[Minimally invasive procedures in the early stages of trapeziometacarpal joint osteoarthritis : Denervation, arthroscopy and autologous fat transplantation]. / Minimal-invasive Verfahren im Frühstadium der Daumensattelgelenksarthrose : Denervierung, Arthroskopie, autologe Fetttransplantation.

BACKGROUND: Resection arthroplasty of the trapezium with or without tendon interposition is the standard procedure in the treatment of advanced, symptomatic thumb carpometacarpal joint osteoarthritis. Treatment recommendation in the early stages without visible or minimal radiographic changes is often difficult, especially when conservative treatment methods have already been exhausted. In these cases, there is the possibility of the minimally invasive methods of denervation, arthroscopic procedures and autologous fat transplantation. OBJECTIVES: Which minimally invasive procedures are available for the treatment of thumb carpometacarpal joint osteoarthritis and how is their value to be assessed? METHODS: The minimally invasive methods of denervation, arthroscopic procedures and autologous fat transplantation for the treatment of thumb carpometacarpal joint osteoarthritis are described and current results from the literature are discussed. RESULTS: Good results have been reported with all three procedures. However, the reports are almost exclusively based on retrospective studies with small numbers of patients, which lack control groups, so the results cannot be regarded as definitive. CONCLUSIONS: Denervation, arthroscopic procedures and autologous fat transplantation appear to be suitable methods in the early stages of thumb carpometacarpal joint osteoarthritis. Further studies, especially comparative randomised trials that report medium and long-term results, would allow further assessment of these methods.

[Joint arthrodesis in functionally favorable position : Considerations on measurement of disability in private accident insurance]. / Gelenkversteifung in gebrauchsgünstiger Stellung : Überlegungen zur Invaliditätsbemessung in der privaten Unfallversicherung.

If an accident results in a functional disorder that persists and permanently restricts physical and/or mental capacity, this is referred to as a disability. In private accident insurance it is the task of the medical expert to assess this disability by examining the medical findings and produce an assessment taking account of the literature and comparing against generally acknowledged guidance values. The priority dismemberment disability rating schedule initially provides loss values. For the "next lowest" disability levels for arthrodesis of extremity joints, the assessment recommendations are based on a functionally favorable position although this functionally favorable position is not more precisely defined.In this article the authors have defined these functionally favorable positions based on the information available in the literature. In particular, the operatively favorable settings for arthrodesis of the affected joint that are stated in the literature on trauma and orthopedic surgery were consulted. Of course, the functional perspective has been especially emphasized.A difficulty in achieving this was that the literature on arthrodesis is now almost only of historical value due to modern endoprosthetics. The knowledge gained was checked against medical experience and is expounded here.

[Revision surgery after failed (partial-) arthrodesis of the wrist]. / Revisionen nach fehlgeschlagenen (Teil­)Versteifungen am Handgelenk.

(Partial) arthrodeses of the wrist have been proven cornerstones to treat many lesions for decades, especially in the case of revision surgery. Four-corner, scapho-trapezo-trapezoidal (STT), radio-scapho-lunate (RSL) and total wrist fusions are very common techniques in hand surgery. However, even these proven surgical procedures have significant non-fusion rates. Prior to revising a failed arthrodesis, it is essential to analyse the latter failure precisely. A technically adequate revision is only feasible when based on a correct and meticulous analysis. The understanding of the biological processes and technical aspects of the implants are the basis for solving this issue.

[Tenolysis of extensor and flexor tendons of the hand]. / Tenolyse von Streck- und Beugesehnen an der Hand.

BACKGROUND: Unrestricted gliding of extensor and flexor tendons is essential for normal functioning of the hand. If tendon gliding is impaired, a restricted range of motion of finger joints and, finally, joint stiffness result. OBJECTIVES: To answer the questions about the causes of tenodesis in the hand, which examinations are most informative, how tenolysis is technically performed, and what results can be expected. METHODS: The reasons, examinations, surgical technique, and results of extensor and flexor tendon tenolysis are presented. RESULTS: Based on the data in the literature tenolysis of flexor tendons leads to range of motion that is only 50-60% of the preoperative range of motion. In about 20% of patients, deterioration as serious as secondary tendon rupture is observed. Meaningful results of extensor tendon tenolysis have not yet been published. CONCLUSIONS: Tenolysis of extensor and flexor tendons in the hand is a demanding surgical procedure, and in addition to detailed knowledge of anatomy and biomechanics, it requires sufficient experience-especially following the primary repair of tendon injuries. The earliest indication for tenolysis can occur at about 3 months, usually after 6 months, if continuous intensive hand therapy and splinting have not been successful. General and individual benefits and risks must be carefully weighed. The key to successful tenolysis is the patient's access to and unrestricted participation in competent postoperative treatment, ideally performed by a specialist in hand therapy, which may last for weeks or months.

[Repair of the pronator quadratus muscle with a part of the brachioradialis muscle insertion in volar plate fixation of a distal radius fracture]. / Refixierung des Musculus pronator quadratus mit einem Teil des M.-brachioradialis-Ansatzes bei der palmaren Plattenosteosynthese einer distalen Radiusfraktur.

THE PROBLEM: Stable pronator quadratus repair following volar plate fixation of distal radius fractures with complete plate coverage is often difficult. THE SOLUTION: Detachment of the pronator quadratus muscle (PQ) with a strong rim of connective tissue consisting of a fibrous portion of the roof of the first extensor compartment and the volar limb of the brachioradialis muscle (BR) insertion; stable suture repair of the PQ with complete coverage of a volar plate after osteosynthesis of a distal radius fracture. SURGICAL TECHNIQUE: Radiopalmar approach between the radial artery and the flexor carpi radialis tendon to the PQ; sharp dissection below the radial artery onto the first extensor compartment, which is opened; retraction of the extensor pollicis brevis and abductor pollicis longus tendon; presentation of the BR insertion at the bottom of the first extensor compartment; incision of the BR insertion halfway to proximal and dissection of the volar limb at the transition to the free BR tendon; release of the PQ from the distal radius; after reduction and internal fixation repair of the PQ with complete coverage of the volar locking plate due to slight distal transposition. RESULTS: Pronator quadratus repair with a part of the brachioradialis muscle insertion is a reliable technique for coverage of a volar plate by slight distal transposition. In the repair of distal radius fractures, this may protect the finger flexor tendons against irritation and/or rupture.

[Surgical approaches to the hand]. / Operative Zugangswege an der Hand.

OBJECTIVE: Accessibility of any anatomical structure of the hand via surgical approach. INDICATIONS: Any surgical treatment of the hand. CONTRAINDICATIONS: Any contraindication to surgical treatment of the hand. SURGICAL TECHNIQUE: Skin incision at the hand with access to any anatomical structure. POSTOPERATIVE MANAGEMENT: Postoperative treatment depends on the disease and hand surgery performed.

[Open reduction and plate/screw osteosynthesis of proximal phalanx fractures]. / Offene Reposition und Schrauben­/Plattenosteosynthese von Fingergrundgliedfrakturen.

OBJECTIVE: Anatomical open reduction and internal fixation using screw/plate osteosynthesis. INDICATIONS: Extra-articular fractures with clinically evident malrotation of the finger, comminution fracture and/or loss of length, which cannot be treated non-operatively; fracture instability; intra-articular fracture with step off greater than 1 mm, which cannot be treated percutaneously but openly using plate/screw osteosythesis; failure of conservative treatment. CONTRAINDICATIONS: General operative limitations. SURGICAL TECHNIQUE: Dorsal, mediolateral, or palmar approach, temporary reduction using pincers or optional Kirschner wires; screw/plate osteosynthesis for internal fixation. POSTOPERATIVE MANAGEMENT: Immediate mobilization facilitated by buddy loops for the first 4-6 weeks, prevention of edema using elastic dressing, physiotherapy. RESULTS: Open reduction and internal fixation using screw/plate osteosynthesis provides good results in combination with immediate mobilization. Nevertheless, adhesion of tendons or capsule tissue with restriction of range of motion is observed.

[Metacarpophalangeal joint replacement]. / Der Gelenkersatz der Fingergrundgelenke.

BACKGROUND: Arthroplasty of metacarpophalangeal (MCP) joints is crucial for patients with rheumatoid arthritis. Motion preserving therapies are mandatory for this joint, since loss of function of the MCP joint is detrimental. Many protheses or spacers have been introduced over the last 80 years, but most of them have been dismissed due to major complications. CURRENT PROCEDURES: Since the 1960s the Swanson spacer has been established as the reference standard for motion preserving procedures of the finger MCP joints. High fracture rates of the spacer do not seem to limit function and patient satisfaction after all. Current long-term studies show at least promising results for pyrolytic carbon protheses with respect to range of motion, survival, and revision rates in comparison to the Swanson spacer.

[Anatomy of the trapeziometacarpal joint in the context of arthroplasty]. / Anatomie des Daumensattelgelenks unter Berücksichtigung der Endoprothetik.

The thumb has a crucial role in the hand due to its position with regard to the fingers. The CMC-1 joint enables an extraordinary range of motion, since its geometry allows for opposition. The former joint may often succumb to osteoarthritis because a great range of motion in combination with large forces, small contact areas, and thorough usage are always present. Joint replacement is challenged by the great range of motion based on the necessary joint stability and the demand for sufficient pain reduction. This review highlights the anatomy of the CMC-1 joint with regard to joint preplacement solutions.

[Anatomy of the metacarpophalangeal and proximal interphalangeal finger joint with respect to arthroplasty]. / Anatomie des Fingergrund- und -mittelgelenks unter Berücksichtigung der Endoprothetik.

BACKGROUND: Precise knowledge of the anatomy and biomechanics of the metacarpophalangeal and proximal interphalangeal joint is the basis for both indication and implantation of a finger joint prosthesis. Currently available finger joint prostheses inadequately take into account individual, ethnological, gender, age, and side differences. They can remain compromised despite the possible combination of their components. OBJECTIVES: To elucidate which problems of finger joint arthroplasty exist due to the anatomy and biomechanics of the metacarpophalangeal and proximal interphalangeal joints. METHODS: The anatomy and biomechanics of the metacarpophalangeal and proximal interphalangeal joint are described, and the problems and solutions of finger joint arthroplasty are presented. RESULTS: Despite precise knowledge of the anatomy and biomechanics of the metacarpophalangeal and proximal interphalangeal joint, not all problems of finger joint arthroplasty have been solved. However, a modular surface replacement appears promising for the proximal interphalangeal joint. CONCLUSIONS: Artificial joint replacement of the metacarpophalangeal and proximal interphalangeal joint is difficult with regard to morphology, small bone dimensions, complex biomechanics, and the strain of the hand. Further improvements, especially in design, should be achieved by exact anatomical imitation.

[Cubital tunnel syndrome : Diagnostics and therapy]. / Kubitaltunnelsyndrom : Diagnostik und Therapie.

Cubital tunnel syndrome is the second most common nerve compression syndrome observed in the upper extremity. Mechanical irritation of the ulnar nerve is also found in the upper and the lower arm even though cubital tunnel syndrome is documented most of the time. Apart from clinical examination electrophysiological testing is the most important contributor to the therapy decision. Depending on the clinical manifestation conservative treatment with elbow splinting may be appropriate. In the event of persistent or advanced nerve irritation surgical decompression may be the sensible intervention. Open or endoscopically assisted in situ decompression is currently recommended as the primary intervention while anterior transposition of the ulnar nerve is recommended for revision surgery.

[Arthrodesis of the distal interphalangeal joint using the headless compression screw]. / Die Fingerendgelenkversteifung mit der Doppelgewindeschraube.

OBJECTIVE: Arthrodesis of the distal interphalangeal joint of the fingers and interphalangeal joint of the thumb in order to gain reliable stability and function. INDICATIONS: Primary and secondary osteoarthritis, rheumatoid arthritis, defect lesions, septic joint destruction, posttraumatic joint deviation, fatal joint instability, fatal tendon lesions. CONTRAINDICATIONS: Persistent infections (empyema, osteomyelitis, phlegmon), deficient soft tissue mantle, bone/screw mismatch. SURGICAL TECHNIQUE: Using Beasley's approach the extensor tendon is identified and sectioned. Incision of the collateral ligaments enables good exposition. Precise resection of the joint surfaces. An orthograde guidewire is place into the distal phalanx. After adjustment of the arthrodesis which is controlled using x­ray, the guide wire is drilled into the middle phalanx in retrograde fashion. An adequate headless compression screw is introduced via a transverse incision at the fingertip using the guide wire, the former screw is placed until sufficient compression is generated. POSTOPERATIVE MANAGEMENT: Finger splint reaching to the proximal interphalangeal joint for 4 weeks after arthrodesis, full weight bearing after 6 weeks. RESULTS: Seventeen patients were examined after arthrodesis of the distal interphalangeal joint using the headless compression screw. The arthrodesis proved to be reliable and safe with a low complication rate and a good functional outcome. The modified Mayo Wrist Score (MMWS) was on average 89 (range 55-100); the outcome parameter DASH (disabilities of arm, shoulder and hand) score was on average 27 (range 1-60).

[Operative treatment of Dupuytren's contracture : Arthrolysis of the proximal interphalangeal finger joint]. / Operative Behandlung der Dupuytren-Beugekontraktur : Arthrolyse des Fingermittelgelenks.

BACKGROUND: In the operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint flexion contracture remains after fasciectomy due to shrinkage, shortening, and/or adhesion of the periarticular structures. OBJECTIVES: How can a residual flexion contracture of the proximal interphalangeal joint after partial fasciectomy in Dupuytren's disease be treated surgically and what follow-up results can be expected? METHODS: Description of anatomy, indication, surgical technique of arthrolysis of the proximal interphalangeal joint, postoperative treatment, and critical analysis of the results reported in the literature. RESULTS: Arthrolysis of the proximal interphalangeal joint is performed in up to six consecutive steps. An improvement of only about 50% compared to preoperative flexion contracture can be expected. CONCLUSIONS: Despite alleged unsatisfactory results arthrolysis of the proximal interphalangeal joint can be recommended in surgery of Dupuytren's disease. In certain cases, patient cooperation during lengthy postoperative treatment is necessary.

[Arthrodesis of the proximal interphalangeal joint of fingers with tension band wire]. / Die Arthrodese des Fingermittelgelenks mittels Zuggurtungsosteosynthese.

OBJECTIVE: Arthrodesis of the proximal interphalangeal joint of fingers in a functional and pain-free position. INDICATIONS: Primary and secondary osteoarthritis, traumatic joint destruction, posttraumatic malposition, instability, joint destruction due to infection, irreparable extensor and/or flexor tendon lesion, recurrent flexion deformity in Dupuytren's disease, arthritis (e. g., rheumatoid arthritis, psoriatic arthritis), failed resection arthroplasty, failed prosthesis, congenital disorder (e. g., camptodactyly). CONTRAINDICATIONS: Persistent joint infection. SURGICAL TECHNIQUE: Resection of the proximal phalanx head and the middle phalanx base, arthrodesis with figure-of-eight tension band wire in a functional position. POSTOPERATIVE MANAGEMENT: Plaster of Paris cast with arthrodesis position of the affected finger and intrinsic plus position of at least one adjacent finger for 2 weeks, custom-made finger splint for 4 weeks. RESULTS: A total of 15 of 16 patients with an arthrodesis of the proximal interphalangeal finger joint of the dominant hand by tension band wire were followed up after an average of 31 months. None was affected by the arthrodesis in everyday live. All patients were very satisfied with the result. Nine of 15 patients were free of pain both at rest and with activity. The average DASH score was 48 points. Grip strength averaged 29 kg, 7 % stronger than the contralateral hand.

[Distal radius fracture of the adult : Diagnostics and therapy]. / Distale Radiusfraktur : Diagnostik und Therapie beim Erwachsenen.

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

[Joint infections of the hand]. / Gelenkinfektionen der Hand.

Joint infections of the hand may lead to irreversible lesions and impairment of hand function due to early cartilage damage. Furthermore, persistent infections which are not treated immediately can cause osteitis and/or spread systemically. Finger joints are prone to infection due to bite wounds or crush and sharp injuries. Whereas the wrist is often affected in patients with immunosuppression or chronic diseases, such as diabetes mellitus. If diagnosis and therapy are delayed, joint damage may be inevitable. Therefore, urgent treatment of the infected joint is imperative to preserve the function of the hand. This article reviews the current diagnostics and treatment of joint infections of the hand.

[Perioperative Anticoagulation in Elective Hand Surgery: A Literature Review]. / Die perioperative Handhabung von Antikoagulantien in der elektiven Handchirurgie - eine Literaturübersicht.

This review highlights pathways regarding the handling of anticoagulation in elective hand surgery based on current literature.

[Proximal carpal row carpectomy]. / Die Entfernung der proximalen Handwurzelreihe.

OBJECTIVE: Resection of the proximal carpal row, termed proximal row carpectomy (PRC), is performed in order to treat pathologies of the proximal carpal row or radiocarpal joint between the scaphoid and scaphoid facet. It entails the articulation of the capitate and the lunate facet. INDICATIONS: Lunate necrosis, carpal collapse, joint infection with concomitant intercarpal ligament lesions. CONTRAINDICATIONS: Severe cartilage lesions of the lunate facet and the capitate, wrist capsule laxity, rheumatoid arthritis, neuromuscular dysbalance of the wrist-covering soft tissue structures. SURGICAL TECHNIQUE: Dorsal approach to the wrist, incision of the third and fourth extensor compartments, resection and coagulation of the dorsal interosseous nerve, usage of a ligament-sparing capsule incision, identification of the proximal carpal row and inspection of cartilage of the lunate facet and capitate, mobilization and excision of the lunate, scaphoid and triquetrum, articulation of lunate facet and capitate is controlled clinically and fluoroscopically, wound closure, application of plaster slabs. POSTOPERATIVE MANAGEMENT: Immobilization of the wrist on plaster slabs for 2 weeks, removal of sutures after 14 days. RESULTS: PRC is a surgical procedure with few complications. Satisfactory range of motion and grip strength could be preserved without limiting function of the upper extremity. Postoperative osteoarthritis of capitate and lunate facet did not correlate with the good clinical outcome.

Suprapatellar nailing of tibial fractures-Indications and technique.

Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment. The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.

[Supplementary arthrolysis of the proximal interphalangeal joint of fingers in surgical treatment of Dupuytren's contracture]. / Die ergänzende Mittelgelenkarthrolyse bei der operativen Behandlung einer Dupuytren'schen Beugekontraktur am Finger.

OBJECTIVE: Correction of residual flexion deformity of the proximal interphalangeal (PIP) joint after excision of diseased connective tissue in Dupuytren's contracture by stepwise arthrolysis. INDICATIONS: Flexion deformity of the PIP joint of 20° or more after excision of the diseased connective tissue in Dupuytren's contracture. CONTRAINDICATIONS: Joint deformities, osteoarthrosis, intrinsic muscle contracture, instability of the PIP joint. SURGICAL TECHNIQUE: Arthrolysis of the PIP joint is performed by six consecutive steps: dissection of the remaining skin ligaments, opening the flexor tendon sheath by transverse incision at the distal end of the A2 pulley, dissection of the checkrein ligaments, dissection of the accessory collateral ligaments, releasing the palmar plate proximally, releasing the palmar plate up to its insertion at the middle phalanx base. POSTOPERATIVE MANAGEMENT: Dorsal plaster of Paris with extended fingers and compressive dressing in the palm for 2 days, occupational/physical therapy, static and possible dynamic extension splint several weeks/months. RESULTS: A total of 31 fingers in 28 patients with Dupuytren's contracture were evaluated an average of 22 months after arthrolysis of the PIP joint. In all, 26 joints with an average recurrent flexion contracture of 29° were improved compared to the preoperative flexion contracture of 81°; 4 PIP joints with a recurrent flexion contracture averaging 60° were worse. In one patient, PIP flexion contracture of 90° was unchanged at follow-up although the joint could be extended intraoperatively to 10° of flexion.