[The complexity of hand-surgical procedures in the context of cross-sector care concepts: a consensus recommendation of the German Society of Hand Surgery] / Die Komplexität handchirurgischer Therapien im Kontext sektorenübergreifender Versorgungskonzepte: Konsensusempfehlung der Deutschen Gesellschaft für Handchirurgie.

Overboarding politcal influence in Germany concerning medical issues has come to a new peak. The report by the IGES Institute published in 2022 made an important contribution in this regard. Unfortunately, only that part of the recommendations of this report were implemented in a new version of the contract for outpatient surgery according to Section 115b SGB V (AOP contract), that called for an expansion of outpatient surgery. In particular, those aspects that are important from a medical point of view for a patient-specific adjustment of outpatient surgery (e. g. old age, frailty, comorbidities) as well as the important structural requirements for outpatient postoperative care were included in the new AOP contract at best in a rudimentary manner. For this reason, the German Society for Hand Surgery felt compelled to give its members a recommendation as to which medical aspects must be taken into account, especially when performing hand surgery operations, in order to ensure the highest level of safety for the patients entrusted to us while performing outpatient surgery. An expert group of experienced hand surgeons and hand therapists who work in hospitals of all levels of care as well as resident surgeons was formed in order to formulate mutually agreed recommendations for action.

Arthroscopic Capsulodesis for the Treatment of Dynamic Scapholunate Dissociations.

Management of scapholunate dissociations remains a significant challenge. Open approaches suffer from a disadvantageous further impairment of the stabilizing local structures. The minimally invasive arthroscopic technique described provides reliable stability of the scapholunate interosseous ligament complex in dynamic lesions. The anatomic key structure is the dorsal capsuloligamentous scapholunate septum, which provides a mechanical connection between the scaphoid, lunate, and dorsal capsule of the wrist. Arthroscopic capsuloplasty aims to tighten and stabilize this complex structure in long term. This approach preserves the adjacent structures, namely the secondary wrist stabilizers and their neuromuscular feedback loops. With a certain degree of experience in wrist arthroscopy, the technique is reliably adaptable and reproducible.

Ulnocarpal Impaction.

Ulnocarpal impaction syndrome is a common cause for ulnarsided wrist pain caused by an abutment between the ulnar head and the lunotriquetral complex. This pain is typically triggered by load bearing and rotation of the forearm. Radiographic examination is often associated with positive ulnar variance and cysts in the lunate, edema of the ulnoproximal lunate is shown in MRI. Operative treatment aims to reduce load on the lunate, either by open ulnar shortening osteotomy or arthroscopic wafer procedure.

Composite tissue allotransplantation in Europe. Logistics and infrastructure of a centre.

BACKGROUND: Composite Tissue Allotransplantation (CTA) is a new medical field of growing importance. This paper focuses on the infrastructure and organisation of European CTA centres and discusses the differences between national health systems. MATERIAL/METHODS: Eight European centres (Valencia, Innsbruck, Munich, Lyon, Amiens, Creteil, Wroclaw, Monza) were sent with a specially-designed, standardized, 20-item questionnaire. RESULTS: Five of the eight centres returned our questionnaire: Munich, Innsbruck, Lyon, Amiens, Wroclaw. Since 1998, CTA has been performed at these centres. In both French centres and the Polish centre public funding is available in addition to the coverage provided by health insurers. In Munich the costs for a double upper-arm transplantation were Euro 150,000 with an additional Euro 50,000-70,000 per year. In Lyon the costs for a singular hand transplantation were Euro 70,000 per year and in Wroclaw (Poland) the costs for a hand or upper arm transplantation were Euro 20,000-30,000. As many as 17 different medical professions are involved in the CTA at the different centres. CONCLUSIONS: CTA is an innovative promising therapeutic tool that is based on the experiences of solid organ transplantation and profound microsurgical skills. Due to the complexity of the infrastructure, sourcing and the organisation CTA can only be successfully performed at specialized centres. A European network with an international European waiting list and a central coordination for CTA should be established. In order to advance CTA as an important tool in reconstructive surgery we must turn our attention to how the costs will be met, the legal environment for procurement of adequate donors and open ethical questions.

Neuroma formation in a rat median nerve model: influence of distal stump and muscular coating.

BACKGROUND: The purpose of this study was to investigate neuroma formation in a rat median nerve model. METHODS: In three groups, the median nerve was exposed and a gap was created. In the first group, a short gap of 1 cm (n = 12) was created; in the second, a long gap of 2 cm (n = 12) was created in the nerve. Another group was used to analyze the development of neuroma formation when the proximal stump was buried in adjacent muscle with an additional gap of 2 cm (n = 12). The use of different lengths should allow one to gain information about dilution effects of distal stump factors that may contribute to neuroma formation. Nine months later, specimens were gathered and histologically analyzed. The cross-sectional areas of neuromas were measured and the neural/connective tissue ratios were estimated. RESULTS: The cross-sectional areas demonstrated that neuroma formation was significantly higher in the short-gap group than in the long-gap group, and smallest in the muscle-covered group. The percentage of neural tissue was highest in the muscle-covered and long-gap groups and lowest in the short-gap group. CONCLUSIONS: These results demonstrate an association between neuroma formation and distal stump distance. This observation may be explained by the factors originating from the distal stump that were blocked when the proximal nerve stump was completely buried in the muscle. For clinical application, the authors recommend not only burying the proximal stump in a muscle but also surgically augmenting the gap between the proximal and distal stumps.

Nerve regeneration across a 2-cm gap in the rat median nerve using a resorbable nerve conduit filled with Schwann cells.

OBJECT: In a rat model, nerve regeneration was evaluated across a 2-cm defect in the median nerve by using a resorbable artificial nerve conduit. The aim of this study was to develop an artificial, biocompatible nerve guide to induce regeneration in the peripheral nervous system. METHODS: The authors compared a nerve conduit of trimethylenecarbonate-co-epsilon-caprolactone (TMC/CL) filled with autologous Schwann cells with both an empty hollow conduit and an autologous nerve graft. Animals that did not undergo surgery served as the control group. Nerve regeneration was evaluated with the grasping test, histological analysis of the nerve, muscle weight analysis (flexor digitorum superficialis muscle), and electrophysiological examination. After an observation period of 9 months, regeneration occurred only in animals that had received an autologous graft or a Schwann cell containing nerve conduit. No signs of regeneration were found in animals supplied with the empty conduit. CONCLUSIONS: Results of this study reveal the important role of Schwann cells in the regeneration process across a 2-cm defect in the rat median nerve. Furthermore, Schwann cell-filled nerve conduits induced functional recovery, as demonstrated in the grasping test, that was comparable with that of the autologous graft 9 months after implantation.

Vascular dominance in the forearm.

The dominance of the radial or ulnar artery at the forearm level and their contributions to the circulation of the hand remain a matter of contention. Therefore, the authors proposed to investigate the predominance of one of these arteries first by anatomic studies on 40 fresh cadaver upper extremities, and then by dynamic studies. The dynamic studies included color Doppler sonography in 22 individuals (44 hands) and five-channel plethysmography in 40 individuals (40 right hands). It was found that the ulnar artery is dominant at the elbow, but after originating its collateral branches, the radial artery becomes the dominant artery in the distal forearm and, consequently, constitutes the major source of vascularization to the hand. The ulnar artery is rarely dominant at the forearm level and is physiologically less important. Therefore, there is no hemodynamic reason to prefer the radial artery to the ulnar artery for any invasive maneuvers.