[Wrist arthroscopy : challenging procedure of modern hand surgery]

Arthroscopy of the wrist has developed in the shadow of arthroscopy of the large joints. Nowadays, wrist arthroscopy has a relevant importance in the diagnostics and therapy in hand surgery and is indispensable for serious surgery of the wrist. Special equipment and extensive knowledge of the surgeon are necessary for carrying out the procedure.

Cubital tunnel syndrome - a review and management guidelines

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression syndrome. In German-speaking countries, cubital tunnel syndrome is often referred to as sulcus ulnaris syndrome (retrocondylar groove syndrome). This term is anatomically incorrect, since the site of compression comprises not only the retrocondylar groove but the cubital tunnel, which consists of 3 parts: the retrocondylar groove, partially covered by the cubital tunnel retinaculum (lig. arcuatum or Osborne ligament), the humeroulnar arcade, and the deep flexor/pronator aponeurosis. According to Sunderland , cubital tunnel syndrome can be differentiated into a primary form (including anterior subluxation of the ulnar nerve and compression secondary to the presence of an anconeus epitrochlearis muscle) and a secondary form caused by deformation or other processes of the elbow joint. The clinical diagnosis is usually confirmed by nerve conduction studies. Recently, the use of ultrasound and MRI have become useful diagnostic tools by showing morphological changes in the nerve within the cubital tunnel. A differential diagnosis is essential in atypical cases, and should include such conditions as C8 radiculopathy, Pancoast tumor, and pressure palsy. Conservative treatment (avoiding exposure to external noxes and applying of night splints) may be considered in the early stages of cubital tunnel syndrome. When nonoperative treatment fails, or in patients who present with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes, surgical treatment should be recommended. According to actual randomized controlled studies, the treatment of choice in primary cubital tunnel syndrome is simple in situ decompression, which has to be extended at least 5-6 cm distal to the medial epicondyle and can be performed by an open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. When the luxation is painful, or when the ulnar nerve actually "snaps" back and forth over the medial epicondyle of the humerus, subcutaneous anterior transposition may be performed. In cases of severe bone or tissue changes of the elbow (especially with cubitus valgus), the anterior transposition of the ulnar nerve may again be indicated. In cases of scarring, submuscular transposition may be preferred as it provides a healthy vascular bed for the nerve as well as soft tissue protection. Risks resulting from transposition include compromise in blood flow to the nerve as well as kinking of the nerve caused by insufficient proximal or distal mobilization. In these cases, revision surgery is necessary. Epicondylectomy is not common, at least in Germany. Recurrence of compression on the ulnar nerve at the elbow may occur. This review is based on the German Guideline "Diagnose und Therapie des Kubitaltunnelsyndroms" ( www.leitlinien.net ).

[Arthroscopic refixation of traumatic 1B-lesions of the TFCC--a retrospective study]

AIM

The aim of the study was to investigate the postoperative outcome of the arthroscopic sutures of traumatic 1B-lesions of triangular fibrocartilage complex (TFCC) tears.

METHODS

Thirty-six patients who underwent an arthroscopic repair of traumatic 1B-lesions of the TFCC without a dislocation of the ulnar styloid process were included in this study. The average age of the 18 male and 18 female patients was 43.8 (range: 22-70) years. In 16 cases, we operated the left and in 20 cases the right TFCC. On average, the follow-up examination was performed after 7.9 years (range: 3.2-14.3) years. Patients with revision operations or neurovascular pathology were excluded. The Mayo modified wrist score and the disability of arm, shoulder and hand (DASH) score were used to identify the outcome.

RESULTS

The Mayo modified wrist score was preoperatively 49.74+/-20.99 and postoperatively 82.43+/-15.89 (p<0.001). The DASH score was preoperatively 48.68+/-21.47 and postoperatively 24.1+/-19.81 (p<0.001). Only five patients demonstrated an isolated 1B-lesion of the TFCC and showed, likewise, significant improvements both regarding the DASH score and the Mayo modified wrist score (p<0.05). However, there was no significant difference to the patients with further wrist injuries (p>0.05).

CONCLUSION

The results of the current study suggest that 1B-lesions of the TFCC can be successfully repaired by arthroscopically assisted suture techniques. An isolated 1B-lesion of the TFCC is rather unusual.

[Diagnosis and therapy of cubital tunnel syndrome--state of the art]

The cubital tunnel syndrome is one of the most widespread compression syndromes of a peripheral nerve. In German-speaking countries it is known as the sulcus ulnaris syndrome (retrocondylar groove syndrome), which is anatomically incorrect. The cubital tunnel consists of the retrocondylar groove, the cubital tunnel retinaculum (Lig. arcuatum or Osborne band), the humeroulnar arcade and the deep flexor/pronator aponeurosis. According to Sunderland it can be divided into a primary form (including the ulnar luxation and the epitrocheoanconaeus muscle) and a secondary form caused by deformation or other processes of the elbow joint. The diagnosis has to be confirmed by a thorough clinical examination and nerve conduction studies. Neurosonography and MRI are becoming more and more important with improving resolution and enable the direct identification of morphological changes. Differential diagnosis is essential in atypical cases, especially C8 syndrome and pressure palsy. Double crush (double compression syndrome) may occur. Operative treatment is more effective than conservative treatment, which consists primarily of the prevention of exposure to external noxes. According to actual randomised controlled studies the therapy of choice of the primary form in most cases is the simple in situ decompression of the ulnar nerve in the cubital tunnel. This has to be extended at least up to 5-6 cm distally of the medial epicondyle and can be performed in the open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. In cases of severe bony or tissue changes of the elbow (especially cubitus valgus) the volar transposition of the ulnar nerve may be indicated. This can be performed in a subcutaneous or submuscular technique. Risks of transposition are impairment of perfusion and, above all, kinking caused by insufficient proximal or distal mobilisation of the nerve has to be avoided. In these cases revision surgery is necessary. The epicondylectomy is not common in our country. Recurrences may occur.

[Arthroscopic examination of the wrist joint]

Arthroscopy is a standard procedure for the diagnosis of wrist disorders. Provided it is preceded by a thorough clinical investigation it is highly effective in detecting cartilagineous, osseous and ligamenteous lesions. Sometimes even intraarticular occult ganglia are visible. Especially triangular-fibrocartilage-lesions can be classified and give hints at instabilities of the distal radioulnar joint. Arthroscopy of the radiocarpal joint alone is not sufficient. The midcarpal joint must be visualized, too. Although disorders of the distal radioulnar joint are frequent, it is usually too narrow to permit an arthroscopic investigation.

[Arthroscopic image of wrist joint instability]

In a consecutive series of 107 arthroscopies, 88 wrists showed a ligamentous lesion on the ulnar side. The TFCC was affected in 90% (79 patients), the triquetrum in 53% (47 patients), the ulnocarpal ligaments in 22% (19 patients) and the hamate in 17% (15 patients). The number of ligament injuries averaged three per wrist. Surprisingly, there were multiple lacerations noted in 22% of the TFCC and these occurred in characteristic combinations.

[Rare lesion of the median nerve caused by elbow dislocation with avulsion of the epicondylus humeri medialis in childhood]

A case of posterior dislocation of the elbow complicated by intraarticular entrapment of the median nerve is reported. Sixteen cases have previously been described in the literature. The mechanism of the injury is discussed. Early exploration of the nerve is advised when signs of median nerve deficit persist following reduction of the dislocated elbow.

Hypothermic circulatory arrest in the treatment of thoracic aortic lesions

The use of hypothermic circulatory arrest has been established in the treatment of aortic arch lesions. We recently used this method of arrest in the treatment of 10 consecutive patients with thoracic aortic lesions. Seven of these patients had dissecting aneurysms of the ascending aorta with extension into the aortic arch. One patient had a mycotic aneurysm of the arch, and 2 patients had arteriosclerotic aneurysms of the ascending aorta and entire aortic arch. All patients were supported and cooled with cardiopulmonary bypass. Circulatory arrest was maintained for periods of 21 to 63 minutes. All 10 patients survived the operative procedure. Nine patients remained intact neurologically. Renal function returned to baseline in all patients. Average blood replacement was 2.9 units. All patients have experienced an excellent surgical result. The average follow-up is 21.1 months. The technique facilitates a surgical approach to these lesions and appears to be the safest form of vital-organ preservation.

[Changes in thyroid hormone levels following severe burns treated topically with povidone-iodine]

The serum concentrations of thyroxine (T4), triiodothyronine (T3) and TSH as well as the effective thyroxine ratio (ETR) and the resin-T3-uptake (RT3U) were studied in 23 severely burned patients during the whole time of hospitalisation. Topical treatment was carried out with povidone-iodine. In all patients T4 and T3 concentrations decreased significantly during the first two weeks especially in extensive burns. Lack of increase was a bad prognostic sign. ETR and RT3U underwent no remarkable changes. The TSH levels increased distinctively until the third week, decreased slowly and turned to normal values only in the late period of illness. The influence of iodine uptake due to external application is discussed.

Surgical catheterization of heptic-portal and peripheral circulations and maintenance in pharmacokinetic studies

A surgical procedure for the chronic catheterization of mongrel dogs was presented with a detailed account of the use and maintenance of these catheters. The methodology allowed for a direct determination of the capacity of the liver to the intact animal to metabolize drugs. The technique permitted the investigator to study the oxidation of drugs by the liver in a specific concentration range and assessment of the first-pass effect of the liver when many drugs are administered via the oral route. The dogs were prepared and use in the drug pharmacokinetic studies for periods up to 24 days.

[Reconstructive surgery for supraaortic occlusions--a report of 356 cases]

Internal carotid endarterectomy is an effective and long-lasting means of preventing cerebrovascular accidents. It was entirely successful in 97% of asymtomatic patients. 85% of patients with transient ischemic attacks experienced no further symptoms. In patients with acute stroke, 52% were improved by the operation, but the mortality in this group was 23,9%. We therefore perform emergency carotid endarterectomy only in a conscious patient and within 8 hours of the stroke. The early and late results after reconstruction of the other supra-aortic vessels were good in 90% of cases.