A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center.

INTRODUCTION: The aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol. MATERIALS AND METHODS: Patients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3). RESULTS: Rupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30-175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90-195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group. CONCLUSION: The gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients.

Diagnostic accuracy of wrist MRI in comparison to wrist arthroscopy regarding TFCC lesions in clinical practice.

INTRODUCTION: The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment. METHODS: A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. RESULTS: Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large. CONCLUSION: The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

The arthroscopic Bankart operation: a 10-year follow-up study.

INTRODUCTION: Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these. MATERIALS AND METHODS: Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score. RESULTS: We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis. CONCLUSIONS: The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.

[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.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex.

PURPOSE: The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions. METHODS: A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done. RESULTS: Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred. CONCLUSION: Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance. LEVEL OF EVIDENCE: Therapeutic IV.

[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.

[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.

[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.

[Arthroplasty of the TMT1 joint-a critical view]. / Daumensattelgelenkendoprothetik ­ eine kritische Beurteilung.

Resection suspension arthroplasty of the trapezium still represents the golden standard in treatment of CMC 1 arthritis. First reports about long-term results of a modern-design endoprosthesis of the CMC 1 joint promise a lower complication and revision rate. Thus, endoprosthesis of the CMC1 joint is becoming more attractive, especially because the rehabilitation and back-to-work times are much faster. While new anatomic prosthesis designs are coming onto the market, which theoretically are less susceptible to loosening and dislocation, they still have to prove their superiority in the clinical setting.

[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.

[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.

[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 and pathobiomechanics of the scaphoid]. / Anatomie und Pathobiomechanik des Skaphoids.

Among the carpal bones the scaphoid (Os scaphoideum) is the most important. The most frequent fracture of the carpus is a fracture of the scaphoid bone. The frequently occurring absence of healing of these fractures as well as unhealed ruptures of the ligament complex between the scaphoid and lunate, lead to the most severe biomechanical and thus the most severe clinical changes of the wrist. The detailed anatomy of the scaphoid, blood flow, ligament attachments, injury mechanisms and pathobiomechanics are described and illustrated.

[Grip strength measurement : Significance and boundaries]. / Die Messung der Griffkraft : Wertigkeit und Grenzen.

BACKGROUND: Grip strength measurement is a widely used method for clinical as well as scientific purposes. In hand surgery, it is an essential component in the diagnosis of disease, treatment sequences and assessment. In epidemiological studies, it is a good predictor of healthy ageing or disease progression. PROBLEM: Measurement results and their interpretation can be influenced by many factors. The historical development of dynamometry, measurement technology and the standard values in various population groups are presented. Comparisons with standard values should only be made using current tables because the grip strength has changed in recent decades. Assessment of the voluntarily submaximal grip strength remains problematic. Proposals are made for how to assess grip strength during the evaluation.

[Ligamentous lesions and instability of the finger joints]. / Ligamentäre Verletzungen und Bandinstabilitäten der Fingergelenke.

Joint capsule and ligamentous lesions are common injuries of the upper extremities. Athletes are particularly inclined to suffer from these injuries. Clinical and radiological examinations are the cornerstone of an adequate treatment. Ultrasound-based diagnostics as a non-invasive and dynamic investigation method are gaining increasing relevance based on the development of high resolution probes. A correct interpretation of the findings is only feasible with a comprehensive knowledge of the anatomy. The most important goal is stability as a prerequisite for early active and passive motion with unrestricted range of motion.

[Anatomy and biomechanics of the distal radioulnar joint]. / Anatomie und Biomechanik des distalen Radioulnargelenks.

BACKGROUND: The functionality of the upper extremity is decisively based on rotation of the forearm. The rotation depends on the extent of motion of the distal radioulnar joint. Rotation enables complete and focused usability of the hand in order to cope with daily activities. The configuration of the distal radioulnar joint has developed over millions of years of evolution. ANATOMIC CONDITIONS: The triangular fibrocartilage complex is the crucial stabiliser of the latter joint since osseous structures are limited. The palmar and dorsal radioulnar ligaments belong to this complex. The superficial and deep parts of the latter ligaments insert both centrically in accordance to the axis of rotation and eccentrically. This arrangement guarantees stability of the joint throughout pronosupination. The interosseous membrane is a further relevant stabiliser that guarantees sufficient load transmission from radius to ulna. The distal oblique bundle of the interosseous membrane is outstanding in this context. The pronator quadratus muscle is the relevant dynamic stabiliser of the distal radioulnar joint. Contraction of the muscle prevents diastasis of the joint. The deep head of the muscle is always activated during pronosupination.

[Diagnosis and treatment of degenerative disc lesions of the wrist]. / Diagnostik und Therapie der degenerativen Diskusläsion.

BACKGROUND: The triangular fibrocartilage complex (TFCC) widens the radiocarpal joint and takes part in load transmission from the carpus to the forearm. It is thereby prone to degenerative changes. The painful situation that can accompany degeneration is called ulnar impaction. DIAGNOSIS: Clinical examination helps differentiate between various causes of ulnar-sided wrist pain. Standard X­rays are needed to determine ulnar variance and stress radiographs can depict narrowing of the ulnocarpal joint space under load. MRI may prove degeneration of the TFCC itself or may indirectly confirm ulnar impaction in the presence of bone marrow edema in the ulnar head or at the proximal ulnar aspect of the lunate. TREATMENT: If conservative treatment fails to alleviate symptoms, arthroscopy may be indicated. On the one hand, this completes the diagnostic cascade, and, on the other hand, allows decompression of the ulnocarpal joint space by resection of the TFCC with partial resection of the ulnar head (wafer resection). In the case of ongoing pain, ulnar shortening sufficiently alleviates ulnar-sided wrist pain. Thereby, modern standardized operation techniques are safe enough to ensure bone healing at the osteotomy site. The aim of alleviating ulnar-sided wrist pain is mostly achieved if the correct treatment option is chosen.

[Defect coverage of fingers and thumb : Indications and treatment]. / Defektdeckung an den Fingern und am Daumen : Indikation und Therapie.

Due to the exposure of the hands in the daily routine, defect wounds of the hand are common. The injury severity varies and ranges from small fingertip defects to large soft tissue lesions with exposed tendons, nerves and vessels. The complete extent of the soft tissue defect is often only recognizable after meticulous debridement. A considerable variety of techniques for defect coverage are available to the surgeon but the actual challenge is to select the most appropriate procedure which will result in the smallest possible residual defect. This review article presents the diagnostic approaches to soft tissue defects of the hand and current treatment options.

[The fibrous skeleton of the hand : Changes with Dupuytren's contracture]. / Das fibröse Skelett der Hand : Veränderungen bei der Dupuytren-Kontraktur.

The exact knowledge of the anatomy of the fibrous skeleton of the hand is an absolute prerequisite for any treatment of Dupuytren's disease. The fibrous skeleton does not only include the palmar aponeurosis, but also numerous retinacula cutis, which are not found in current anatomy books. Here, eponyms facilitate the otherwise difficult and over-pronounced names of the fiber systems. Skoog, Legueu and Juvara, Gosset, Grapow, Grayson, Cleland, Thomine, and Barton are the most important. This systematic review of the fibers and strands is designed to help reduce iatrogenic complications.

[Percutaneous needle aponeurotomy for Dupuytren's contracture]. / Perkutane Nadelaponeurotomie bei Dupuytren-Kontraktur.

Dupuytren disease is a benign fibroproliferative disease of the palmar aponeurosis, which can cause considerable functional deficiencies for the person concerned. Partial aponeurectomy is the gold standard in primary surgery. Because it is minimally invasive and has short recovery and low complication rates, the importance of needle aponeurotomy under specific indications has been increasing in the last years. Needle aponeurotomy is a cost-effective treatment with low complication rates. The revision rate compared to partial aponeurectomy is higher. Under consideration of specified indications, needle aponeurotomy is an alternative treatment option.