Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Evaluation of prestyloid recess morphology and ulnar-sided contrast leakage in CT arthrography of the wrist.

BACKGROUND: In wrist arthrograms, aberrant contrast material is frequently seen extending into the soft tissue adjacent to the ulnar styloid process. Since the prestyloid recess can mimic contrast leakage in CT arthrography, this study aims to provide a detailed analysis of its morphologic variability, while investigating whether actual ulnar-sided leakage is associated with injuries of the triangular fibrocartilage complex (TFCC). METHODS: Eighty-six patients with positive wrist trauma history underwent multi-compartment CT arthrography (40 women, median age 44.5 years). Studies were reviewed by two board-certified radiologists, who documented the morphology of the prestyloid recess regarding size, opening type, shape and position, as well as the presence or absence of ulnar-sided contrast leakage. Correlations between leakage and the presence of TFCC injuries were assessed using the mean square contingency coefficient (rɸ). RESULTS: The most common configuration of the prestyloid recess included a narrow opening (73.26%; width 2.26 ± 1.43 mm), saccular shape (66.28%), and palmar position compared to the styloid process (55.81%). Its mean length and anterior-posterior diameter were 6.89 ± 2.36 and 5.05 ± 1.97 mm, respectively. Ulnar-sided contrast leakage was reported in 29 patients (33.72%) with a mean extent of 12.30 ± 5.31 mm. Leakage occurred more often in patients with ulnar-sided TFCC injuries (rɸ = 0.480; p < 0.001), whereas no association was found for lesions of the central articular disc (rɸ = 0.172; p = 0.111). CONCLUSIONS: Since ulnar-sided contrast leakage is more common in patients with peripheral TFCC injuries, distinction between an atypical configuration of the prestyloid recess and actual leakage is important in CT arthrography of the wrist.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment.

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

The importance of radial multiplanar reconstructions for assessment of triangular fibrocartilage complex injury in CT arthrography of the wrist.

BACKGROUND: Triangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography. METHODS: One hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPRStandard), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPRStyloid) or in the ulnar fovea (MPRFovea). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer's and Atzei's classification and diagnostic confidence was stated on a five-point Likert scale. RESULTS: Compared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPRFovea: p < 0.001; MPRStyloid: p ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPRStandard 78.6%/80.4%, MPRStyloid 94.6%/94.6%, MPRFovea 91.1%/89.3%) and accuracy (MPRStandard 86.8%/86.8%, MPRStyloid 96.2%/96.2%, MPRFovea 94.3%/93.4%) improved with additional styloid-centered (p = 0.004/0.008) and fovea-centered (p = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR (p = 0.688/0.250). Interrater agreement was almost perfect for each dataset (κStandard = 0.876, κStyloid = 0.894, κFovea = 0.949). Diagnostic confidence increased with addition of either radial MPR (p < 0.001). CONCLUSIONS: Ancillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

Outcome of proximal interphalangeal joint replacement with pyrocarbon implants: a long-term longitudinal follow-up study.

INTRODUCTION: The aim of this study was to compare the short-, mid-, and long-term results of pyrocarbon PIPJ arthroplasty. MATERIALS AND METHODS: Twenty-seven consecutive patients (9 males, 18 females) had arthroplasty for 32 pyrocarbon PIPJ prostheses. Two patients (two joints) were lost for follow-up. Four implants were removed during follow-up. Fifteen patients (18 implants) were available for a long-term follow-up assessment on average 9.7 (9-10.8) years postoperatively and seven patients with eight implants had telephone interviews to calculate the implant survival and complications. Of the 15 patients who came to the latest follow-up, 12 (14 implants) passed each of the three follow-up visits for short-term (ø 19 months), mid-term (ø 54 months), and long-term follow-up (ø 9.8 years) to compare functional and radiological parameters longitudinally. RESULTS: In total, seven of the 30 joints (23%) required a revision surgery, all within the first 2 years postoperatively, including three arthrodesis due to early infection or dislocation, and one distal component removal due to primary loosening. Three patients required soft tissue revisions. The implant survival after 9 years was 87%. There was minimal pain at rest throughout the 9-year follow-up analysis; pain with activity was rated 1.9 at the short-term assessment, 1.5 at mid-term, and 1.6 at long-term. The average active range of motion was at short-, mid-, and long-term examination 49°, 50°, and 48° and grip strength averaged 24, 24, and 21 kg, respectively. The DASH score was stable with 35, 36, and 33 points. At the long-term follow-up, all evaluated implants showed radiological signs of implant loosening or migration. According to the PIP joint outcome score, 57% resulted finally in a "good" outcome. CONCLUSIONS: Pyrocarbon PIPJ arthroplasty has a risk of early complications necessitating revision surgeries. In spite of radiological implant migration, good pain relief, grip strength, and high quality-of-life ratings are stable for a long time.

[Tenoarthrolysis after flexor tendon injuries]. / Tenoarthrolysen nach Beugesehnenverletzungen.

Normal function of the fingers and thumb depends on properly gliding flexor tendons and a free range of motion of the involved joints. This normal gliding function may be inhibited by adhesions due to damage of the tendon, tendon sheath and adjacent tissue. When digital function is still limited despite a long-term course of hand therapy and there are no signs of further improvement, surgical intervention should be considered. There are no absolute indications for tenoathrolysis of the flexor tendons. With respect to complications, such as secondary tendon rupture, loss of annular pulleys and scar formation, it is part of a stepwise reconstructive concept including further procedures, such as staged flexor tendon reconstruction. Important preconditions for tenoathrolysis are motivation of the patient, the possibility of readily available and frequent postoperative follow-up hand therapy, healed fractures and osteotomy, mature soft tissue, intact tendons and gliding tissue. Preoperatively, a maximum passive range of motion of the involved joints should be achieved. During the operative procedure all adhesive tissue surrounding the tendon within and outside the tendon sheath is consistently resected preserving the annular pulleys as far as possible. Therefore, extensive approaches, arthrolysis, dissolution of unfavorable scar tissue, resection of scarred lumbrical muscles and annular pulley reconstruction are frequently necessary. Salvage procedures, such as arthrodesis, amputation, ray resection or multistage flexor tendon reconstruction are recommended in failed cases and should be considered even preoperatively. In order to retain the intraoperative functional improvement hand therapy for at least 3-6 months should follow.

Midterm Outcomes of the Use of a Spherical Ulnar Head Prosthesis for Failed Sauvé-Kapandji Procedures.

PURPOSE: The use of a spherical ulnar head prosthesis (UHP) for the treatment of symptomatic radioulnar convergence after Sauvé-Kapandji (SK) procedure has shown promising results in the short term. This study aims to evaluate the midterm outcome of the original cohort of patients treated with this technique. METHODS: Seventeen patients with unstable ulnar stumps confirmed both clinically and radiographically were studied. The etiology for the initial SK procedure included posttraumatic distal radioulnar joint (DRUJ) incongruity, primary DRUJ arthrosis, and dysplastic DRUJ. Fourteen of the 17 patients had a minimum of 2, and a maximum of 6, operations prior to having a spherical UHP. All patients suffered from severe pain with difficulty in performing work and daily activities. Ceramic UHP was used for all patients, except 2 in whom a cobalt chrome head was used. RESULTS: The average follow-up was 6 years (range, 4-17 years). A marked reduction in pain was observed with 11 patients reporting that they remained pain free. The range of motion of the wrist and power grip was maintained and showed a statistically significant improvement at the late follow-up. The Disabilities of the Arm, Shoulder, and Hand score also significantly improved from 77 to 41. There were no signs of prosthetic loosening at the midterm follow-up. The 2 patients with cobalt chrome prostheses had pain and osteolysis requiring revision to total DRUJ prosthesis. Two patients with dorsal prosthetic subluxation were successfully treated with distal radial osteotomy. CONCLUSIONS: The midterm results of ceramic spherical UHP for failed SK procedures in this small patient series are encouraging. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Influence of Maximal or Submaximal Effort on the Load Distribution of the Hand Analyzed by Manugraphy.

PURPOSE: This study aims to investigate if the hands' load-distribution pattern differs during maximal and submaximal grip. METHODS: Fifty-four healthy subjects used the 200-mm Manugraphy cylinder to assess the load-distribution pattern of both hands. On 2 testing days, the subjects performed grip-force testing: 1 hand with maximal effort and the other with submaximal effort. Sides changed for the second testing day. The whole contact area of the hand was sectioned into 7 anatomical areas, and the percent contribution of each area, in relation to the total load applied, was calculated. Maximal and submaximal efforts were compared across the 7 areas in terms of load contributions. RESULTS: Comparing maximum effort of the left and right hand, the load distribution was very similar without statistically significant differences between the corresponding areas. Comparing the maximal and the submaximal effort for each hand, 4 (left) and 5 (right) of the 7 corresponding areas showed statistically significant differences. Comparing the right hand, performing with maximal effort, with the left hand, performing with submaximal effort, 5 areas varied significantly. With the right hand performing submaximal effort, all 7 anatomical areas were significantly different. CONCLUSIONS: The load distribution of a healthy hand is different when performing with submaximal effort compared with maximal effort. To analyze a hand's load-distribution pattern, the opposite hand can be used as a reference. CLINICAL RELEVANCE: The hand's load-distribution pattern may be a useful indication of submaximal effort during grip-force testing.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance.

INTRODUCTION: The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance. MATERIALS AND METHODS: For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one. RESULTS: Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly. CONCLUSIONS: Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

[Treatment reality of distal radius fractures in a center]. / Versorgungsrealität distaler Radiusfrakturen in einem Zentrum.

Distal radius fractures are the third most common type of fracture in Germany after fractures of the femoral neck and peritrochanteric femoral fractures. In 2019 a total of 72,087 cases were registered with an incidence of 106 cases per 100,000 inhabitants (81,570 fractures of the femoral neck, 73,785 peritrochanteric fractures). Many of these fractures are surgically treated also in this hospital but with controversial views on the optimal treatment. Against the background of the coronavirus disease 2019 (COVID-19) pandemic, disappearing personnel resources and the political pressure to form centers and a switch to outpatient treatment, the authors ask the question what the treatment reality in this hospital looks like and whether the general changes in the framework conditions also have an affect in this context. This is not a strictly scientific study but a stocktaking without any claims of completeness and the retrospective evaluation of a larger data pool with all its weaknesses. On the contrary, the data provide interesting aspects that are explained in detail in the individual sections.

[Physiolysis with Resection of Vickers' Ligament in Adolescent Patients with Madelung's Deformity]. / Physiolyse mit Resektion des Vickers-Bandes bei adoleszenten Patienten mit Madelung-Deformität.

BACKGROUND: Madelung's deformity is a congenital or acquired growth disorder of the forearm that can lead to significant impairments in the quality of life of affected patients. Various surgical treatment options for the condition have been described in the literature. This study aimed to investigate whether physiolysis with resection of the Vickers ligament can successfully halt the progression of the disease in a cohort of young patients, as would be expected based on existing literature on this topic. MATERIAL AND METHODS: An analysis was performed on the records of all patients with Madelung's deformity who were primarily treated with physiolysis with resection of the Vickers ligament between January 2001 and June 2017. Patients were invited for follow-up examinations, and surgical outcome was assessed. Parameters evaluated included pain at rest and under load, range of motion of the wrists, and activity level. Additionally, standard X-rays and radiological measurements were performed for each operated wrist. The collected data was compared with the preoperative data from patient records. RESULTS: Nine wrists were included in the study. The average age at the time of surgery was 13.2 years, and the average follow-up period was five years. Extension and ulnar abduction showed a slight decrease from preoperative to follow-up, while flexion improved minimally, and radial abduction and forearm rotation showed noticeable improvement. The visual analogue scale score for pain at rest increased from preoperative 0.25 points to 1.88 points at follow-up. Under load, the average pain score increased from 2.00 to 4.25 points. The mean DASH score increased from 6.04 points before the surgical procedure to 12.20 points at follow-up. The average values of two out of the five measured McCarroll parameters increased, the increase being statistically significant for lunate subsidence. A follow-up procedure was required in one wrist. CONCLUSION: In our cohort, the progression of Madelung's deformity was only partially halted by physiolysis with resection of the Vickers ligament, and a significant increase in pain symptoms during the study period could not be avoided. Therefore, this procedure should be used cautiously in skeletally immature patients.

Prospective study on harvesting autologous bone grafts from the anterior iliac crest using a new specialized reamer.

The iliac crest remains the most frequent donor site for bone harvesting. Despite the surgical access to the iliac crest being relatively simple and the operation being carried out regularly, there are frequent complications. Therefore, a new, manual iliac crest reamer (R group) was compared to the classical harvesting of a corticocancellous bone graft by means of an oscillating saw (Con group) in a prospective study on 80 consecutive patients having hand surgery. Follow-up time was 3 months. Operation time and incidence of hematomas, seromas, and paresthesias in the R group were significantly shorter and less, respectively, than in the Con group. Pain at harvest site measured with the visual analogue scale (VAS) at 5 days, 6 weeks, and 12 weeks postoperatively was significantly less in group R as well. The utilization of the iliac crest reamer allows bone graft harvest in a relatively quick and simple operation with relatively few complications but with the limitation in that the maximum diameter of a bone cylinder that it can harvest is 20 mm.

The effect of additional video documentation to photo documentation in wrist arthroscopies on intra- and interobserver reliability.

INTRODUCTION: The reproducibility of diagnoses based on photo documents in wrist arthroscopies is limited and is expected to improve through the addition of video documents. AIM: The purpose of this study was to determine the effect of additional video documentation to photo documentation on intra- and interobserver reliability in wrist arthroscopies. MATERIALS AND METHODS: Sixty consecutive arthroscopies were documented by photographs of at least eight standard views and videos of the radiocarpal and midcarpal joints. After 3 months, the photographs and then the photographs together with the videos were reevaluated by the surgeon and by two hand surgeons to determine intra- and interobserver reliability. Percentage agreement and kappa coefficients were calculated. RESULTS: Using videos along with the photographs did not improve reproducibility in general. The assessments of the cartilage status were even worse. Some of the videos were criticized as being too short to allow adequate assessment of the cartilage. Lesions of the TFCC as well as its tension were assessed notably better by the videos, whereas assessment of SL and LT ligaments was not improved by the videos. Intraobserver reliability was better than interobserver reliability. CONCLUSION: As long as videos do not meet further quality criteria, they are not able to improve reliability in general. Nevertheless, videos should be used for documentation of the TFCC.

Median neuropathy in malunited fractures of the distal radius.

PURPOSE: Irritation of the median nerve is a well-characterized complication after acute fractures of the distal radius, but there is limited literature on median neuropathy in malunited fractures. The aims of our prospective study were to estimate the prevalence of the median neuropathy, explore the relationship between radiographic findings and the condition, and investigate whether corrective osteotomy without carpal tunnel release was a sufficient treatment. METHODS: Thirty consecutive patients, who were referred to us for treatment of symptomatic distal radial malunion, underwent nerve conduction studies of both wrists by one board-certified neurologist under standardized conditions. Test results were correlated with conventional radiographic parameters (radial tilt, radial inclination, palmar shift, ulnar variance, radiolunate and capitolunate angle) and computer tomography (CT) based measurements of the cross-sectional area of the carpal tunnel. After corrective osteotomy without carpal tunnel release, 10 of 13 patients with unilateral preoperative median neuropathy agreed to an electrodiagnostic re-examination by the same neurologist. RESULTS: Nineteen patients demonstrated abnormal test results, but only seven patients complained about paresthesias of median-innervated fingers. There was no correlation between median neuropathy and conventional radiographic parameters. Surprisingly, the cross-sectional area of the carpal canal was significantly greater for patients with median neuropathy. Symptoms resolved in all patients after corrective osteotomy. Postoperatively, six of ten patients demonstrated improved nerve conduction studies, although only four patients demonstrated normal test results. DISCUSSION: There is a high rate of subclinical median neuropathy in malunited distal radial fractures that cannot be predicted by conventional radiographic parameters. Corrective osteotomy without carpal tunnel release is a sufficient treatment for neuropathy in malunited distal radius fractures.

Diagnostic performance of traditional radiographic indices in detection of carpal collapse in Kienböck's disease.

Correctly identifying carpal collapse is important for adequate treatment of Kienböck's disease. This study aimed to assess the accuracy of traditional radiographic indices in detecting carpal collapse to differentiate between Lichtman stages IIIa and IIIb. In 301 patients, carpal height ratio, revised carpal height ratio, Ståhl index and radioscaphoid angle were measured on plain radiographs by two blinded observers. As a reference standard, Lichtman stages were determined by an expert radiologist using CT and MR imaging. The interobserver agreement was excellent. In the differentiation between Lichtman stages IIIa and IIIb, measurements of indices showed moderate to good sensitivity (0.60-0.95) and low specificity (0.09-0.69) using normal cut-off values from the literature, while receiver operating curve analysis revealed poor area under the curve (58-66%). Traditional radiographic indices showed poor diagnostic performance in detecting carpal collapse in Kienböck's disease and did not reach sufficient accuracy in the differentiation between Lichtman stages IIIa and IIIb.Level of evidence: III.

[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.

Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole.

PURPOSE: To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy. METHODS: We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10-47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. RESULTS: Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A. CONCLUSIONS: Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted.

Salvage of failed resection arthroplasties of the distal radioulnar joint using an ulnar head prosthesis: long-term results.

PURPOSE: The aim of this prospective multicenter study was to evaluate the long-term outcome of the Herbert ulnar head prosthesis for painful instability of the distal radioulnar joint (DRUJ) following resection of the ulnar head. METHODS: Twenty-three patients were treated with a Herbert ulnar head prosthesis in 3 international hand centers. One patient was excluded from the study because a septic prosthesis had to be removed after 3 months. Sixteen of the remaining 22 patients could be assessed at 2 follow-up times, 28 months (range, 10-43 mo) and 11 years and 2 months (range, 97-158 mo) after surgery, for DRUJ stability, forearm rotation, grip strength, pain level (0-10), and satisfaction (0-10). Standardized radiographs of the wrist were evaluated for displacement of the ulnar head and loosening or bony reactions at the sigmoid notch or the ulna shaft. RESULTS: All patients demonstrated a clinically stable DRUJ at the latest examination, and no patient required further surgery at the DRUJ since the short-term evaluation in 1999. Average pain measured 3.7 before surgery, 1.7 at the short-term follow-up, and 1.7 at the long-term follow-up; patients' satisfaction, 2.2, 8.2, and 8.9; pronation, 73°, 86°, and 83°; supination, 52°, 77°, and 81°; and grip strength, 42%, 72%, and 81% of the unaffected side. All clinical parameters improved significantly from before surgery to the short-term follow-up, with no further statistically significant change between the short-term and long-term follow-up. Radiographs demonstrated no signs of stem loosening or incongruity of the DRUJ. CONCLUSIONS: The previously reported short-term results with the Herbert prosthesis did not deteriorate in the long term. Reconstruction of the DRUJ with this prosthesis in painful radioulnar impingement following ulnar head resection is a reliable and reproducible procedure with lasting results.

Malunion of the distal radius.

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.