutive pronation contracture require a palmar approach. Reduction and osteosynthesis of fractures in the area of the ulnar head are preformed using a lateral approach along the styloid process and the ulnar head between the flexor and the extensor carpi ulnaris tendons. Along the ulnar shaft elective ulnar shortening osteotomy as well as fracture reduction and osteosynthesis are best performed from an ulno palmar approach.

[Effect of a single proximal interphalangeal Joint Fusion of the Index, Middle or Ring Finger on the Grip and Finger Force and Load Distribution in the Hand]

BACKGROUND

Due to the functional coupling of adjacent finger joints and the quadriga effect, arthrodesis of the proximal interphalangeal joint (PIPJ) can be assumed to lead to a different grip pattern resulting in altered force distribution of the hand.

PATIENTS AND METHOD

Ten patients with isolated arthrodesis of the PIPJ due to posttraumatic osteoarthritis (4×PIPJ II, 4×PIPJ III, 2×PIPJ IV) were assessed 59 (17-121) months postoperatively on average. The angle of arthrodesis was assessed by radiographs. Grip force and load distribution of both hands were measured by manugraphy using 3 differently sized cylinders. Grip force was separately assessed and compared for the whole hand as well as for each of the fingers and each phalanx.

RESULTS

Average total grip force of the affected hand compared to the uninjured opposite side was 74% (38-136%) for the small cylinder, 104% (68-180%) for the mid-sized cylinder and 110% (69%-240%) for the large cylinder. Arthrodesis of the PIPJ of the index finger led to a reduction of the grip force (91%) for the small cylinder, but increased grip force for the mid-sized (120%) and large cylinder (139%). Grip force was reduced for all cylinder sizes by arthrodesis of the PIPJ of the middle finger (56%, 88% and 91%). Arthrodesis of the PIPJ of the ring finger resulted in a grip force of 76%, 105% and 91%, respectively, for the different cylinder sizes.The finger force of the affected finger was reduced after arthrodesis of the PIPJ, with the exception of the index finger, which was stronger than the unaffected opposite finger when using the large cylinder. The force of the healthy fingers on the affected side was greater when compared with the same finger on the opposite side, which led to increased grip force for the mid-sized and the large cylinder of the affected hand. A reduction in load distribution was measured mostly for the middle phalanx but also for the distal phalanx of the operated-on finger.

CONCLUSION

Arthrodesis of the PIPJ almost always led to force reduction in the middle and distal phalanx of the affected finger. However, the total grip force of the hand was compensated by a higher force of the adjacent healthy fingers. In many cases, total grip force was even higher on the affected side. However, arthrodesis of the PIPJ resulted in a noticeable force reduction when smaller objects were gripped.

[Differented Aproaches for Fracture Treatment in the Hand - when doing what?]

Treatment of finger fractures is demanding twice. Malunion and incongruence of the joints frequently result in severe functional restriction and should not be tolerated. On the other hand surgical access to the fracture site is frequently limited by the proximity of vulnerable structures like nerves, vessels, ligaments, and tendons.This article presents a selection of treatment options, that in the opinion of the authors have been proven beyond the background of a large institution with reference to alternative procedures and the management of special situations.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist

Background

In wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC).

Methods

Eighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (r_ɸ).

Results

The most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior–posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (r_ɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (r_ɸ = 0.172; p = 0.111).

Conclusions

Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

[Infections of the Proximal and Distal Interphalangeal Joint: 4 weeks of Immobilisation between initial Surgery with Joint Resection and secondary Joint Fusion is sufficient]

BACKGROUND

In 2011 we published our treatment regime for infections of the interphalangeal joints of the hand with infection-related macroscopic cartilage damage. We recommended the resection of the infected joint followed by 6 weeks of immobilisation by external fixation before secondary arthrodesis. In 2013 we reduced the period of immobilisation to 4 weeks within a prospective study.

PURPOSE

This paper analyses the effect of a shortened immobilisation time of 4 instead of 6 weeks between joint resection and secondary joint fusion in bacterial infection of the proximal and distal interphalangeal joint.

PATIENTS AND METHODS

Between March 2013 and July 2014, 20 patients with an infection of an interphalangeal joint of the hand were treated by joint resection and secondary arthrodesis after a reduced time of immobilisation of 4 weeks. The patients were clinically and radiologically evaluated at median of 5,8 (4,7-10,5) months. The results were statistically analysed and compared with the previous study published 2011.

RESULTS

The reduced immobilisation period from 6 to 4 weeks did not result in a significant difference of revisions (p = 0.148). In 18 of 20 patients, the joint infection was reliably cured and the following arthrodesis consolidated. One patient required a revision surgery due to a persistent joint infection, a second patient got a revision surgery after arthrodesis because of a displaced implant. The range of motion of the infected finger was median 147.5 (30-220)°. Achieving a grip strength of 26 (4-64) kg, the affected hand reached 88.5 (47,8-223,1) % of the strength of the opposite side. The subjective functioning of the hand was good (DASH 37.9 (3.3-71.7), Krimmer-Score 2 (1-4)). We did not observe any persistent pain at rest (VAS 0 (0-3)) or under daily activities (VAS 1.3 (0-7)). 50 % of patients stated a sensitivity to cold. Our study of 2011 revealed similar results (ROM of the infected finger 142.5 (30-220)°, grip strength 95 (33-127)%, DASH-Score 23.3 (0-130), Krimmer Score 2 (1-4), VAS at rest 0 (0-7), VAS under stress 4.5 (0-9), sensitivity to cold in 41 % of 27 patients).

CONCLUSION

A decreased immobilisation period from 6 to 4 weeks between joint resection and secondary arthrosis for infections of the interphalangeal joints of the hand do not lead to a negative outcome. The described therapeutical regime results in reliable cure of the bacterial joint infection with a good function of the finger and only minor subjective discomfort.

Die Spül-Saug-Drainage zur Therapie der septischen Tenosynovialitis der Fingerbeugesehnen

BACKGROUND/PURPOSE

Pyogenic flexor tenosynovitis within the flexor tendon sheath requires urgent treatment to avoid tendon necrosis and loss of the finger. Objective of this article is the treatment by revision and postoperative continuous irrigation via a closed irrigation system.

PATIENTS AND METHODS

From 1.1.2007 to 31.12.2016 54 patients with a pyogenic flexor tenosynovitis were treated by revision and closed continuous irrigation. Besides the evaluation of the patient´s records with respect to the involved fingers and hand, duration of hospitalisation, and required revision surgery, 33 patients (19 males, 14 females) with an average age of 51 (8-85) years were re-examined on average after 21 (4-38) months. Re-examination included measurements of the mobility of the involved fingers and thumbs, grip and pinch strength, pain using the numeric rating scale (BRS), and DASH score. The overall result was graded according to the grading system by Buck-Gramcko for flexor tendon reconstruction.

RESULTS

Hospital stay was 9 (3-26) days on average. In 11 patients revision surgery was required including 3 re-installations of the continuous irrigation system, 2 ray amputations, and 1 finger amputation at the level of the proximal interphalangeal joint. The re-examined patients averaged a grip strength of 84 (23-163) % of the unaffected side. On average pain at rest was 0,2 (0-4), pain at daily living activity 1,2 (0-8) on the NRS, the DASH score 16,8 (0-58) points. According to the rating system for flexor tendon function there were one poor, one fair, 5 good and 26 excellent results.

CONCLUSIONS

Continuous irrigation by a closed irrigation system for pyogenic flexor tenosynovitis is a successful procedure with a low amputation rate. The functional results are predominantly good and excellent.

[Resection arthoplasty of the trapezium with ligament reconstruction and tendon interposition and variations]

OBJECTIVE

Creation of a pain-free, flexible and stable (pseudo) joint between the carpus and the base of the 1st metacarpal bone.

INDICATIONS

Painful carpometacarpal (CMC)‑I joint due to primary or secondary osteoarthritis, CMC‑I instability.

CONTRAINDICATIONS

Carpal instability, local infection, tumors.

SURGICAL TECHNIQUE

Resection of the trapezium (and of the arthritic joint surfaces in CMC‑I and STT [scaphoid-trapezium-trapezoid-joint]), stabilization of the base of the 1st metacarpal bone by suspension with a distally pedicled strip of the flexor carpi radialis tendon or variants thereof.

POSTOPERATIVE MANAGEMENT

Immobilization in a splint for 3-5 weeks, followed by hand therapy.

RESULTS

Worldwide for almost 40 years, regardless of the exact technique, almost always (90%) significant pain reduction, increased strength in the grip and slightly less in the pinch grip, very good mobility, 85-95% very satisfied patients and very good long-term results.

Interdisciplinary consensus statements on imaging of scapholunate joint instability

Objectives

The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.

Methods

Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists.

Results

Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.

Conclusions

Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.

Key Points

• Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability.

• Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability.

• Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

[Comparison of scaphoid reconstruction with a non-vascularised bone graft, with and without shock waves; preliminary results]

BACKGROUND

Focused, high energy shock wave therapy (ESWT) stimulates bone healing by neo-angiogenesis and activating osteocytes. This study investigates if applying an ESWT intraoperatively improves and accelerates the healing of a scaphoid nonunion after reconstruction using a non-vascularized bone graft.

PATIENTS AND METHODS

In this prospective, ongoing study, patients with a scaphoid reconstruction using a non-vascularized bone graft and stabilization for non-union, are randomized for having additionally an intraoperative ESWT (intervention group) or not (control group). In 6 weeks-intervals, patients have a clinical and radiological follow-up, including a CT scan at 12, 18, and if needed 24 weeks postoperatively. The intervention group and the control group are compared with regard to the proportion of the bridged contact area between scaphoid and the bone graft at 12, 18, and 24 weeks postoperatively and the rate of the healed scaphoids at the final follow-up. At time of this data analysis, 35 patients of the intervention group and 33 patients of the control group had passed all of their scheduled follow-ups.

RESULTS

Twenty-four weeks postoperatively, the scaphoids of 27 patients (77 %) in the intervention group and those of 20 patients (61 %) in the control group were healed. At 12, 18, and 24 weeks, the contact area between scaphoid and the bone graft proximally was bridged by 80 %, 84 %, and 86 % respectively in the intervention group, and 74 %, 81 %, and 84 % in the control group. Distal to the bone graft, the gap was bridged by 91 %, 94 %, and 95 % for the intervention group and 77 %, 90 %, and 94 % for the control group. At 12 weeks postoperatively, the proportional healing distal to the bone graft was significantly higher after ESWT.

CONCLUSION

A single, intraoperative ESWT improves the healing rate of scaphoid reconstruction with a non-vascularized bone graft and accelerates the gap bridging during the first 12 weeks after surgery.

[Scaphoid non-union: Experience from more than 280 reconstructions using a medial femur condyle bone graft]

BACKGROUND

Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences.

PATIENTS AND METHODS

Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable.

RESULTS

In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions.

CONCLUSIONS

These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations.

[Results following isolated fourth ray resection]

BACKGROUND

 After partial resection of the fourth finger ray, many hand surgeons perform a transposition of the fifth ray to the position of the fourth ray. Others, us included, resect the fourth ray in total through exarticulation in the carpometacarpal joint and tightly readapt the deep transverse metacarpal ligament, assuming that the gap between the third and fifth metacarpal bones will be sufficiently reduced through spontaneous radial translocation of the fifth ray. The aim of this retrospective study was to examine the clinical, radiological and patient-reported results after total resection of the fourth ray with adaption of the deep transverse metacarpal ligament.

PATIENTS AND METHODS

 Seven patients (three women, four men) with a mean age of 50 (26-62) years were reached for a follow-up examination after a mean of 43 (2-174) months. Parameters assessed included finger movement, hand strength, sensitivity (Tinel sign, Semmes-Weinstein monofilament), dexterity (nine-hole peg test), pain (at rest and during stress, phantom pain, weather sensitivity) and patient-reported functional and cosmetic outcome. Radiological assessment included measurement of the distance between the heads and bases of metacarpal bones III and V before and directly after surgery and at follow-up.

RESULTS

 The only complication encountered was a mild wound healing disorder in one patient, which was controlled conservatively. Sensitivity was not impaired in any patient and no patient showed signs of neuromas. Finger movement for both flexion and extension was slightly impaired in two patients. Mean grip and pinch strength was 61 (54-78) % and 65 (35-122) % compared with the unaffected hand. The mean DASH score was reduced from 42.2 preoperatively to 27.5. Dexterity was slightly reduced with a nine-hole peg test prolonged by 23 % compared with the unaffected hand. At follow-up, the intermetacarpal gap was reduced by a mean of 67 % between the bases and by 50 % between the heads of metacarpal bones III and V. Patients rated the cosmetic appearance of the hand as very good.

CONCLUSION

 Total resection of the fourth finger ray with soft tissue adaption enables a sufficient closure of the intermetacarpal gap without rotational malalignment and results in good to very good functional and cosmetic outcomes and a low complication rate.

The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist

Background

Triangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography.

Methods

One hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPR_Standard), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPR_Styloid) or in the ulnar fovea (MPR_Fovea). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer’s and Atzei’s classification and diagnostic confidence was stated on a five-point Likert scale.

Results

Compared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPR_Fovea: p < 0.001; MPR_Styloid: p ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPR_Standard 78.6%/80.4%, MPR_Styloid 94.6%/94.6%, MPR_Fovea 91.1%/89.3%) and accuracy (MPR_Standard 86.8%/86.8%, MPR_Styloid 96.2%/96.2%, MPR_Fovea 94.3%/93.4%) improved with additional styloid-centered (p = 0.004/0.008) and fovea-centered (p = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR (p = 0.688/0.250). Interrater agreement was almost perfect for each dataset (κ_Standard = 0.876, κ_Styloid = 0.894, κ_Fovea = 0.949). Diagnostic confidence increased with addition of either radial MPR (p < 0.001).

Conclusions

Ancillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

Midterm Outcomes of the Use of a Spherical Ulnar Head Prosthesis for Failed Sauvé-Kapandji Procedures

PURPOSE

The use of a spherical ulnar head prosthesis (UHP) for the treatment of symptomatic radioulnar convergence after Sauvé-Kapandji (SK) procedure has shown promising results in the short term. This study aims to evaluate the midterm outcome of the original cohort of patients treated with this technique.

METHODS

Seventeen patients with unstable ulnar stumps confirmed both clinically and radiographically were studied. The etiology for the initial SK procedure included posttraumatic distal radioulnar joint (DRUJ) incongruity, primary DRUJ arthrosis, and dysplastic DRUJ. Fourteen of the 17 patients had a minimum of 2, and a maximum of 6, operations prior to having a spherical UHP. All patients suffered from severe pain with difficulty in performing work and daily activities. Ceramic UHP was used for all patients, except 2 in whom a cobalt chrome head was used.

RESULTS

The average follow-up was 6 years (range, 4-17 years). A marked reduction in pain was observed with 11 patients reporting that they remained pain free. The range of motion of the wrist and power grip was maintained and showed a statistically significant improvement at the late follow-up. The Disabilities of the Arm, Shoulder, and Hand score also significantly improved from 77 to 41. There were no signs of prosthetic loosening at the midterm follow-up. The 2 patients with cobalt chrome prostheses had pain and osteolysis requiring revision to total DRUJ prosthesis. Two patients with dorsal prosthetic subluxation were successfully treated with distal radial osteotomy.

CONCLUSIONS

The midterm results of ceramic spherical UHP for failed SK procedures in this small patient series are encouraging.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Influence of Maximal or Submaximal Effort on the Load Distribution of the Hand Analyzed by Manugraphy

PURPOSE

This study aims to investigate if the hands' load-distribution pattern differs during maximal and submaximal grip.

METHODS

Fifty-four healthy subjects used the 200-mm Manugraphy cylinder to assess the load-distribution pattern of both hands. On 2 testing days, the subjects performed grip-force testing: 1 hand with maximal effort and the other with submaximal effort. Sides changed for the second testing day. The whole contact area of the hand was sectioned into 7 anatomical areas, and the percent contribution of each area, in relation to the total load applied, was calculated. Maximal and submaximal efforts were compared across the 7 areas in terms of load contributions.

RESULTS

Comparing maximum effort of the left and right hand, the load distribution was very similar without statistically significant differences between the corresponding areas. Comparing the maximal and the submaximal effort for each hand, 4 (left) and 5 (right) of the 7 corresponding areas showed statistically significant differences. Comparing the right hand, performing with maximal effort, with the left hand, performing with submaximal effort, 5 areas varied significantly. With the right hand performing submaximal effort, all 7 anatomical areas were significantly different.

CONCLUSIONS

The load distribution of a healthy hand is different when performing with submaximal effort compared with maximal effort. To analyze a hand's load-distribution pattern, the opposite hand can be used as a reference.

CLINICAL RELEVANCE

The hand's load-distribution pattern may be a useful indication of submaximal effort during grip-force testing.

[Effect of distal interphalangeal joint fusion of the index or middle finger on the grip or finger force and load distribution in the hand]

BACKGROUND

Due to the functional coupling of adjacent finger joints and the quadriga effect of the flexor digitorum profundus an influence of the grip pattern of the hand after fusion of a distal interphalangeal joint (DIPJ) is assumed.

PATIENTS AND METHODS

Two patients with DIPJ II- fusion and 8 patients with DIPJ III- fusion due to a posttraumatic osteoarthritis, but without any other pathology of both hands were assessed on average 55 (17-121) months postoperatively by manugraphy. Using three sizes of cylinders the total grip force and the load distribution of the hand and each finger were measured. The grip pattern was analyzed by 2D-graphs. The results of the affected hand were compared to the healthy opposite side. The consolidation of the DIPJ arthrodesis was confirmed and the angle of the joint fusion measured by radiographs. Patients rated their pain in rest or under strain by a visual analogue scale.

RESULTS

The total grip force of the affected hand compared to the opposite side was 93 % for the small cylinder, 97 % for the middle, and 96 % for the large cylinder. Both patients with a DIPJ II- fusion neglected the index finger considerably and had a remarkably weak grip force (68/62/68 % for the 3 cylinders respectively). The grip pattern of all fingers has changed. Eight patients with DIPJ III- fusion averaged 99/106/103 % grip force. In six of them, the affected hand was stronger than the opposite hand when using the middle cylinder. The finger force of the middle and ring finger was reduced, but of the index and little finger increased. Five patients had a striking peak of local pressure at the fused DIPJ III.The angle of the fused DIPJ averaged 6° (0-21°) for all patients. Pain was rated on average 1.4 (0-5) at rest and 2 (0-8) with strain. Both aspects were not found to influence the grip force or the load distribution.

CONCLUSION

After DIPJ- fusion of the middle finger its finger force is reduced; but, the total grip force is compensated by an increased finger force of the index and little finger. Despite limitations due to the small number of patients, a DIPJ II- fusion might have a considerable effect on grip force and load distribution of the hand rather due to omitting this finger than purely biomechanical effects.

Isoliert motorischer Teilausfall des Nervus medianus nach muskulärer Überbeanspruchung

Ein 22-jähriger Patient stellte sich mit einer seit rund zwei Monaten bestehenden Schwäche des Mittel-, Ring- und Kleinfingers der rechten Hand in unserer handchirurgischen Sprechstunde vor. Insbesondere im Rahmen seiner Tätigkeit als professioneller Pianist bestünden dadurch deutliche Einschränkungen, da beim Betätigen der Tasten nicht ausreichender Druck ausgeübt werden könne und es zu einer ungewollten Streckung der betroffenen Fingermittelgelenke komme. Dies konnte der Patient auch demonstrieren. Ein vorheriges Trauma war nicht erinnerlich. Der Patient berichtete jedoch von rund drei Monate zurückliegenden intensiven Umzugsarbeiten. Im Anschluss an diese ungewohnte muskuläre Beanspruchung hätten für mehrere Wochen beugeseitig am rechten Unterarm ziehende Schmerzen, ähnlich denen eines Muskelkaters, bestanden.

[Results of the reconstruction of the middle phalangeal base of the finger through an osteochondral autograft from the hamate bone]

OBJECTIVE

The fractured base of the middle phalanx was reconstructed in 13 patients using an osteochondral transplant from the carpometacarpal joint surface of the hamate bone. The goal was to restore joint stability with preservation of mobility. Indications were acute and missed isolated destruction of the palmar middle phalanx base ≥ 30 %. Contraindications were destruction of the head of the proximal phalanx, advanced chondropathy of the head of the proximal phalanx, and extensive soft tissue injury with loss of skin coverage for the proximal interphalangeal joint.

SURGICAL TECHNIQUE

In this procedure the fractured middle phalangeal base was debrided and the defect replaced by a size-matched autograft from the dorsal carpometacarpal osteoarticular surface of the hamate bone, which was secured in place with miniscrews.

RESULTS

Bone fusion was achieved in 100 % with restoration of joint congruity in 12 of 13 cases and a slight subluxation in one case. Follow-up was possible in 9 cases after 23 (5-51) months. The average range of motion in the reconstructed joint for extension/flexion was 0/9/73°; grip strength was 82 % of the unaffected side. Five out of 9 patients developed a mild flexion contracture in the PIP joint. The DASH score was 6 (0-33) points, pain at rest was 1 (0-5), and pain at exercise 2 (0-6) on a visual analogue scale from 0-10. All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by an osteochondral graft from the hamate bone is a reliable procedure to restore stability and mobility of the joint.

Preventable Repeat Wrist Arthroscopies: Analysis of the Indications for 133 Cases

Background Frequently, patients undergo repeated wrist arthroscopies for single wrist problems. Purpose The purposes of this study were to assess the indications for repeat wrist arthroscopies and to identify potentially preventable procedures. Methods For this retrospective, two-center study, the electronic patient records were examined for patients, who underwent repeat wrist arthroscopy in a 5-year period. The cases were sorted by the underlying pathologies and the causes that necessitated repeat arthroscopies. Results Ulnar-sided wrist pain accounted for 100 (77%) of all 133 revision arthroscopies: 67 of which due to suspected ulnar triangular fibrocartilage complex (TFCC) avulsions, 33 due to ulnar impaction syndromes. Cartilage was reassessed in 22 (17%) wrists. Thereby, insufficient preoperative diagnostics necessitated pure diagnostic before therapeutic arthroscopy in 49 (37%) wrists: 48 of which for TFCC pathologies, one for a scapholunate (SL) ligament lesion. The uncertainty of diagnosis despite previous arthroscopy necessitated 18 (14%) revision arthroscopies: 15 for ulnar TFCC avulsions, 1 for a central TFCC lesion, 2 to reevaluate the SL ligament. Inadequate photo or video documentation of the cartilage necessitated arthroscopic reassessment in 16 (12%) wrists. Conclusion In this series, two out of three revision arthroscopies could potentially have been prevented. Inadequate preoperative diagnostics with the lack of reliable preoperative diagnoses necessitated pure diagnostic arthroscopies for ulnar-sided wrist pain. However, even arthroscopically, the diagnosis of ulnar TFCC avulsions or SL ligament lesions is not trivial. Surgical skills and experience are necessary to detect such lesions. Finally, adequate photo or video documentation may prevent repeated arthroscopic diagnostic procedures. Level of Evidence Level IV.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

INTRODUCTION

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

MATERIALS AND METHODS

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

RESULTS

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

CONCLUSIONS

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability

INTRODUCTION

The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve through the addition of video documents.

AIM

The purpose of this study was to determine the effect of additional video documentation to photo documentation on intra- and interobserver reliability in wrist arthroscopies.

MATERIALS AND METHODS

Sixty consecutive arthroscopies were documented by photographs of at least eight standard views and videos of the radiocarpal and midcarpal joints. After 3 months, the photographs and then the photographs together with the videos were reevaluated by the surgeon and by two hand surgeons to determine intra- and interobserver reliability. Percentage agreement and kappa coefficients were calculated.

RESULTS

Using videos along with the photographs did not improve reproducibility in general. The assessments of the cartilage status were even worse. Some of the videos were criticized as being too short to allow adequate assessment of the cartilage. Lesions of the TFCC as well as its tension were assessed notably better by the videos, whereas assessment of SL and LT ligaments was not improved by the videos. Intraobserver reliability was better than interobserver reliability.

CONCLUSION

As long as videos do not meet further quality criteria, they are not able to improve reliability in general. Nevertheless, videos should be used for documentation of the TFCC.

Midcarpal fusion is also indicated in patients with advanced carpal collapse and already highly restricted range of motion preoperatively

Although midcarpal fusion is a well-accepted treatment of advanced carpal collapse, 1 question remains unanswered: is this technically demanding procedure worthwhile in wrists with an already highly restricted flexion-extension arc (FEA) of less than 60 degrees preoperatively? Therefore, a retrospective analysis of the records of 142 consecutive patients who had had a midcarpal fusion of the wrist was performed. There were 50 patients in group 1 (FEA < 60 degrees) and 92 patients in group 2 (FEA ≥ 60 degrees) with a mean follow-up of 23 months. Flexion-extension arc preoperatively and postoperatively, pain evaluated by a visual analog scale from 0 to 10 as well as the patients' upper extremity functioning captured with the Disabilities of the Arm, Shoulder and Hand questionnaire were statistically analyzed. Functional range of motion was defined as 5-degree wrist flexion and 30-degree wrist extension. Median wrist flexion before versus after midcarpal fusion was 18 versus 22 degrees and 23 versus 25 degrees for wrist extension in group 1. In group 2, the data were 42 versus 27 degrees and 43 versus 30 degrees, respectively. Midcarpal fusion led to an improvement of FEA in 52% of patients in group 1 but only in 5.4% of patients in group 2. In group 1, the median FEA improved by 122%, whereas the median FEA declined to 69% in group 2. Preoperatively 20% of patients in group 1 and 95% of patients in group 2 reached a functional range of motion for flexion/extension, which changed to 36% in group 1 versus 62% in group 2 postoperatively. The visual analog scale score improved for group 1 from 5.7 to 2.4 and for group 2 from 5.7 to 3.2, respectively. The postoperative DASH score was for both groups 33 points. Our data demonstrate that even in patients with a highly restricted range of motion in advanced carpal collapse, it is still reasonable to perform a midcarpal fusion instead of total wrist fusion.

Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole

PURPOSE

To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy.

METHODS

We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10-47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score.

RESULTS

Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A.

CONCLUSIONS

Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted.

Long-term results after midcarpal arthrodesis

Background and Purpose Midcarpal arthrodesis is a well-accepted treatment option for advanced carpal collapse. In this study, we retrospectively assessed survival, analyzed complications and reviewed the long-term follow-up after midcarpal fusion. Materials and Methods The computerized medical records of 572 patients who had undergone 594 four-corner fusions between 1992 and 2001 were explored. Furthermore 56 patients with 60 midcarpal fusions were randomized for clinical and radiological follow-up at a mean of 14.7 years. Results Forty midcarpal fusions (6.7%) had to be converted into complete wrist arthrodesis. The reasons were ongoing pain in spite of a well-healed midcarpal fusion (31) or nonunion (9). Sixty-three patients (11%) required revision surgery because of nonunion (22), hematoma (8), wound infection (3) or persisting pain (31). In clinical follow-up the mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 20.4. Pain at rest was infrequent, a mild increase with daily activity was complained of (mean visual analog scale [VAS] 3.3). The mean active range of wrist motion for extension and flexion, ulnar and radial deviation and supination and pronation reached 62.5%, 68.4%, 94.7%, and mean grip strength 84.9% of the unaffected side. All patients had radiographic abnormalities, with frequent evidence of osteoarthritis of the lunate fossa. Patients with preserved carpal height appeared to have less pain, better DASH scores and a better range of motion. Conclusions The midcarpal arthrodesis is a long-lasting treatment option for advanced carpal collapse and has good long-term results. Level of Evidence Level IV, Therapeutic study.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck's disease: first results of an ongoing observational study

INTRODUCTION

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease.

MATERIALS AND METHODS

Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.

RESULTS

In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.

CONCLUSION

One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

Salvage of failed resection arthroplasties of the distal radioulnar joint using an ulnar head prosthesis: long-term results

PURPOSE

The aim of this prospective multicenter study was to evaluate the long-term outcome of the Herbert ulnar head prosthesis for painful instability of the distal radioulnar joint (DRUJ) following resection of the ulnar head.

METHODS

Twenty-three patients were treated with a Herbert ulnar head prosthesis in 3 international hand centers. One patient was excluded from the study because a septic prosthesis had to be removed after 3 months. Sixteen of the remaining 22 patients could be assessed at 2 follow-up times, 28 months (range, 10-43 mo) and 11 years and 2 months (range, 97-158 mo) after surgery, for DRUJ stability, forearm rotation, grip strength, pain level (0-10), and satisfaction (0-10). Standardized radiographs of the wrist were evaluated for displacement of the ulnar head and loosening or bony reactions at the sigmoid notch or the ulna shaft.

RESULTS

All patients demonstrated a clinically stable DRUJ at the latest examination, and no patient required further surgery at the DRUJ since the short-term evaluation in 1999. Average pain measured 3.7 before surgery, 1.7 at the short-term follow-up, and 1.7 at the long-term follow-up; patients' satisfaction, 2.2, 8.2, and 8.9; pronation, 73°, 86°, and 83°; supination, 52°, 77°, and 81°; and grip strength, 42%, 72%, and 81% of the unaffected side. All clinical parameters improved significantly from before surgery to the short-term follow-up, with no further statistically significant change between the short-term and long-term follow-up. Radiographs demonstrated no signs of stem loosening or incongruity of the DRUJ.

CONCLUSIONS

The previously reported short-term results with the Herbert prosthesis did not deteriorate in the long term. Reconstruction of the DRUJ with this prosthesis in painful radioulnar impingement following ulnar head resection is a reliable and reproducible procedure with lasting results.

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

[Dorsal capsulodesis for the treatment of scapholunate instability]

OBJECTIVE

To regain stability of the proximal carpal row after scapholunate ligament rupture in order to avoid osteoarthritis and carpal collapse.

INDICATIONS

As additional therapy in scapholunate ligament repair especially in patients with static, but reducible scapholunate malalignment.

CONTRAINDICATIONS

Fixed scapholunate malalignment. Osteoarthritis of the radiocarpal or the midcarpal joint.

SURGICAL TECHNIQUE

Dorsal approach to the carpal joint with release of the second, third and fourth extensor compartment and resection of the dorsal interosseous nerve. Opening of the radiocarpal joint for inspection of the chondral surfaces and the scapholunate ligament for possible repair. If needed, reduction of scaphoid and lunate. Repair of the scapholunate ligament. If a reduction of scaphoid and lunate is necessary, temporary Kirschner wire fixation of the scaphoid to the capitate and the lunate. The dorsal intercarpal ligament is identified and its middle third is dissected and elevated from the triquetrum remaining attached to the distal scaphoid pole. The ulnar end of the elevated part of the dorsal intercarpal ligament is pulled through a split in the dorsal radiotriquetral ligament and fixed to itself. Closure of the proximal and distal third of the dorsal intercarpal ligament.

POSTOPERATIVE MANAGEMENT

Management Immobilization in a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires, if used, 8 weeks postoperatively. Physiotherapy to improve wrist motion.

RESULTS

Most of the reports in the literature show an improvement of pain. The effect on radiologic parameters and the development of osteoarthritis remains uncertain.

[Stabilization of the scaphoid according to Brunelli as modified by Garcia-Elias, Lluch, and Stanley for the treatment of chronic scapholunate dissociation]

OBJECTIVE

Stabilization of the scaphoid correcting rotary subluxation and replacement of the biomechanically essential dorsal part of the scapholunate ligament for prevention of osteoarthritis.

INDICATIONS

Scapholunate dissociation without useful remnants of the ligament and reducible malalignment of the scaphoid.

CONTRAINDICATIONS

Fixed scaphoid malalignment. Osteoarthritis (SLAC [scapholunate advanced collapse] wrist).

SURGICAL TECHNIQUE

Dorsal approach to the wrist using the flap described by Berger. Correction of rotary subluxation and stabilization of the scaphoid using a distally based strip of flexor carpi radialis tendon, which is created through a separate palmar incision, and fixed to a bone anchor in the lunate through a tunnel from the palmar side of the distal pole of the scaphoid to the origin of the dorsal part of the scapholunate ligament from the scaphoid combined with transfixation of the scaphoid to the capitate and the lunate bone in corrected position using two Kirschner wires (1.6 mm). Additionally, the flexor carpi radialis strip is looped through a split in the dorsal radiotriquetral ligament and fixed to itself.

POSTOPERATIVE MANAGEMENT

Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires 8 weeks postoperatively, followed by physiotherapy to improve wrist motion.

RESULTS

14 out of 17 patients were available for a clinical and radiologic examination after a mean follow-up time of 10.5 months (minimum 6, maximum 15 months). Two of these patients had to undergo another operative procedure in the meantime, one partial and the other total wrist fusion. The remaining twelve patients had a mean DASH Score (Disabilities of the Arm, Shoulder and Hand) of 25 (minimum 0, maximum 59 points) and a mean modified Mayo Wrist Score of 80 points (minimum 60, maximum 97 points). Contrary to the good clinical results, the final radiologic examination demonstrated a tendency toward loss of correction compared to the postoperative X-rays.

[The dorsal flag flap for skin coverage of finger and thumb-tip injuries]

OBJECTIVE

Immediate two-step coverage of dorsal finger and thumb-tip soft-tissue defects with a dorsal flag flap, which can bridge over two fingers if necessary.

INDICATIONS

Soft-tissue defects on the dorsal aspect of fingers between the metacarpophalangeal and the distal interphalangeal joint as well as on the tip of the thumb.

CONTRAINDICATIONS

Large defects, complex hand trauma, need of a sensible thumb tip, infections, noncompliance.

SURGICAL TECHNIQUE

Marking of the flap at the middle phalanx and its flagpole pedicle, containing the dorsal digital artery. The breadth should reach to the middle of the finger and the proximal pole should not cross the middle of the proximal phalanx. With tourniquet dissection of the flap above the peritendineum with respect of the dorsal digital artery and subcutaneous veins in the pedicle. Opening of the tourniquet, in the case of flap perfusion transposition of the flap into the defect. Coverage of the donor site with skin graft.

POSTOPERATIVE MANAGEMENT

Palmar cast splinting in intrinsic-plus position for 1 week, followed by physiotherapy. Pedicle separation after 3 weeks. Continuation of physiotherapy and scar care.

RESULTS

In 2006, ten patients were operated on, three of them for reconstruction of the thumb tip. All patients showed a survival of the flap and a good wound healing without complications. One patient developed a flexion contracture at the donor finger due to noncompliance following immobilization. The functional and aesthetic results were satisfactory in all patients, the average DASH Score ("Disabilities of the Arm, Shoulder and Hand") was 16.4, mainly due to the residuals of the overall injury.

Clinical and electrophysiological comparison of different methods of soft tissue coverage of the median nerve in recurrent carpal tunnel syndrome

OBJECTIVE

To evaluate the clinical and electrophysiological results of 26 patients treated with either a hypothenar fat flap or a synovial flap to prevent recurrent scar compression of the median nerve after previously failed carpal tunnel decompression.

METHODS

A total of 26 patients underwent flap coverage as a result of a nerve tethering attributable to a position within scar; 15 were covered by a synovial flap and 11 by a hypothenar fat flap. Only patients in whom the median nerve was significantly enveloped in scar tissue were included. All candidates underwent a thorough clinical examination and nerve conduction test. The pre- and postoperative nerve conduction tests and the results of the two groups were statistically compared.

RESULTS

The reduction rates of brachial nocturnal pain and pillar pain were 25 and 25%, respectively, in the synovial flap group and 64 and 37%, respectively, in the hypothenar fat flap group. The reduction rates of a positive Tinel's sign (25%) and a positive Phalen's test (13%) were lower in the synovial flap group compared with hypothenar fat flap coverage (55% Tinel's sign, 46% Phalen's test). Thenar atrophy and paresthesia were reduced in 44 and 62%, respectively, in the synovial flap group and in 46 and 64%, respectively, in the hypothenar fat flap group. The overall patient satisfaction (73%) and the Disabilities of the Arm, Shoulder and Hand score (31 points) appeared superior in the hypothenar fat flap group compared with the synovial flap group (56%; 37 points). Nerve conduction tests demonstrated a significant improvement when comparing the pre- and postoperative measurements in both groups. Distal motor latency decreased in the hypothenar fat flap group from 6.81 ms to 4.92 msec (P = 0.01; mean value) and in the synovial flap group from 6.04 ms to 4.43 msec (P < 0.001; mean value).

CONCLUSION

Coverage by an ulnar-based hypothenar fat flap appeared to produce superior clinical results compared with coverage with synovial tissue from adjacent flexor tendons, although conclusive statistical evaluation of clinical outcomes was not possible. Further studies to confirm this are warranted.