A prospective, randomized comparison of 3 types of proximal interphalangeal joint arthroplasty.

PURPOSE: For surface replacement arthroplasty in proximal interphalangeal joint osteoarthritis, titanium-polyethylene (TI) and pyrocarbon (PY) implants are frequently used. However, their superiority in comparison to the silicone (SI) spacer has not been established. The purpose of this study was to compare these 3 types of implants with regard to outcome. METHODS: A prospective, randomized, multicenter trial was performed. A total of 43 patients (62 proximal interphalangeal joints) had surgery in the 3 participating centers, and each patient was randomly allocated to one of the 3 groups (TI, PY, SI). Range of motion (ROM) and strength were measured before surgery; pain and disability self-assessment and radiographic analysis were also completed. The same examination protocol was planned for 3 months, 6 months, and 1, 2, and 3 years after surgery, but some follow-up visits did not take place due to patient death or poor compliance. RESULTS: The mean follow-up time at the final follow-up was 35 ± 3 months (range, 30-41 mo). All implant types led to significant pain reduction at rest and at load. Tip pinch strength was slightly improved by all 3 devices at the 3-year follow-up. No significant improvement in ROM for silicone or resurfacing implants was found. However, when comparing the highest ROM values reached after surgery, the resurfacing devices tended to show superior joint motility compared to silicone spacers, albeit only temporarily and not significantly. Sixteen explantations were necessary: 2 of 18 SI (11%), 7 of 26 TI (27%) and 7 of 18 PY (39%) implants had to be removed. An additional 4 secondary surgical procedures were performed in group TI. CONCLUSIONS: Surface replacement arthroplasty devices showed a tendency for a temporarily superior maximum postoperative ROM, but markedly higher postoperative complication and explantation rates were observed compared to the silicone spacer implantation.

[Benign bone tumors]. / Gutartige Knochentumoren.

Benign bone tumors are neoplasms which have their origin in bone and lack criteria of malignant tumors, i.e. infiltrative growth pattern and distant metastases. They are classified according to the WHO criteria concerning the tumor matrix (osseous, cartilaginous, fibrous etc.). Traditionally there are also some non-neoplastic bone lesions which are classified as benign bone tumors and belonging to the group of tumor-like bone lesions. For the physician it is important to know those entities which are harmless, as well as those which can tend to re-occur or which ones can be locally destructive. Finally, some tumors are at risk of becoming malignant (large and proximal enchondromas or multiple tumors within a syndromal disease). Treatment is in most cases uncomplicated and can range between observation, curettage and sometimes extensive resection with complex defect reconstruction.

[Benign soft tissue tumors in orthopedics]. / Gutartige Weichteiltumoren in der Orthopädie.

For the most part soft tissue tumors are benign. However, the clinical presentation, including radiological aspects, is not always clear. Therefore, a biopsy is necessary in some cases to detect malignant tumors at an early stage. The course of even benign tumors is sometimes complicated. A not insignificant group of local, aggressive or intermediary tumors tend to recur and in exceptional cases can be fatal. Benign soft tissue tumors are subdivided according to the current WHO classification from 2002. They are classified by the tissue they mimick. In clinical practice they are additionally grouped according to aggressiveness. Some benign soft tissue tumors occur in the context of a syndrome, leading to multiple tumors. In these cases there is the threat of a tumor becoming malignant (neurofibromatosis, Maffucci syndrome).

[Phlegmon of the palm of the hand as initial manifestation of the Lemierre syndrome]. / Hohlhandphlegmone als Erstmanifestation des Lemierre-Syndroms.

Lemierre's syndrome is a rare disease in young otherwise healthy people showing septic embolism in the lungs and peripheral vessels. We report the case of a 19-year-old male patient who presented initially with a phlegmon of the right palm and beginning septic shock. During the clinical course a subcutaneous abscess of the left shoulder, multiple lesions of the lungs and a pericardial abscess were identified and Lemierre's syndrome was diagnosed. In this case, positron emission tomography (PET) was revealed to be an appropriate instrument to determine the extent of the disease in a one step procedure.

Comparison of external fixation, locking and non-locking palmar plating for unstable distal radius fractures in the elderly.

This study compares the effectiveness of locking and non-locking palmar plating and external fixation for unstable distal radius fractures in the elderly. In a retrospective match-paired study, 45 patients aged 50 to 70 years who underwent surgery for C1/C2 distal radius fractures were evaluated. The surgical procedures were external fixation or plating with locking or non-locking palmar plates. Radiological and functional outcomes were assessed. Outcomes according to Gartland and Werley, Martini and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were compared. The locking palmar plate fixation method demonstrated significantly better radiological and functional results in comparison to external fixation and the non-locking palmar plating methods. The subjective assessment of plate fixation proved to be better than that of external fixation. Complications and reoperations were fewer for both plate fixation groups. Our data indicates that most displaced intra-articular distal radius fractures can be treated successfully with the locking palmar plate.

[Reconstruction of phalanx and metacarpal defects by autologous iliac crest transplants after tumour resection with joint involvement]. / Phalangen- und Metakarpalerekonstruktion durch autologe Beckenkamminterponate nach Tumorresektion mit Gelenkbeteiligung.

BACKGROUND: The reconstruction of large phalanx or metacarpal defects after tumour resection is still a challenge. In contrast to orthopaedic oncology there are no modular prostheses available in hand surgery. If the tumour affects the joint, often the only therapeutic option is an arthrodesis of the joint with a bone graft. In this study, a technique of joint reconstruction with an autologous bone graft from the iliac crest is presented. METHODS: Curative tumour resection is the main goal of the operation, including hemiresection of a finger joint if necessary. The bony defect is reconstructed with a bone graft from the iliac crest which is prepared to match the opposite joint surface as nearly as possible. An additional arthroplasty with the palmar plate might be performed. Postoperative care includes either 6 weeks transfixation of the affected joint with a K-wire or, if possible, early joint motion with a dynamic external fixateur. The operation technique and postoperative treatment are described; further the clinical and radiological follow-ups of three patients are shown and a review of the literature is given. RESULTS: The replacement of larger parts of the phalanx or metacarpal bone revealed good results with regard to joint movement of the partly replaced metacarpophangeal joint (MCP). Besides a good functional outcome patients were also nearly pain-free. Regarding the proximal interphalangeal (PIP) joint after resection of the middle phalanx, limited movement was found on the basis of a rapidly developing osteoarthritis, however, being accompanied by tolerable pain. CONCLUSION: The usage of autologous iliac crest transplants for reconstruction of metacarpal or phalanx defects which include one partner of the MCP joint can be advised after tumour resection, especially because of rare functional alternatives. Bone defects including one part of the PIP joint might also be replaced by iliac crest transplants. However, the functional outcome seems to be less attractive than in MCP reconstruction. In cases of development of osteoarthritis after iliac crest transplantation, arthroplasty with silicone spacers might be a salvage procedure to maintain joint movement.

[A national hand surgery alloarthroplasty registry]. / Ein nationales Endoprothesenregister für die Handchirurgie.

In hand surgery multiple different alloarthroplasties are available. However, the clinical outcome of them is largely unknown. Therefore, clinical evaluation of the different alloarthroplasties is essential. To ensure the quality standards that exist in endoprostheses of large joints the initialization of a central alloarthroplasty registry is essential.

[Results of ligament reconstruction in advanced scapholunate dissociation]. / Ergebnisse der skapholunären Bandplastik zur Therapie der fortgeschrittenen skapholunären Dissoziation.

Scapholunate dissociation is one of the most common disorders of the wrist. Untreated it might lead to osteoarthrosis (scapholunate advanced collapse, SLAC wrist). Choosing the best surgical treatment option is still challenging, especially in cases of carpal collapse in combination with beginning osteoarthrosis of the radial styloid and the proximal pole of the scaphoid. We report the results of a homogenous group of eight patients with reducible carpal collapse and beginning arthrosis treated by reconstruction of the scapholunate ligament. The operation was performed 66 (range: 20 to 252) months after trauma. The average length of follow-up was two years. Five patients stated general improvement, while three reported a change for the worse. At follow-up, the average total range of motion of the operated wrist was decreased by 16 % compared to the unaffected side. The average grip-strength (measured with a Jamar dynamometer) was 77 % of the uninvolved wrist. The DASH score was 43 +/- 25. In three cases the Martini score showed a good or an excellent result. The average scapholunate angle was 72.3 degrees preoperatively and decreased to 61.0 degrees at follow-up. At follow-up as well as pre- and postoperatively the carpal height ratio showed pathologic mean values. Therefore, reconstruction of the carpal alignment was not achieved in most of the cases. Progression of the osteoarthrosis has to be expected. Reconstruction of the scapholunate ligament for treatment of carpal collapse with beginning osteoarthrosis therefore remains an unsolved problem.

A software tool for prediction of prosthesis failure at the carpometacarpal joint of the thumb.

Early recognition of prosthesis failure is difficult. A tool that helps to identify faulty prosthesis - a cause of early implant loosening - is needed. The aim of this study was to detect early implant loosening by applying a software program EBRA (Ein-Bild-Röntgen-Analyse). EBRA was applied to the radiographs of a series of 76 patients, with a total of 102 thumb carpometacarpal joint de la Caffinière prostheses, with an average follow-up of 14.5 months (range 0.5-24). The data were used to draw graphs of cup migration and inclination over time. Corresponding regression lines of migration and inclination in relation to time were made up to the point of loosening. The gradient of regression was calculated for all implants. The gradient of regression on the x and y axes differed significantly between stable and loose implants. Loose and stable implants showed significantly different cup migration on the x and y axes over time. EBRA proved to be a reliable tool to visualize cup migration in the trapeziometacarpal joint and to predict implant failure.

Shock-wave therapy is effective for chronic calcifying tendinitis of the shoulder.

We report a prospective study of the effects of extracorporeal shock-wave therapy in 195 patients with chronic calcifying tendinitis. In part A 80 patients with chronic symptoms were randomly assigned to a control and three subgroups which had different treatment by low-energy and high-energy shock waves. In part B 115 patients had either one or two high-energy sessions. We recorded subjective, functional and radiological findings at six months after treatment. The results showed energy-dependent success, with relief of pain ranging from 5% in our control group up to 58% after two high-energy sessions. The Constant scores and the radiological disintegration of calcification were also dose-dependent. Shockwave therapy should be considered for chronic pain due to calcific tendinitis which is resistant to conservative treatment.

[Proximal row carpectomy in carpal collapse]. / Resektion der proximalen Handwurzelreihe bei karpalem Kollaps.

Proximal row carpectomy (PRC) is a generally accepted procedure in the treatment of an advanced radiocarpal arthrosis. The aim of this retrospective study was the evaluation of individual, functional and radiological results after proximal row carpectomy. Seventeen patients (15 male, two female) who had undergone proximal row carpectomy between 1991 and 1999, were reviewed. The most common indication was degenerative arthrosis secondary to carpal collapse associated with chronic scaphoid nonunion (SNAC), scapholunate advanced collapse (SLAC) deformity, late Kienböck's disease or perilunate dislocations. Clinical and subjective results were assessed using different scores (DASH-, modified Mayo wrist-score) and evaluating the individual wrist range of motion. Anteroposterior and lateral X-rays were obtained for radiological analysis. At follow-up evaluation (mean 65.4 months), the majority of patients reported pain relief and a significant increased range of motion for the operated wrist. Radiographical analysis showed degenerative changes at the radiocapitate articulation in ten patients. The intermediate-term results of this review would suggest that proximal row carpectomy is an effective procedure providing pain relief and a satisfactory range of motion in a variety of pathologic wrist disorders. Because of eventual radiocapitate arthrosis, we suggest PRC only in patients without significant degenerative changes at the proximal pole of the capitate or the lunate fossa.

[Kapandji-Sauvé procedure for chronic disorders of the distal radioulnar joint with special regard to the long-term results]. / Die Kapandji-Sauvé-Operation bei der chronischen Dysfunktion des distalen Radioulnargelenks unter besonderer Berücksichtigung der Langzeitergebnisse1.

We present the preliminary results of a retrospective study on 56 patients who underwent the Kapandji-Sauvé procedure for chronic disorders of the distal radioulnar joint (DRUJ). Outcome was assessed with special regard to the long-term results. The average follow-up was 5.9 years (1 to 12 years). 15 of the 56 operations were performed before 1996. Most procedures were performed because of secondary arthrosis or chronic dislocation of the DRUJ after distal radius fracture. Patients were assessed for pain, range of motion of wrist and forearm and radiological features. The DASH score and Mayo wrist score were used. Pain was improved in 94 % of the patients, but only 53 % were free of symptoms during heavy manual labour concerning the operated site. In four cases symptoms of ulnar impingement were found. Improvement in range of motion of wrist and forearm was significant. The post-operative DASH score was 22.6 +/- 20.0 and the Mayo wrist score was 79.5 +/- 14.6. One non-union of the DRUJ with consecutive fracture of the fixation screw and an algodystrophy in another case were found as postoperative complications. The only long-term complication consisted of a beginning humeroradial arthrosis ten years after the operation. The results demonstrate high patient satisfaction and reliable improvement in range of motion. Our results confirm the Kapandji-Sauvé procedure to be a reliable salvage procedure for arthrosis or chronic dislocation of the DRUJ even after long-term follow up.

[Osteoid osteoma in the differential diagnosis of knee pain in athletes]. / Das Osteoidosteom in der Differentialdiagnose des Knieschmerzes beim Sportler.

We report on a 24-year old recreational sportswoman who is suffering on a knee pain after taking part in sports involving strength. The diagnosis of an osteoid osteoma was established. Diagnostic and therapeutic possibilities are presented.

High frequency failure of the Moje thumb carpometacarpal joint arthroplasty.

Arthroplasty is one of several options for treating symptomatic osteoarthritis of the thumb carpometacarpal joint. There are various hemi- and total arthroplasties available on the market. We report our experience of treating 12 patients with the Moje Acamo CMC1 prosthesis. We reviewed all the patients at a mean of 50 months postoperatively. All patients presented with loosening, migration or tilting of one or both implant components. Nine patients were symptomatic enough to warrant revision surgery with removal of the implant leaving a pseudarthrosis. At the last follow-up, five patients (42%) had already received revision surgery. All patients still possessing an implant showed progressive signs of implant loosening, although some of them had no symptoms. In order to assess their overall disadvantage compared with patients treated by primary trapeziectomy, the outcomes of these two groups were compared (matched pairs). The outcomes after revision surgery were comparable with those of primary trapeziectomy. We no longer use the Moje Acamo CMC1 implant and recommend that patients who have received this implant should be monitored carefully both clinically and radiologically.

[Kienböck's disease: an actual summary with long-term results of the therapeutic options]. / Lunatumnekrose: eine aktuelle Zusammenfassung mit Langzeitergebnissen der therapeutischen Verfahren.

Only a few diseases are treated by such a wide spectrum of therapeutic options as avascular necrosis of the lunate bone. The ultimate aim of all these very different biomechanical concepts is to avoid carpal collapse and wrist osteoarthritis. To be able to assess the efficiency of the separate operative methods, a crucial analysis of the present long-term publications is needed. We have reviewed 20 long-term studies (mean follow-up interval >10 years) to evaluate the different therapeutic options. The main results of these publications have been collected here. Decompression osteotomies can provide in the long term a ROM of 80-87%, a pain-free state in 20-67%, a progression in 20-50% and osteoarthritis in 25-73% of the cases. In contrast, revascularisation procedures can provide in the long term a ROM of 68-81%, pain-free state in 35-72%, progression in 11-100% and osteoarthritis in 32-100%. Salvage procedures can be applied at a later stage of the disease; they can provide in the long term a ROM of 61-78%, pain-free state in 38-50%, and osteoarthritis in 24-48% of the cases. Based on the listed long-term studies, it was demonstrated that a differentiated therapy should be based on the anatomic conditions and stage of the disease. Due to the restricted comparability of the studies, the formulation of a common therapy algorithm was not possible.

[Long-term results after mediocarpal and total arthrodesis of the wrist--a matched paired study]. / Langzeitergebnisse nach mediokarpaler Teilarthrodese und nach Vollarthrodese des Handgelenks -- Ein Matched-Pair-Vergleich.

AIM: Indications for total wrist arthrodesis are still a matter of discussion. The aim of this study was to investigate the long-term results (mean 118 +/- 49.5 months) of total wrist arthrodesis (TA) in comparison to mediocarpal arthrodesis (MA). METHOD: A paired study of the TA group and the MA group was performed including 22 patients after posttraumatic wrist arthrosis in each group. Subjective, objective and radiological parameters were assessed. In addition, the modified Mayo wrist score, the DASH score and the SF-36 were utilized. RESULTS: Mean pain did not differ significantly in both groups. Mean wrist function (DASH) was assessed better by MA patients (25.3 +/- 25.8) compared to TA patients (35.5 +/- 25.9; p > 0.1). Mean total wrist motion in the MA group was 66.1 % of the opposite side. The average grip strength of the TA group was 85.5 % +/- 58.4 % and of the MA group 79.9 % +/- 25.4 % of the uninvolved wrist. The Mayo score of the MA group (56.4 +/- 12.4) was significantly higher than in the TA group (65.9 +/- 16.3; p = 0.04). The SF-36 showed no significant difference between both groups. CONCLUSION: In self-assessment, pain was of higher importance then wrist motion. According to our findings the type of arthrodesis did not influence patient satisfaction. Total wrist arthrodesis should not be excluded categorically as a possible alternative to mediocarpal arthrodesis.

[The role of endoprostheses in the scope of hand surgery. Endoprostheses vs. traditional surgical procedures]. / Stellenwert der Endoprothetik im Bereich der Handchirurgie Endoprothetik vs. traditionelle Operationsverfahren.

Alloarthroplasty has largely replaced traditional procedures in arthrosis of hip and knee joints. In contrast the role of alloarthroplasty in comparison to traditional procedures in hand surgery has been uncertain. To evaluate this question every registered hand surgery department (n=307) in Germany received a questionnaire requesting information on number and type of implanted prostheses and traditional procedures concerning the wrist joint, distal radioulnar joint (DRUJ), first carpometacarpal joint (CMC), metacarpal phalangeal joint (MP), interphalangeal joint (PIP), and preferred characteristics of the prostheses. Of the 307 hand surgery departments, 150 (57% of the hospitals and 42% of the visiting surgeons) participated in the inquiry. Per year, only 98 wrist prostheses were implanted (distributed among five different models) but 1534 traditional procedures were performed. The Sauve-Kapandji procedure was the most popular for the DRUJ and was performed 264 times per year. In comparison 24 hemiarthroplasties were implanted at the DRUJ. Trapezectomy remains the standard procedure for arthrosis of the first CMC joint (n=1399). The future importance of alloarthroplasty of the CMC joint is doubted by the majority of participating hand surgeons (90.3%). In contrast the majority (85.3/71.8%) is convinced that alloarthroplasty will be of importance for the MCP and PIP joints, respectively. Currently, the number of implanted prostheses is close to the number of traditional procedures performed at the MP joint. Irrespective of the joint involved, cementless anchorage is preferred as is the surface replacement anatomical design. The results confirm that alloarthroplasty in hand surgery is of minor importance. Thus, the role of alloarthroplasty differs depending on the joint involved. Traditional procedures except for the MP joint continue to be of major importance in hand surgery.

[Secondary treatment for undetected Essex-Lopresti lesion]. / Die Sekundärversorgung nach übersehener Essex-Lopresti-Verletzung.

AIM: Essex-Lopresti lesion (ELL) consists of a radial head fracture in combination with a rupture of the interosseous membrane and a dislocation of the distal radioulnar joint. In the case of radial head resection proximal migration of the radius occurs. The aim of this retrospective study was to analyse the treatment and outcome for chronic ELL. METHOD: Altogether 6 patients with secondary ELL were detected and clinically reviewed. Therapy consisted of implantation of a silastic radial head prosthesis in 3 cases and ulna shortening in 2 other cases. One patient received both procedures. In two patients a Sauve-Kapandji procedure was performed 1.5/18 years later. Additional injuries were frequent. RESULTS: Pain at the wrist improved in 5 cases and was unchanged in one case. Clinical results demonstrate a limited range of motion concerning the forearm rotation in all but one case (mean: 98 degrees). Ulnar variance decreased from 5.2 mm to 2.7 mm postoperatively. CONCLUSION: Results of treatment for undetected Essex- Lopresti lesion are limited. Therefore in the case of a radial head fracture, meticulous examination of the distal radioulnar joint is recommended to detect an ELL.

Long-term effects of extracorporeal shockwave therapy in chronic calcific tendinitis of the shoulder.

Various short-term studies have demonstrated the effectiveness of extracorporeal shockwave therapy in the treatment of calcific tendinitis. To evaluate the long-term effects and any complications, the 4-year outcome was determined in a prospective study of 115 patients. One session (group A, n = 56) or two sessions (group B, n = 59) of high-energy shockwave therapy were administered to each patient. The 6-month results showed that the level of success achieved in pain relief and the Constant score was energy-dependent and that there were significant differences in radiologic changes between the groups. By 4 years after shockwave therapy, 20% of the entire patient population had undergone surgery on the involved shoulder. The effects of extracorporeal shockwave therapy not followed by any other therapy within the first 6 months were evaluated in 59% (n = 68) of the original 115 patients. Subjectively, 78% of patients in group A and 87% in group B thought the shockwave treatment had been successful. The Constant score increased from a mean of 45 before treatment to 88 in group A and 85 in group B after treatment. Radiologic changes were found in 93% of patients in each group. In conclusion, the failure rate after ESWT is high, but for 70% of the patients in this study, the treatment was successful and no long-term complications were seen.

[Extracorporeal shockwave therapy (ESWT) in tendinosis calcarea of the rotator cuff. Long-term results and efficacy]. / Extrakorporale Stosswellentherapie (ESWT) bei der Tendinosis calcarea der Rotatorenmanschette. Langzeitergebnisse und Stellenwert.

Calcifying tendinitis (TC) of the rotator cuff is a transient shoulder disease with a high rate of spontaneous resorption of the deposit. Therefore, primary treatment should be conservative. In cases of persistent pain despite conservative treatment, extracorporeal shock wave therapy (ESWT) can be performed as an alternative minimally invasive method. Various short-term studies have demonstrated the efficiency of ESWT for TC. To evaluate the short- and long-term results, complications, and the number of operations avoided by ESWT, a prospective study with 115 patients was performed over a period of 4 years. The patients had received high-energy ESWT once (group A: n = 56) or twice (group B: n = 59). Six months after therapy, 47% in group A and 77% in group B showed evidence of disappearance or disintegration of the calcium deposits. Pain relief was achieved in 45% of group A and 53% of group B. Four years after treatment, 20% of the patients had undergone surgery on the involved shoulder. Of the remaining patients, 59% (68 patients) were seen for follow-up. Subjectively, 78% of group A and 87% of group B judged the treatment to be successful. X-ray examination revealed complete or partial resorption of the calcium deposit in 93% in both groups. The Constant score increased from 45 before treatment to 88 in group A and 85 in group B after treatment. ESWT was successful for about 70% of the treated patients with no long-term complications seen.