[Treatment errors in hand surgery. Comparison criteria for education in hand surgery and additional training in hand surgery based on error statistics of Chamber of Medicine, North Rhine-Westphalia]. / Behandlungsfehler in der Handchirurgie. Ein Vergleich zwischen handchirurgischen Ausbildungskriterien chirurgischer Fachgebiete und der Zusatz-Weiterbildung anhand der Behandlungsfehlerstatistik der Ärztekammer Nordrhein.

Hand surgery is an interdisciplinary specialty in which the contents of further training in the individual fields differ widely. We have first investigated general quality criteria and then the further training programmes of the specialties general surgery, orthopaedic and trauma surgery as well as plastic and aesthetic surgery. On the basis of the treatment error statistics of the Chamber of Medicine of North Rhine-Westphalia from the years 2004-2008, the treatment error quotas for a period of 5 years were evaluated according to specialty and the presence of additional training in hand surgery. This revealed that treatment errors in hand surgery with 41.7% were markedly more frequent than the general average value of 31.1%. On individual evaluations, the error quota for qualified surgeons without additional training was 44% whereas that for surgeons with additional training was 26%. Most frequently treatment errors were reported for distal radius fractures, followed by soft-tissue and cut injuries, carpal tunnel syndrome and finger fractures. The largest difference in the error quotas for the groups with and without further training in hand surgery was found for soft-tissue injuries including tendon injuries, 13.3% as compared with 53.7%.

[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.

[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.

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.

[The dynamic treatment of intraarticular fractures of the base of the middle phalanx with the Suzuki dynamic fixator]. / Die dynamische Behandlung von intraartikulären Mittelgliedbasisfrakturen mit dem Bewegungsfixateur nach Suzuki*

Between 1994 and 1998, we have treated eleven patients with intraarticular fractures of the base of the middle phalanx including impaction, dislocation, and pilon types of injuries. All patients were evaluated after a median follow-up period of 25.8 (8 to 57) months. Treatment was carried out according to Suzuki's technique with a dynamic PIP-joint distraction fixator consisting of Kirschner wires and rubber bands. In five cases, there was additional osteosynthesis (Kirschner wires, resorbable hemicerclage) or cancellous bone-grafting for reconstruction of the joint surface. Early mobilisation commenced with active exercises for the PIP joint on the day of surgery. The dynamic extension fixator was applied for an average duration of 28 (15 to 42) days. By the time of follow-up examinations, we found a range of motion on an average of 64 (0 to 105) degrees including a lack of extension of 11 (0 to 60) degrees and a median flexion capacity of 75 (30 to105) degrees. All fractures healed uneventfully with restored joint stability. Eight patients were completely painfree, three complained of mild occupational pain.

[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.

[The nutritive vascular canals. The magnetic resonance differential diagnosis of carpal cystic lesions?]. / Nutritialgefässkanäle. Magnetresonanztomographische Differentialdiagnose karpaler zystischer Läsionen?

PURPOSE: To find and describe potential MRI criteria of nutrient vessel canals of carpal bones. METHODS AND MATERIAL: 16 wrists of 13 patients with pain and radiographic depiction of cystic changes within the lunate were examined. The MRI protocol included coronal and sagittal T1- and T2-weighted SE sequences (4 mm slices, 120 FOV, 256 x 256 matrix) as well as coronal STIR images. Final diagnosis was confirmed by surgery (n = 5) and follow up. 10 cadaveric ossa lunata were studied to describe size, number, location and shape of nutrient vessel canals. RESULTS: Ganglion cysts (n = 6) showed characteristic signs. In ulnar impaction syndrome (n = 1) small cystic lesions in the lunate were surrounded by a sclerotic rim and located near the proximal ulnar surface. In Kienböck's disease (n = 3) cystic components were irregular and surrounded by bone marrow edema. Nutrient vessel canals (n = 7) imaged as 1 to 3 small cystic lesions within the palmar or dorsal subchondral region. CONCLUSION: MRI can aid in differential diagnosis of cystic carpal lesions. Nutrient vessel canals may not be mistaken for pathologic cystic lesions. Carpal ganglion cysts show distinct diagnostic pattern.

Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision.

Forty-two patients (45 fingers) were retrospectively reviewed after operative release of flexion contractures of the proximal interphalangeal (PIP) joint. The release was accomplished through a palmar incision in 19 fingers, usually followed by skin coverage using a lateral transposition flap. A midlateral incision was used in 26 fingers. The 2 groups were comparably matched with respect to degree of contracture and demographic characteristics. Active range of motion (ROM) was measured before and after surgery. In the palmar incision group, preoperative median PIP joint ROM was 60 degrees to 90 degrees (extension/flexion) and 30 degrees to 90 degrees at the 3-year follow-up examination. In the midlateral incision group, preoperative median PIP joint ROM was 50 degrees to 90 degrees (extension/flexion) and 0 degrees to 90 degrees at the 1.5-year follow-up examination. The improvement in ROM was significantly better in the midlateral incision group than in the palmar incision group.

[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.

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.

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.

[Surgical treatment of carpal tunnel syndrome: a comparison between long and short incision and endoscopic release]. / Die operative Behandlung des Karpaltunnelsyndroms: Ein Vergleich zwischen langer und kurzer Schnittführung sowie endoskopischer Spaltung.

The results of open carpal tunnel release employing a short incision (2.5 cm) were compared with those following a long incision (4.5 cm) in a prospective randomized study. These results were then compared with those found by Agee et al. (1992), following endoscopic carpal tunnel release. The criteria examined included grip strength as well as key and pulp pinch strength, sensory function and scar tenderness. Subjective symptoms such as tingling, numbness, and nocturnal paraesthesia were specifically inquired into, and time off work was noted. The examinations took place pre-operatively, as well as one, two, three, and six weeks postoperatively. The endoscopic method demonstrated no advantages when compared to the short incision. The long incision led to a temporary 10% loss of strength only during the first three weeks. These results should be kept in mind in the light of occasionally severe neurovascular complications following endoscopic carpal tunnel release.

[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.

[Fresh fractures! Classification, management, results and problems: the wrist joint]. / Frische Frakturen! Einteilung, Management, Ergebnisse und Probleme: Handwurzel.

Carpal bone fractures are rare, with an incidence of 13% compared to that of fractures and luxations of the hand bones. Generally they are intraarticular fractures. Fracture of the scaphoid bone occurs most frequently, with an incidence of 75%. The greater number of fractures is found in the middle-third of the wrist bordering on the os lunatum. They are usually treated conservatively by splinting with a cast. Surgery is indicated only when the fracture is open, instable, dislocated or combined with carpal instabilities.

[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.

[Long-term results following resection arthroplasty and prosthesis implantation in idiopathic saddle joint arthrosis]. / Langzeitergebnisse nach Resektionsarthroplastiken und Prothesenimplantationen bei der idiopathischen Sattelgelenkarthrose.

Thirty-six patients with arthrosis of the carpometacarpal joint of the thumb were treated, 19 patients by resecting the trapezium and interposing a tendon, 17 patients by replacing the resected trapezium with silastic prosthesis (Swanson). The follow-up time was in average 22 respectively 44 months; both groups were comparable. The patients treated by resection of the trapezium and tendon interposition were more satisfied and had less pain than those treated by implantation of a Swanson prosthesis. There was no difference in mobility and strength of pinch between the two groups. After resection of the trapezium and tendon interposition the authors found a proximal translocation averaging 7 mm (6 to 14), however these patients had a good functional result and no pain. Five patients had a luxation of the Swanson prosthesis, and four required a second operation.

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.