[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]. / Begleitende Verletzungen von Karpus, distaler Elle und distalem Radioulnargelenk bei distaler Radiusfraktur : Primäre operative Mitversorgung vs. Heilung ohne zusätzliche Therapie.

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

[Selective Neurectomy in Spastic Paralysis of the Upper Extremity]. / Die hyperselektive Neurektomie bei spastischen Lähmungen der oberen Extremität.

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

Cone-beam computed tomography in the treatment of distal radius fractures / Digitale Volumentomografie bei der Behandlung von Radiusfrakturen.

Cone-beam computed tomography (CBCT) is a relatively new imaging technique in hand surgery. Being the most common fractures in adults, distal radius fractures are of special importance not only to hand surgeons. The quantity alone calls for fast, efficient and reliable diagnostic procedures. Surgical techniques and possibilities are progressing, especially regarding intra-articular fracture patterns. The demand for exact anatomic reduction is high. There is an overall consensus regarding the indication for preoperative three-dimensional imaging and it is frequently used. Typically, it is obtained by multi-detector computed tomography (MDCT). Postoperative diagnostic procedures are usually limited to plain x-rays. Commonly accepted recommendations regarding postoperative 3D imaging are not yet established. There is a lack of relevant literature. In case of an indication for a postoperative CT scan, it is generally also obtained by MDCT. CBCT for the wrist is not widely used as yet. This review focuses on the potential role of CBCT in the perioperative management of distal radius fractures. CBCT allows for high-resolution imaging with a potentially lower radiation dose compared with MDCT, both with and without implants. It is easily available and can be operated independently, thus being time-efficient and making daily practice easier. Due to its many advantages, CBCT is a recommendable alternative to MDCT in the perioperative management of distal radius fractures.

State of the art review: The management of chronic vascular disorders in the hand and upper limb.

This review article summarizes the basic principles of vascular anatomy, physiology, diagnostic work-up and treatment for patients with nontraumatic upper extremity vascular disorders. Vascular disorders can be considered vasospastic or occlusive. The most commonly encountered vasospastic condition is Raynaud's Phenomenon secondary to scleroderma. While historically this has been managed medically with vasodilators, more advanced cases can benefit from surgical treatment to improve blood flow and minimize tissue loss, with compelling evidence that earlier surgical intervention can modify disease process and should be considered. Occlusive disease can present as aneurysm or thrombosis and often requires surgical treatment with resection of the occluded segment with or without vascular reconstruction. In advanced atherosclerotic disease or end stage ischemia, arterialization of the venous system can be considered to avoid more proximal amputations.

Relevance of the Scaphoid Shift Test for the Investigation of Scapholunate Ligament Injuries.

Background: Although it is part of the common clinical examination of scapholunate ligament pathologies, there are only little data on the diagnostic value of the scaphoid shift test. The aim of this study was to evaluate the scaphoid shift test in a large cohort of patients. Materials and Methods: We retrospectively analysed 447 patients who underwent the scaphoid shift test and wrist arthroscopy because of various suspected injuries of the wrist, correlating the results of clinical examination with data obtained during the wrist arthroscopy. Sensitivity, specificity, and positive and negative predictive values were calculated and evaluated. Results: The sensitivity of the scaphoid shift test was low (0.50) when examining the whole cohort. In a subgroup of patients specifically referred for suspected scapholunate ligament injury, the sensitivity was higher (0.61), but the specificity was low (0.62). In detecting more serious lesions (Geissler 3 + 4), the scaphoid shift test demonstrated higher sensitivity (0.66). Conclusions: An isolated scaphoid shift test may only be of limited value in the diagnosis of scapholunate ligament lesions and should, therefore, be viewed as a useful tool for a preliminary assessment, but a negative test should not prevent the surgeon from indicating a more extensive diagnostic workup.

Major traumatic amputations and replantations of the upper extremity in Germany - National quality reports 2014-2018.

The treatment of traumatic major upper limb amputation is complex and of great urgency. Loss of time often represents a majorrestriction for replantation. Thus, logistical and infrastructural developments, such as the expansion of specialised hand trauma centres, are crucial for optimizing delivery of care. Surveillance represents the fundament for a proper, demand-adapted implementation of such therapeutical improvements. However, a comprehensive database for surveillance of these injuries does currently not exist in Germany or Europe. In this study quality reports of German hospitals from 2014 to 2018 were screened retrospectively for traumatic major upper extremity amputations and replantations. A total of 329 amputations and 87 replantations were recorded, accounting for an overall replantation rate (RR) of 26%. Most of the injuries affected the level of the wrist and forearm. Treatment of these injuries experienced an increasing centralisation to medical teaching facilities, which accounted for higher RRs compared with non-teaching facilities. The cumulatively most populous federal states handled most of the amputation injures in this five-year study period. Ratio calculations on the basis of population counts, however, revealed great discrepancies to these results, with Hamburg, Rhineland-Palatinate and Saarland accounting for the highest per capita incidences. In 2018 Germany was provided with 46 specialised hand trauma and replantation centres, which performed 45% of the replantations in that year, revealing a RR of 17%, compared to an overall RR of 14% in that year. Nevertheless, there might be potential for improvement in the geographical distribution of these specialised centres. The provision of highly specialised therapy in highly specialised centres for highly complex injuries is a future challenge in replantation surgery. This data is contributing to logistical improvements for a need-adapted expansion of these specialised hand trauma centres. The study demonstrates an approach of a standardised and comprehensive injury surveillance program based on national quality reports, while underlining the importance of such a national or rather European database for optimisations in medical care. Level of evidence IV.

[WALANT - Wide Awake Local Anaesthesia No Tourniquet: Complications in elective and acute traumatological Hand Surgery Procedures]. / WALANT ­ Wide Awake Local Anaesthesia No Tourniquet: Komplikationen bei elektiven und akut-traumatologischen handchirurgischen Eingriffen.

INTRODUCTION: The WALANT (Wide Awake Local Anaesthesia No Tourniquet) technique has rapidly gained popularity. The advantages are often described, whereas information about complications is rare. Therefore, we followed up on our own patients regarding complications.Patients and Method Between January 2013 und June 2017, the complications experienced by one single surgeon were evaluated. The study included all elective (n = 195) and acute (n = 90) surgical procedures performed in WALANT. Minimum age of the patients was 18 years. All patients received Articaine 1 % and Suprarenine (1:200.000). Different volumes were injected with a minimum delay to surgery of 30 minutes. Complications were identified retrospectively by evaluation of patient files and a survey via telephone using a standardised questionnaire. Mean follow-up was 73 weeks. RESULTS: In 285 patients, there were 13 (4.6 %) complications. After injection of 16 ml of Articaine/Suprarenine, one patient had coronary symptoms, which ceased when two puffs of nitroglycerin spray were given. In one patient with a neurovascular injury in the palm, a bloodless field could not be obtained. A short tourniquet time was necessary for exploration. In one patient undergoing flexor tendon tenolysis, there was a need to convert to general anaesthesia with tourniquet because there was insufficient vasoconstriction due to marked scar tissue. One patient had an erythema around the injection site for a prolonged time, two had extensive erythema on the dorsum of the hand and seven patients reported swelling of the hand that lasted more than one week. SUMMARY: The WALANT method is safe. Perioperative complications are rare. Nevertheless, there are some disadvantages that should be considered.Vascular injuries, especially in fingers, are to be monitored closely regarding perfusion, and the off-label use should be remembered. Also, caution should be exercised in patients with cardiac disease. Larger injuries may need a short tourniquet time. Tissue that was operated on before does not always seem to be suitable for the technique as diffusion may be compromised. In rare cases, patients may suffer from prolonged erythema or swelling. Generally, patients should be evaluated for suitability to an operation in local anaesthesia.

The Declining Number of Finger Replantations in Germany.

INTRODUCTION: Data from the United States have shown that finger replantation numbers have declined significantly in recent years. It is unclear whether this is due to a decrease in amputation injuries or other reasons. MATERIALS METHODS: Since 2005, all German hospitals have been required to produce structured quality reports. Based on these reports, we analyzed finger and hand replantation development and the incidence of amputation injuries between 2006 and 2018. RESULTS: Replantations decreased by 30%, whereas amputation injuries increased slightly. In 2018, only 17 centers carried out more than 10 replantations. Most hospitals had replanted less than 4 times a year. The majority of residents participated in fewer than 1 replantation per year. Most specialists performed fewer than 1 replantation per year. The reasons for the decline in replantation remain speculative. CONCLUSIONS: However, a reduction in amputation injuries was not observed. A change in medical indications, technical skills, and economic motivations needs to be considered. A further loss of specialized technical skills and experience with replantations might be a future consequence of this trend.

Corrigendum to "Do your surgical glove characteristics and wearing habits affect your tactile sensibility?" [Ann. Med. Surg. Volume 57, September 2020, Pages 281-286].

[This corrects the article DOI: 10.1016/j.amsu.2020.08.002.].

Bacterial bioburden of wounds: influence of debridement and negative-pressure wound therapy (NPWT).

OBJECTIVE: To clarify the role of microbiological swabs in surgical decision-making, we investigated the effect of negative-pressure wound therapy (NPWT) and serial surgical debridement on bacterial bioburden in hard-to-heal wounds and ultimately correlated them with the success of surgical closure. METHOD: All patients were treated with surgical debridement, jet lavage and NPWT before their wounds were finally closed. The treatment effect was assessed by correlating microbiological swabs obtained immediately after intervention with those obtained after removal of the dressings during the following surgical procedures. The result of the last microbiological swab taken before definitive surgical closure was correlated with the requirement for revision surgery. RESULTS: We included the results of 704 microbiological swabs from 97 patients in 110 wound localisations in this monocentric, retrospective study. NPWT did not improve bacterial bioburden in 77% of cases and the duration of NPWT did not affect the result. Furthermore, no significant effect of NPWT could be found for either anaerobic (p=0.96) or aerobic bacteria (p=0.43). In contrast, surgical debridement decreased bacterial load in approximately 60% of cases. If sterile wound swabs could be obtained at all, it was during the first four surgical debridements in 60% of patients; after that only 10% became sterile. CONCLUSIONS: Sterile microbiological wound swabs before surgical closure were associated with lower rates of revision surgery, while low or medium bacterial loads did not increase revision rates.

Donor Defect Morbidity of Intrinsic Flaps in the Posttraumatized Hand.

INTRODUCTION: There are many types of intrinsic flaps to cover wound defects on the hand, which have been well described in scientific literature. However, the donor sites are often neglected in such studies. Therefore, we aimed to evaluate donor site morbidity for homodigital island flaps, cross-finger flaps, Foucher's pedicle flaps, and flaps of the dorsal metacarpal artery system (DMCA). MATERIALS AND METHODS: A total of 106 intrinsic flap procedures were performed on 106 patients (16 women, 90 men). The donor sites were retrospectively followed up after an average of 3.4 years by a questionnaire, a Disability of the Arm, Shoulder and Hand score, and clinical examination. Donor sites of different flap types were compared for aesthetic outcome, trophic level, and sensation, including 2-point discrimination, temperature, sharp/dull discrimination, the Semmes-Weinstein monofilament test, pain (visual analog scale), and functionality. RESULTS: In general, primarily closed donor sites showed more favorable results than did grafted donor sites. Satisfaction among patients regarding aesthetics of the donor site was highest in patients who had received homodigital island flaps. Grip strength and pain at the operated hand were very heterogeneous and rather influenced by the primary trauma than the type of flap. Homodigital island flap donor sites demonstrated the best results for 2-point discrimination and sharp/dull discrimination, and those for DMCA flaps in the Semes-Weinstein test. CONCLUSIONS: Overall, intrinsic flaps demonstrated low donor site morbidity with reliable coverage of the defects. Of these, the DMCA (especially after primary closure) and homodigital island flaps seemed to produce the best donor site results.

Do your surgical glove characteristics and wearing habits affect your tactile sensibility?

BACKROUND: Tactile sensibility plays a critical role in medicine, especially in surgical practice. In order to prevent surgical site infections and protect the surgeon, the use of surgical gloves is standard practice. However, wearing these might affect the sensibility of the hand disadvantageously, especially in disciplines that require precision work. METHODS: We evaluated the influence of six different glove types, as well as gloves wearing habits (double gloving, over- and undersized gloves) on tactile sensibility using two-point-discrimination and Semmes-Weinstein monofilament testing in 27 non-surgeons. RESULTS: There were significant differences regarding tactile sensibility of gloved compared to bare hands and between different types of gloves. While undersized gloves and double gloving did not affect tactile sensibility, oversized gloves were associated with a significant deterioration of the sensibility of the hand in the Semmes-Weinstein monofilament test. CONCLUSION: This study demonstrates that surgical gloves negatively affect the sensibility of the hand and show significant differences between different types of gloves.

Overuse syndrome of the hand and wrist in musicians: a systematic review.

We systematically searched medical publication databases for articles in English on upper extremity overuse syndrome in musicians. We focused on non-specific pain disorders, including diagnostic definitions, epidemiology, pathophysiology, risk factors, symptoms, treatment, and prevention. We included 42 out of 156 identified articles. The point prevalence of playing-related musculoskeletal disorders ranges from 37% to 47% in musicians with the hand and wrist among the most commonly affected areas, and the lifetime prevalence is reported as high as 89%. Leading symptoms are pain, weakness, stiffness, and loss of control. Intense repetitive use during practice, or before an audition or concert, recent changes in conductors or teachers, psychological stress, the effort of holding a weighty instrument, wrong technique, and joint laxity have all been identified as risk factors. The need for prevention is highlighted. Today's therapy is mostly based on individual rehabilitation programmes rather than on long-term rest. However, treatment remains predominantly based on beliefs rather than on evidence. The entire subject needs intensive future research.

The Usage of Pedicled or Free Muscle Flaps Represents a Beneficial Approach for Periprosthetic Infection After Knee Arthroplasty.

INTRODUCTION: Periprosthetic joint infection (PJI) is a severe complication after a total knee replacement that is primarily associated with soft tissue defects. Finding an appropriate therapy for PJI is a major challenge because of the lack of guidelines and research comparing treatment options. METHODS: In this study, we retrospectively compared 78 patients who had a knee prosthetic infection within a mean follow-up period of 24 months. Group A received a soft tissue coverage in addition to orthopedic surgical therapy with or without a component replacement (CR) of the prosthesis. Group B received the same orthopedic treatment without plastic surgery for soft tissue coverage. RESULTS: Only 21% of the patients in group A received a CR compared with 70% in group B (P = 0.0001). In group A, 83% did not have a recurrent infection, and in group B, 57% of the patients had no further infection and regained joint function (P = 0.0376). In group A, only 15% of the patients who received a CR had a significant complication within the follow-up period of 2 years, whereas in group B, 75% of patients exhibiting a major complication (P = 0.0048*). CONCLUSIONS: Soft tissue coverage improves the outcome after PJI of the knee with soft tissue defects. Patients who simultaneously needed plastic surgery for defect coverage and orthopedic surgery for CR had the lowest number of complications overall. Based on the results of this study, a therapy algorithm could be identified considering the soft tissue defect grade leading to the lowest major complication rates and maximizing the outcome of knee prosthesis infection therapies.

[Consensus of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM) on minimum standards for microsurgical training courses and accreditation - Minimum Standards for Microsurgical Training Courses and Accreditation]. / Konsensus der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) für Mindeststandards mikrochirurgischer Trainings- und Übungskurse zur Vergabe eines Qualitätssiegels.

Microsurgical training courses are an integral part of surgical education and training. Due to the changes in the surgical everyday routine, the competence and skills training outside the operating room has an increasingly important status. Multi-day, hands-on exercises with different models of increasing difficulty use artificial, avital and vital microsurgical models. The skills are evaluated with regard to fine motor skills as well as orientation in space and low-tremor motion sequences as well as bimanual manipulation exercises by means of "lobal rating scales". However, with numerous course offerings in German-speaking countries, there are no uniform and transparent contents and evaluation standards to reflect the quality of the courses. At a consensus meeting, minimum requirements for the contents of microsurgical training courses in the context of continuing medical education were defined and drafted as a German-language consensus in order to award a DAM quality seal. The parameters include the definition of targets, the existence of a scripts, the number of hours used, models used, practical exercise time on the microscope, trainer to participant ratio, types of anastomosis or coaptation (artery, vein, nerve, lymph vessel), application of a global rating scale , examination (grade/passed - failed), participant certificate and course evaluation. With the aim to meet the available courses/course concepts to maintain or improve the quality of education and training, the assignment of a "Basic" and an "Advanced" quality seal has been defined. The further stepwise development of the courses is necessary to sustain all skills and competencies for future microsurgeons. Integration of validated microsurgical simulators may reduce animal use and thus contribute to the ethical responsibility. The introduction of quality seals for microsurgical training courses should strengthen the transparency and commitment of participants and provide support to course providers with appropriately substantiated content through DAM.