[Modified volar plate arthroplasty for posttraumatic and idiopathic osteoarthritis of the metacarpophalangeal and proximal interphalangeal joints]. / Die Resektionsarthroplastik mit Interposition der palmaren Faserplatte zur Behandlung posttraumatischer oder idiopathischer Arthrosen der Fingergrund- und Mittelgelenke.

This article presents the results of modified resectional arthroplasty with interposition of the proximally based palmar plate and economic partial resection of the proximal joint surface without cutting the collateral ligaments. Indications were posttraumatic, idiopathic, and tumorous arthrosis of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints.In MP joints, the range of motion improved in eight patients from 40 degrees to a median of 70 degrees with an extension deficit of 10 degrees and a pinch strength of 4.5 kg. All patients (n=8) were free of complaints at a DASH level of 8. In PIP joints, the range of motion improved from 40 degrees to 60 degrees after 35 months in 12 patients with dynamic postoperative treatment. All patients except one were pain-free at a DASH level of 27. Postoperative dynamic splinting was superior to static care.

[Long-term follow-up of fracture dislocations and comminuted fractures of the PIP joint treated with Suzuki's pin and rubber traction system]. / Spätergebnisse der frühfunktionellen Behandlung von intraartikulären Mittelgliedbasisfrakturen mit dem Bewegungsfixateur nach Suzuki.

Fracture dislocations and comminuted fractures of the PIP joint are considered as severe injuries with uncertain outcome. Short-term results of several traction devices in the treatment of PIP joint fractures have been published. But the further course concerning the injured joint surface has not been described yet. From 1995 to 2001 we treated 26 patients who suffered comminuted intraarticular fractures and fracture dislocations with the digital dynamic external fixator from Suzuki. The time of follow-up was 8 years (median) with a range of 5 - 11 years. Due to this rather long period only 13 patients were available for follow-up. The flexion of PIP joint gained a median value of 95 degrees (range: 35 - 100 degrees ), extension loss was 0 degrees (median; range: 0 - 35 degrees ). Range of motion of the PIP joint was 85 degrees (median; range: 0 - 100 degrees ). The evaluation of the X-rays shows an initial anatomic reduction with complete joint congruency in only 20 % of the cases, but over time there was a remodelling of the joint surface in 89 % without obvious signs of degeneration of the joint. We suppose that the surprisingly good long-term results are linked to this extraordinary remodelling. No patient complained about pain using the affected finger without load and only 2 patients experienced mild pain on heavy use. Compared to the 2-years results of another patient group that we published in 2001 the long-term results tend to be slightly better. We conclude that dynamic traction and early motion of intraarticular PIP joint fractures are the treatment of choice, as virtually pain-free and good motion is achieved also in the long-term due to the remarkable remodelling capacity of the joint surface.

[Long-term results after lunate replacement by the vascularised os pisiform for treatment of Kienböck's disease III b]. / Langzeitergebnisse nach Transposition des gestielten Os pisiforme zur Behandlung der Mondbeinnekrose Stadium III b.

Saffar's procedure is used only rarely today. In order to assess the value of this operation in the treatment of advanced Kienböck's disease, after a mean follow-up period of 19 years we could review 7 of 12 patients who had had their lunate replaced by the vascularised pisiform. At the time of follow-up all patients were fully employed without restrictions, and no patient had had to change his job. The mean DASH score was 5.9. The average pain level by VAS was 0.9 and four patients were totally free of pain. Grip strength of the affected arm was reduced to 77% of the opposite side, the active range of motion (extension/flection) was 97 degrees, which was 72% of that of the not affected side. All patients reported high satisfaction with the results of the operation. Although the clinical results were very good, we found substantial radiographical alterations: In 5 patients we found an advanced intercarpal osteoarthritis. Four patients presented a spontaneous synostosis between the pisiform and the triquetrum. The average CHR (carpal height ratio) was 0.43. The presented long-term results after lunate replacement by the vascularised pisiform indicate a high patient satisfaction and very good functional results in spite of significant radiological changes.

[Clinical results of terminolateral neurorrhaphy in digital nerves]. / Klinische Ergebnisse von End-zu-Seit-Nervennähten.

In end-to-side-neurorrhaphy the collateral sprouting of axons has been proven in many animal studies. It has not yet been determined if a satisfactory sensory recovery occurs. Unfortunately, there is still a lack of well documented clinical studies. We have used end-to-side nerve sutures in five patients. Four of them showed gaps in digital nerves, the fifth patient had a partial transsection of the superficial branch of the radial nerve. At the time of follow-up examination, surgery had been performed an average of 21 months previously (11 - 39 months). We examined sensibility, temperature perception, patient satisfaction and the presence of pain and neuroma. Two of the patients with injured digital nerves reached an almost normal two-point discrimination of 6 mm, the other two patients only achieved a value > 10 mm. With monofilaments one patient was able to recognise the 3.61 filament, which constitutes a standard value. The other three recognised the 4.31 filament, which is only one degree less. All measurements concerning the superficial branch of the radial nerve turned out to be less satisfactory, however, one must consider that the sensation qualitiy in this area is less to begin with. No neuromas occurred, except in the case of the radial nerve. None of the patients showed full recovery of temperature perception. Two were able to recognise a warm and three a cold probe head. Our results confirm the findings made in other studies which also found a clinical correlate to collateral axonal sprouting. Unfortunately results are still inconsistent.

Reconstruction of heel and sole defects by free flaps.

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.

Contralateral transplantation of a finger for restoration of thumb function.

Transplantation of a finger from the contralateral hand for thumb reconstruction is seldom done because of possible psychological problems for the patient. We present two cases in which a previously damaged index finger of the contralateral hand was transplanted. In both patients the metacarpophalangeal joint of the index finger replaced that of the thumb. A powerful pinch to the fingers was achieved and the appearance of both the donor and the recipient hands was considerably improved.

Fixation of metacarpal fractures using absorbable hemi-cerclage sutures.

We retrospectively reviewed the use of biodegradable hemi-cerclage sutures in the treatment of 79 metacarpal fractures in 66 patients. The polyglycolic acid hemi-cerclages achieved sufficient fracture fixation to permit early motion exercises, but fractures were also immobilized for a mean of 3.7 (range, 1.5-6) weeks postoperatively, during which time physiotherapy was given. Adequate bony stability was achieved after a mean of 4.5 (range, 3.5-7) weeks and fracture redisplacement occurred in only one case.

Fingers, hands or patients? The concept of independent observations.

In hand surgery trials, it is often possible to take several measurements from the same patient, because many disorders here affect bilateral or multiple structures, such as the hand itself, the finger joints or the tendons. Most conventional statistical analyses that take place on the level of hands, digit rays or joints rather than patients violate the assumption that observations should be independent. Furthermore, ignoring the multiplicity of data inflates sample size and thus may lead to spurious significance. This article describes three options to deal with such problems. First, the analysis can simply be restricted to only one measurement per patient. Second, a self-controlled design may be advantageous for conditions that usually have a bilateral pattern. Third, complex statistical modelling (involving generalized estimating equations) can be used to analyse all available measurements with adjustment for data dependency.

Tendon transfer for tardive ulnar nerve palsy.

Irreparable damage to the motor function of the ulnar nerve results primarily in paralysis of the intrinsic muscles and reduces the functional capacity of the hand by about one-half. Tendon transfers are therefore indicated when the following grasp functions are impaired: (1) claw hand with dyskinetic finger movements; (2) impaired thumb adduction with limited key pinch power; (3) instability of the index MP joint; (4) adduction weakness of the little finger. The various procedures and transposition techniques are discussed and the author's preferred methods of tendon transfer are presented.

[Flexion contractures of the PIP joints: pathogenesis, classification and results following arthrolysis]. / Beugekontrakturen der Mittelgelenke: Pathogenese, Klassifikation und Ergebnisse nach Arthrolysen.

The most frequent cause of flexion contracture is immobilization, which may occur with or without trauma. Posttraumatic flexion contracture mainly develops from direct injury, intraarticular fluid and the physiological muscle balance. Nontraumatic post-immobilisation stiffness is due to biochemical and biomechanic changes as well as processes, which are determined by the metabolic activities of tissue and the lack of stress. Because of the variable and the changing anatomical substrates, and owing to different prognostic factors, it is necessary to subdivide the group of flexion contractures with regard to their prognostic factors. Thus, we recommend to differentiate between simple periarticular contractures, complex periarticular contractures with tenodesis and/or contractures caused by scars, as well as a corresponding classification of corresponding treatment procedures. The results in the literature will then be categorized accordingly within a metaanalysis. With regard to the reduction of flexion contractures and the range of motion, the group of simple periarticular arthrolysis shows better results than the group of complex periarticular arthrolysis. The mediolateral approach is preferred in the first group.

[Pathology of the sesamoid bones of the hand]. / Die Pathologie der Sesambeine an der Hand.

Sesamoid bones are osseous parts of certain joints and can either be included in pathological changes of these joints or separately in those of the sesamoidal joint itself. The clinical relevance of such findings is described in the following examples: Rheumatoid variants, psoriasis, different types of hyperostotic forms, chronic sesamoiditis as well as post-trauma. In three out of four cases of fracture, the ulnar sesamoid bone of the metacarpophalangeal joint of the thumb was affected.

[The motion stable intraosseous wire suture--a prospective study]. / Die übungsstabile intraossäre Drahtnaht--eine prospektive Studie.

In a prospective study the results of 86 cases of transverse metacarpal and phalangeal fractures, corrective osteotomies and bone grafts treated by intraosseous wiring were reviewed six months postoperatively. The follow-up rate was 98%. Data included the time off work, the functional results in terms of total active range of motion of finger joints, intraoperative and postoperative complications, and additional stabilizing procedures.

[Clinical research in hand surgery: the problem and value of retrospective studies]. / Klinische Forschung in der Handchirurgie: Problematik und Wert retrospektiver Studien.

Retrospective studies are still very important in clinical decision making although they present severe methodological deficiencies compared to controlled trials. Imprecise and incomplete data gathering, lack of homogeneity in the group studied, and lack of randomisation are the main drawbacks. Indications for retrospective studies and criteria for their execution are presented.

[What results can be expected following the biceps replacement operation? An analysis of retrospective data]. / Welches Ergebnis können wir nach einer Bizeps-Ersatzoperation erwarten? Eine Analyse retrospektiver Daten.

The authors reviewed the literature and analysed the results of Steindler's technique, the transfer of pectoralis major muscle and its modifications, and the transfer of latissimus dorsi muscle. They determined the average extension lag, flexion, mobility, and strength in the publications they reviewed. Their own results were included in the statistics. The analysis of the results of the various techniques showed, 1. There is not always good correlation between the theoretical advantages and disadvantages of a surgical method and the clinical results of a particular operation in the restoration of elbow flexion. 2. The technical difficulty of a particular surgical method and the postoperative results must be taken into consideration when selecting the right operation. 3. There is a need for controlled studies of the different methods.

[Contralateral finger transplantation for reconstruction of thumb function]. / Kontralaterale Fingertransplantation zur Wiederherstellung der Daumenfunktion.

Finger transplantation from the contralateral hand for the purpose of thumb reconstruction is rarely performed, more widespread use of this procedure being prevented by the psychological problems for the patients. Two cases are described, in which a previously damaged index finger of the contralateral hand was transplanted. The metacarpophalangeal joint of the index finger replaced that of the thumb in both cases. A strong pinch grip with sensibility was achieved. The aesthetic result was substantially improved, both on the donor and the recipient hand.

[Radial island flap for the reconstruction of the 1st commissure]. / Der Radialis-Insellappen zur Rekonstruktion der 1. Kommissur.

The fasciocutaneous radial forearm island flap was used in six cases for reconstruction of the first web space after tumor resection, severe burns, a complex hand injury and a congenital adduction contracture of the thumb. Reconstruction of a deep and wide first web was possible in all cases. All flaps except the last one operated fifteen months ago have recovered protective sensation although nerve reconstruction was performed only twice. The donor defect could be closed directly in three cases. Corrective surgery for an unsightly scarred donor area was considered in one case. The radial forearm island flap is therefore a reliable and low-risk procedure for coverage of first web defects.

[Value of clinical diagnosis in carpal tunnel syndrome]. / Die Wertigkeit der klinischen Diagnostik beim Karpaltunnelsyndrom.

The aim of this study was to examine sensitivity and specificity of Durkan test in 54 patients with carpal tunnel syndrome confirmed by electrophysiological testing, as compared to a control group of 54 patients without clinical signs of the syndrome. Sensitivity and specificity of Durkan test alone, as well as in combination with Phalen test and Hoffmann-Tinel test, were determined. The sensitivity of Durkan test was 0.87, its specificity was 0.96. The sensitivity of Phalen test was 0.85 with a specificity of 0.96. It was discovered that the combination of Phalen with Durkan test achieved a sensitivity of 0.94 and a specificity of 0.96, thus equalling the respective values for electrophysiological testing (nerve conduction velocity, electromyography) which so far is regarded as the golden standard diagnostic test for carpal tunnel syndrome. If Hoffmann-Tinel test is included as a further clinical parameter, then both sensitivity and specificity reach 0.96. This study, therefore, raises the question of whether costly electrophysiological testing is in fact necessary before surgery for carpal tunnel syndrome, when the clinical tests have already proven positive.

[Arthrosis of the articulation of the pisiform bone]. / Arthrose der Articulatio ossis pisiformis.

Osteoarthritis of the pisiform at its articulation with the triquetral bone is rarely reported in the literature. Four cases are presented with involvement of both hands in one. The diagnosis can be verified by clinical examination and X-rays. The method of treatment selected was arthrodesis by means of wire suture.

[Transposition of pedicled pisiform bone in the treatment of stage III lunate malacia]. / Die Transposition des gestielten Os pisiforme zur Behandlung der Lunatum-Malazie Stadium III.

In six patients who were suffering from Stage III Kienböck's disease, as defined by Decoulx, the lunate was completely removed and replaced by the pisiforme on its vascular pedicle. There was an average follow-up of twenty months. The authors report a reduction in the level of pain and a 40 degrees average increase in mobility.

[Does Epping resection arthroplasty lead to loss of hand strength? A prospective study]. / Führt die Resektionsarthroplastik nach Epping zur Kraftminderung der Hand? Eine prospektive Studie.

FCR-sling resectional arthroplasty does not definitely prevent a proximalisation of the first metacarpal bone. Since power transmission of the thenar muscles requires a particular length of the thumb, does proximalisation lead to a reduction of grip strength of the hand? In a prospective study, hand-, key- and pinch-grip strength was compared to preoperative data. Pain intensity and thumb mobility were also examined. In comparison to preoperative data, the pain-free pinch grip improved 60% after three months and 100% after 12 months (p < 0.01). The maximum pinch grip improved 11% after three and 34% after 12 months (p < 0.01). The pain-free key grip improved 22% after three months and 50% after 12 months (p < 0.01). The maximum key grip showed a fair reduction after three months, but after 12 months the key pinch strength came up to preoperative level. The hand grip strength showed a statistically significant improvement of 9% after three months and 34% after 12 months (p < 0.01). After one year, 80% of the patients were completely painfree. There was no clinically relevant disturbance of thumb movement following surgery. Owing to proximalisation of the first metacarpal, a scapho-metacarpal distance of 5.3 (2-9) mm was measured. Despite proximalisation of the first metacarpal, a significant improvement of the grip strength was observed, which was rooted in simultaneous pain reduction.