[Revision surgery for carpal and cubital tunnel syndrome]. / Revisionseingriffe beim Karpal- und Kubitaltunnelsyndrom.

BACKGROUND: Carpal tunnel syndrome, a compressive neuropathy of the median nerve at the wrist and cubital tunnel syndrome, a compressive neuropathy of the ulnar nerve at the elbow, are the two most common peripheral nerve compression syndromes. Chronic compressive neuropathy of peripheral nerves causes pain, paraesthesia and paresis. Treatment strategies include conservative options, but only surgical decompression can resolve the mechanical entrapment of the nerve with proven good clinical results. However, revision rates for persistent or recurrent carpal tunnel syndrome is estimated at around 5% and for refractory cubital tunnel syndrome at around 19%. Common causes for failure include incomplete release of the entrapment and postoperative perineural scarring. THERAPY: Precise diagnostic work-up is obligatory before revision surgery. The strategy of revision surgery is first complete decompression of the affected nerve and then providing a healthy, vascularized perineural environment to allow nerve gliding and nerve healing and to avoid recurrent scarring. Various surgical options may be considered in revision surgery, including neurolysis, nerve wrapping and nerve repair. In addition, flaps may provide a well vascularized nerve coverage in the case of recurrent carpal tunnel syndrome. In the case of recurrent cubital tunnel syndrome, anterior transposition of the ulnar nerve is mostly performed for this purpose. RESULTS: In general, revision surgery leads to improvement of symptoms, although the outcome of revision surgery is less favourable than after primary surgery and complete resolution of symptoms is unlikely.

[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.

[Trigger finger-pitfalls and differential diagnosis]. / Der schnellende Finger ­ Pitfalls und Differenzialdiagnostik.

The differential diagnosis of a trigger finger presents a clinical challenge. This case depicts a 32-year-old male patient who presented with persistent snapping of the right index finger at the metacarpophalangeal joint without localized tenderness despite previous surgical A1-annular ligament release. CT diagnostics demonstrated a prominent articular tuberosity. The MRI showed no pathological findings. Surgical revision with concomitant excision of the tuberosity restored smooth mobility of the index finger.

[Management of spinal metastases, strategies and surgical indications]. / Management der Wirbelsäulenmetastasen, Strategien und operative Indikationen.

The number of bone metastases increases with prolonged survival of primary tumors of kidney, breast, prostate and other tumors. The spine is the most frequent site of bone metastases. This leads to high number of patients where the decision has to be made what kind of treatment should be the best. Several scores have been developed to solve this problem. The decision has to include the biology of the metastatic disease according to primary tumor and dissemination of the disease, the general condition of the patient, the residual stability of the spine, the neurologic status and most important the quality of life of the patient. Treatment options range from conservative treatment up to en bloc resection of the metastatic lesion. Therefore, the strategy of treatment always has to be decided on an individual base.

Prostate cancer characterization on MR images using fractal features.

PURPOSE: Computerized detection of prostate cancer on T2-weighted MR images. METHODS: The authors combined fractal and multifractal features to perform textural analysis of the images. The fractal dimension was computed using the Variance method; the multifractal spectrum was estimated by an adaptation of a multifractional Brownian motion model. Voxels were labeled as tumor/nontumor via nonlinear supervised classification. Two classification algorithms were tested: Support vector machine (SVM) and AdaBoost. RESULTS: Experiments were performed on images from 17 patients. Ground truth was available from histological images. Detection and classification results (sensitivity, specificity) were (83%, 91%) and (85%, 93%) for SVM and AdaBoost, respectively. CONCLUSIONS: Classification using the authors' model combining fractal and multifractal features was more accurate than classification using classical texture features (such as Haralick, wavelet, and Gabor filters). Moreover, the method was more robust against signal intensity variations. Although the method was only applied to T2 images, it could be extended to multispectral MR.

[Surgical treatment of carpal tunnel syndrome: open release of the flexor retinaculum and hypothenar fat flap for revision surgery]. / Operative Behandlung des Karpaltunnelsyndroms: offene Retinakulumspaltung und Hypothenarfettlappenplastik beim Rezidiv.

OBJECTIVE: Decompression of the median nerve by complete release of the flexor retinaculum and the distal antebrachial fascia. In the case of revision surgery providing of a scar-free covering of the median nerve, if necessary. INDICATIONS: Carpal tunnel release is indicated for symptomatic patients with painful paraesthesia or neurological deficits after adequate diagnostic evaluation. The hypothenar fat flap is indicated in revision surgery if a sufficient nerve bed of the median nerve is needed and to restore nerve gliding. CONTRAINDICATIONS: General operative limitations. The hypothenar fat flap is not indicated in revision surgery if median nerve irritation is not caused by surrounding scaring but other reasons like tendonitis. SURGICAL TECHNIQUE: Proximal longitudinal incision of the palm. Subcutaneous dissection and incision of the palmar aponeurosis. Careful ulnar incision of the transverse carpal ligament. Considerate release of the distal and proximal parts of the retinaculum as well as the distal part of the antebrachial fascia. Exploration of the median nerve and palpation of the carpal tunnel and resection of compressive structures, if necessary. In case of revision surgery, if required, the hypothenar fat flap is raised. The fat flap is transposed without tension palmar to the median nerve and fixed to the radial side of the carpal tunnel. POSTOPERATIVE MANAGEMENT: Early functional mobilization. Immobilization for a short period is optional. After revision surgery and hypothenar fat flap, splinting for one week is recommended.

[Cerebral blood flow in elderly hypertensives after enalapril of calcium channel blockers].

25 elderly hypertensive patients (mean age 66.5 +/- 5.0 years) were given enalapril (E) 20-40 mg daily, or calcium channel blockers (CCB): either slow-release nifedipine (40 mg) or long-acting verapamil (120-360 mg) daily, 6 weeks each, in a single-blind crossover study. At the end of each treatment period cerebral blood flow (CBF) was assessed by single proton emission, computed tomography, using 99m-Tc-exametazime. In the 20 patients who completed the study, supine BP was lowered from 194/106 to 167/90 mmHg (p less than 0.001/0.001) by E and from 185/104 to 172/91 (p less than 0.01/0.001) by CCB. Standing BP was lowered from 184/106 to 160/93 (p less than 0.001/0.001) by E and from 175/102 to 162/93 (p less than 0.01/0.01) by CCB. Although there were great interpatient differences in CBF, the individual pattern remained unaltered by either E or CCB and mean quantitative changes were not significant. We conclude that in elderly hypertensives both E and CCB effectively lower BP, while cerebral perfusion is not adversely affected by either.

[Effect of captopril on pulmonary function].

During the past few years, dry cough has been described as a possible adverse effect of treatment with angiotensin converting enzyme (ACE) inhibitors. There have been several studies of the effect of long-term administration of ACE inhibitors on pulmonary function. We examined spirometrically the effect of a single oral dose of captopril (25 mg) on bronchial tonus in those who had not received the drug previously, in 4 patients who had previously had dry cough during ACE inhibitor therapy, in 20 patients with obstructive pulmonary disease and in 20 control subjects without pulmonary disease. 1 hour after ingestion of captopril there were no significant changes in the spirometric tests of any group. These findings supplement the results of similar tests done during longterm administration of ACE inhibitors, indicating that the pathogenesis of cough elicited by ACE inhibitor therapy does not seem to have an asthmatic basis.

[Synovial cyst of the temporomandibular joint]. / Le kyste synovial de l'articulation temporomandibulaire.

OBSERVATION: A 30-year-old patient presented with a left painful pre-auricular tumefaction for one year. CT-scan suggested the diagnosis of temporomandibular synovial cyst or first branchial cleft cyst. This was confirmed by surgery. DISCUSSION: Temporomandibular synovial cysts are rare, the etiology is not documented. Revealing symptoms are those mentioned above. The common treatment is surgery.