[Results after revision surgery for carpal tunnel release]. / Ergebnisse von Karpaltunnel-Revisionseingriffen.

PURPOSE: The aim of this study was to assess the clinical results of revision surgery due to persistent neurological disturbances after carpal tunnel release. PATIENTS AND METHOD: In a previous study we showed the reasons for persisting neurological symptoms after carpal tunnel release on the basis of the intraoperative findings in 200 patients who underwent revision surgery in the years 2001 - 2003. We classified them into four groups (1: incomplete release of the retinaculum flexorum, 2: traction neuropathy, 3: real recurrent carpal tunnel syndrome, and 4: nerve lesions). 122 of these patients have been investigated regarding the clinical results using two questionnaires in the year 2004. We used the DASH questionnaire as well as an additional self-assessment questionnaire asking about remaining symptoms of median nerve irritation and the subjective results of revision surgery. The completely filled-out forms were assigned to the four groups, analysed and the results compared with each other. RESULTS: Within group 1 (incomplete release), 78 % reported only one persistent neurological symptom, 89 % described a benefit from revision surgery and 84 % were satisfied with a median DASH score of 11. Within group 2 83 % complained about at least one persistent neurological problem and only 60 % reported on an improvement following revision surgery. The DASH score within group 2 averaged 30. 87 % of group 3 patients reported of an improvement following the revision operation (DASH score 24), whereas this was the case for only 55 % (DASH score 37) of group 4 patients. CONCLUSION: The incomplete release of the flexor retinaculum is the most common reason for revision surgery. In most of these patients the clinical symptoms can be resolved with revision surgery leading to a very high satisfaction of the patients. A similarly high satisfaction can be expected following revision surgery of a true recurrent carpal tunnel syndrome although in most patients a significant degree of functional deficit will remain. Revision surgery due to fibrotic adhesions of the median nerve, leading to a traction neuropathy, or iatrogenic nerve lesions during the primary surgery will definitely lead to unsatisfactory overall results.

[Aseptic osteonecrosis of the head of the metacarpal (Mauclaire's disease)--case report and review of the literature]. / Die aseptische Osteonekrose des Metakarpalekopfes (Morbus Mauclaire)--Fallbericht und Literaturübersicht.

Aseptic osteonecrosis of the head of metacarpal is a rare disease with an unknown aetiology. It was first described by Mauclaire 1927. We now report on the treatment of 2 patients with Mauclaire's disease via transplantation of the calotte of the head of the 2nd metatarsal. At 26 and 30 months, respectively, after surgery both patients were free of complaints in activities of daily live and had free function of their fingers. There was no discomfort in the resection area at the 2nd metatarsal. Based on this experience, the method seems to be a recommendable option in young adults. A prerequisite is that the base of the proximal phalanx be intact.

[Septic arthritis of the wrist]. / Die septische Arthritis des Handgelenks.

BACKGROUND: Septic arthritis of the wrist is correlated with a high morbidity. To show diagnostic and therapeutic options we reviewed the patients treated with wrist infections at our institution for one year. METHODS: The data of ten patients who were treated for septic arthritis of the wrist in 2003 and 2004 were collected in a retrospective survey. Etiology, risk factors, microorganism and resistance data were recorded. RESULTS: Six infections were of an iatrogenic nature (four following surgery, one joint puncture and one joint injection). In nine cases there was a single arthritis of the wrist. One patient had oligoarthritis. In four cases Staphylococcus aureus, in one Proteus mirabilis and in one Pseudomonas aeroginosa were identified. In four cases, no microorganism could be identified. Two of the patients suffered from diabetes mellitus, one had rheumatoid arthritis. There was no significant elevation in the white blood cell count with 9.2 (4.5 - 12.5) x 10 (9)/L. Arthroscopic debridement and synovialectomy could be performed in one case. In the other cases open surgery was necessary. In four cases partial bone resection was required. Local antibiotics were installed in eight cases. All infections healed. In nine patients the joint was immobilized with an external fixation device. All patients received systemic antibiotics. Four wrists ended in an arthrodesis, one in a four-corner fusion. On average, two (1 - 6) surgical interventions were necessary per patient. The six patients without an arthrodesis had a range of motion in extension/flexion of 30-0-24 degrees. CONCLUSION: Surgical treatment is sufficient in septic arthritis of the wrist. However, an early diagnosis and therapeutic intervention are essential to avoid a permanent disability.

Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period.

Carpal tunnel release (CTR) is regarded as a common and successful operative procedure in hand surgery. However, an increasing number of patients with complications have been referred to our hospital. This retrospective investigation was undertaken to clarify the reasons for persisting or recurrent symptoms in 200 patients who underwent secondary exploration during a 26 month period at a single institution. In 108 cases, the flexor retinaculum was found to have been released incompletely. In 12 patients, a nerve laceration had occurred during the primary intervention. In 46 patients, symptoms were due to the nerve being tethered in scar tissue. The re-exploration revealed circumferential fibrosis around and within the median nerve in 17 patients and a tumour in the carpal tunnel in four patients. In 13 patients, no specific reason was found for recurrence of symptoms. We conclude that CTR seems to be a widely underestimated procedure and revision surgery could be largely avoided by reducing technical errors during the primary operation.

[Long-term results after resection arthroplasty in patients with arthrosis of the thumb carpometacarpal joint: comparison of abductor pollicis longus and flexor carpi radialis tendon suspension]. / Ergebnisse nach Resektions-Suspensions-Arthroplastik bei Rhizarthrose: Vergleich der Abductor pollicis longus- mit der Flexor carpi radialis-Sehnensuspension.

PURPOSE/BACKGROUND: This retrospective analysis focused on a comparison of long-term results in patients who underwent resection of the trapezium with subsequent arthroplasty and tendon suspension using either the abductor pollicis longus (APL) or the flexor carpi radialis (FCR) tendon. METHOD AND MATERIAL: Based upon a positive history along with a clinical and radiological examination, 20 patients underwent suspension arthroplasty using the APL tendon (APL group) and 21 patients suspension arthroplasty using the FCR tendon (FCR group) after trapeziectomy. In both groups mean age (APL group: 60.4 +/- 5.3; FCR group: 61.7 +/- 6.8 years), pain severity according to the Visual Analogue Scale (VAS; APL group: 6.7 +/- 1.9; FCR group: 6.9 +/- 1.7), severity of arthrosis in the thumb carpometacarpal joint according to the Eaton-Littler classification (APL group: 3 +/- 0.7; FCR group: 3.2 +/- 0.6) and time interval from onset of symptoms to surgery (APL group: 27 +/- 8.1; FCR group: 41.5 +/- 14.1 months) did not significantly differ. Each patient of both groups was treated surgically and reviewed by one experienced hand surgeon. Both groups received the same standardized postoperative treatment. RESULTS: In the APL group the mean operative time was significantly shorter (31.7 +/- 9.5 min) than in the FCR group (48.7 +/- 7.9 min). The follow-up period from surgery to the final examination was similar in both groups (APL group: 23.1 +/- 12.2; FCR group: 31 +/- 17.6 months). At the time of the final examinations, no statistically significant differences were found when analyzing the results of the DASH score (APL group: 20.1 +/- 15.1; FCR group: 29.3 +/- 15.7), the self-administered hand ability score (APL group: 1.7 +/- 0.6; FCR group: 2.1 +/- 0.6) and the VAS (APL group: 1.1 +/- 1.6; FCR group: 0.8 +/- 1.5). The time period from surgery to the offset of postoperative pain was also comparable in both groups (APL group: 5 +/- 1.8; FCR group: 5.3 +/- 2.5 months). The range of abduction in the first carpometacarpal joint after arthroplasty, parallel and perpendicular to the dorsum of the hand, was also similar in both groups (APL group: 63.4 +/- 14.3 degrees /62.1 +/- 11 degrees ; FCR group: 67.8 +/- 12.7 degrees /66 +/- 12.1 degrees ). However, patients enrolled in the APL group revealed significantly better results compared to patients in the FCR group regarding grip-strength, key and pinch grip (APL group: 23.9 +/- 9.7/6.6 +/- 2.4/6.2 +/- 2.8 kg; FCR group: 17 +/- 7.2/4.5 +/- 1.5/3.6 +/- 1.5 kg). CONCLUSION: Both techniques led to highly satisfactory results as seen in DASH and VAS data together with a near normal range of abduction in the first carpometacarpal joint in all enrolled patients. However, in direct comparison the APL procedure is technically easier to perform with significantly shorter surgery time recorded and significantly higher values in all force parameters compared to the FCR procedure.

[Differential diagnosis of the signal-compromised lunate in MRI]. / Zur Differenzialdiagnostik des "signalkompromittierten" Os lunatum in der MR-Tomographie.

PURPOSE: To define both the underlying pathology and diagnostic criteria in lunates presenting with conspicuous signal pattern in MRI. MATERIALS AND METHODS: The retrospective evaluation of 2940 MRI examinations revealed 203 patients with signal alterations of the lunate. All MRI examinations were performed on 1.5-Tesla platforms using dedicated surface coils and an intravenous contrast agent. To establish a definitive diagnosis, a total of 252 MRI examinations (49 follow-ups), 22 CT examinations and 4 arthroscopic studies were obtained in addition to the obligatory conventional radiographs. RESULTS: Incorporating all clinical data, radiographs and MRI examinations succeeded in assigning a diagnosis in 136 signal-compromised lunates (67.0 %), whereas additional diagnostic procedures or follow-up examinations were required for the definitive diagnosis in 57 cases (33.0 %). The most frequent entities were 51 cases of Kienbock's disease (25.1 %), 47 cases of ulnolunate-(triquetral) impaction syndromes (23.2 %) and 44 cases of intra-osseous ganglion cysts (21.7 %). Other pathologies included 23 degenerative, 19 traumatic and 10 inflammatory changes as well as 9 congenital conditions. For MRI assessment of the altered lunate, the most important parameters were location and morphology as well as involvement of the articular and osseous structures of the carpus. CONCLUSION: The lunate may be affected by different pathological states of the wrist. In total, only one quarter of the signal-compromised lunate represented Kienboeck's disease.

Non-vascularized free toe phalanx transplantation in the treatment of symbrachydactyly and constriction ring syndrome.

Forty-eight patients underwent a total number of 113 non-vascularized free toe phalanx transplantations for congenital short digits between 1975 and 2003, a mean number of 2.3 transplanted phalanges per patient. The mean age at the time of initial surgery was 3.6 years (range 6 months to 21 years). The follow-up time ranged from 4 months to 14 years with a mean of 6 years. Sixty-four phalanges showed radiographically measured growth, 22 phalanges showed signs of resorption, while 27 phalanges showed neither growth nor resorption. Resorption increased with patient age. Three patients developed donor site problems. The optimum timing for initial surgery is as early as possible because of the safer and greater growth potential and less resorption of the transplanted phalanges. Non-vascularized free toe phalanx transplantations offer a simple and safe method of lengthening with a significant improvement of hand function.

[Bilateral carpal tunnel syndrome with familial accumulation]. / Das bilaterale Karpaltunnelsyndrom (KTS) mit familiärer Häufung.

We report on a six-year-old girl with bilateral carpal tunnel syndrome with familial accumulation. Parents and one grandmother had positive history for CTS, treated by surgical decompression. Following neurologic and radiologic evaluation and after failed conservative treatment in a plaster cast, open carpal tunnel release was performed in a two-stage procedure. Postoperatively symptoms diminished and now six months after surgery, all complaints disappeared completely.

[Computed tomographic findings in carpal tunnel syndrome]. / Computertomographische Befunde beim Karpaltunnelsyndrom.

Morphometric measurements of the carpal bones were carried out in 32 patients with carpal tunnel syndrome (CTS) and in 47 normal persons, using high resolution CT. Measurements of distances and areas were carried out at the entry of each carpal tunnel and at its narrowest point. In idiopathic CTS there were no significant differences in these measurements from normal carpal measurements. The situation was different in ten patients with nonidiopathic CTS; in these CT showed the cause of median compression reliably. Our results suggest that there are no indications for performing CT of the wrist in idiopathic CTS, but that valuable information may be expected from CT in cases of nonidiopathic CTS.

[Direct MR arthrography of the wrist in comparison with arthroscopy: a prospective study on 125 patients]. / Direkte MR-Arthrographie des Handgelenks im Vergleich zur Arthroskopie: Eine prospektive Studie an 125 Patienten.

OBJECTIVE: In literature the diagnostic value of MRI for detecting lesions of the carpal ligaments and the TFCC is judged controversially. The aim of the following study is to determine the diagnostic accuracy of direct MR arthrography for depicting and staging of intraarticular lesions of the wrist. MATERIAL AND METHODS: One day before undergoing arthroscopy, 125 patients suffering from wrist pain were examined with direct MR arthrography in a prospective and blinded study. A mixture of contrast medium (iodine-containing contrast medium and gadopentetate in relation 200 : 1) was injected into both radiocarpal and midcarpal joints. The following sequences were acquired on a 1.5T scanner: coronal T1-weighted SE, coronal fat-saturated T1-weighted SE, coronal T1-/T2*-DESS-3D, and sagittal T2*-weighted MEDIC. MRI results were compared with arthroscopic findings using statistical analysis (SEN = sensitivity, SPE = specificity, PPV = positive predictive value, NPV = negative predictive value, ACC = accuracy). RESULTS: In comparison to arthroscopy as the accepted diagnostic gold standard, the following results were found for MR arthrography. Detection of TFCC lesions: SEN 97.1 %, SPE 96.4 %, PPV 97.1 %, NPV 96.4 %, ACC 96.8 %. Detection of complete tears of the scapholunate ligament: SEN 91.7 %, SPE 100 %, PPV 100 %, NPV 99.1%, ACC 99.2%. Detection of partial tears: SEN 62.5 %, SPE 100 %, PPV 100 %, NPV 94.8 %, ACC 95.2 %. Detection of cartilage defects: SEN 84.2 %, SPE 96.2 %, PPV 80 %, NPV 97.1 %, ACC 94.4 %. In total, only three lesions of the lunotriquetral ligament were present. CONCLUSION: Direct MR arthrographic imaging is well suited for detecting intraarticular lesions of the wrist. The presented diagnostic results of MR arthrography are superior to the results of unenhanced MRI reported in the literature. Direct MR arthrography as a reliable diagnostic tool is strongly recommended if lesions of the scapholunate ligament and the triangular fibrocartilage complex are suspected. In contrast, an attitude of caution must be adopted in diagnosing lesions of the articular cartilage of the wrist.

Congenital unilateral muscle hyperplasia of the hand with ulnar deviation of the fingers.

Three cases of congenital unilateral muscular hyperplasia of the hand combined with ulnar deviation of the fingers are presented. In all three patients the deformity was confined to the right upper extremity, and there were no other associated congenital malformations. All patients displayed anomalous or hyperplastic musculature acting on the proximal phalanges of the fingers, contributing to the associated ulnar drift of the hand. This condition is previously unreported, and is a different entity from the previously described "windblown hand".

Explosion injuries of the hand. Spatial relationship and injury pattern.

Twenty-six hands in 25 male patients were treated for peace-time explosion injuries of the palmar aspect. All patients were examined after a mean interval of 7 (1-17) years. In order to establish a regional pattern for each injury the palmar surface of the hand was divided in 21 fields. For each field a score depending on the extent of injury was calculated. Comparing this regional score with the spatial relation between hand and exploding object resulted in six typical patterns depending on the grip during explosion. With knowledge of the three-dimensional relation between the hand and exploding object, the hand surgeon is prepared for potential problems during operation.

Quantitative analysis of the linkage between the interphalangeal joints of the index finger. An in vivo study.

We have established a simple method of measuring joint motion under physiological conditions. For this purpose we use an ultrasound measuring system employing marker points consisting of miniaturized ultrasound transmitters. This device was tested on a simple biomechanical model, the linkage of the proximal and distal interphalangeal joints. The angles of these joints were recorded during opening and closing of the fist in 34 index fingers of 17 healthy persons. The results of the measurements were plotted on a rectangular coordinate system. Analysis showed an approximately linear linkage between the IP joints of the index finger. The curve for extension was the same as that for flexion. The linkage varies greatly. On average 1 degree of PIP joint flexion is equivalent to 0.76 degree of DIP joint flexion. Our study showed no significant difference between the dominant and non-dominant hand. The results showed that there is a linear linkage between the proximal and distal interphalangeal joints, which is equal for flexion and extension.

Outcome after corrective osteotomy for malunited fractures of the distal end of the radius.

This retrospective study evaluated the outcome of corrective osteotomy for malunited distal radial fractures and investigated the influence of the radiological result on the clinical outcome. Twenty-nine patients underwent corrective osteotomy for malunited, dorsally tilted fractures of the distal radius and 20 underwent corrective osteotomy for malunited, palmarly angulated distal radial fractures. All were surveyed at an average of 18 months after surgery and assessed for: pain; grip strength; range of motion; radial tilt; radial inclination; and ulnar variance. Postoperative radial tilt, radial inclination and ulnar variance were significantly improved by corrective osteotomy. Patients with no, or only minor residual deformity after corrective osteotomy had significantly better results than those with gross residual deformity.

Severe contracture of the proximal interphalangeal joint in Dupuytren's disease: does capsuloligamentous release improve outcome?

This prospective study assessed whether patients with severe proximal interphalangeal joint contracture (#10878;60 degrees ) due to Dupuytren's disease which persisted after fasciectomy alone benefited from an additional capsuloligamentous release. Forty-three patients with 43 severely contracted proximal interphalangeal joints underwent operative correction followed by a standardized postoperative rehabilitation programme. All were followed for 6 months. In 11 patients correction of the proximal interphalangeal joint to 20 degrees could not be achieved by fasciectomy alone, and an additional capsuloligamentous release was performed which effectively corrected all their residual flexion contractures. There were no statistically significant differences between the capsulotomy and the non-capsulotomy group with respect to the residual proximal interphalangeal joint contracture at the end of surgery, or at their last follow-up examination.

[Intraneural ganglion in the peroneal nerve]. / Intraneurales Ganglion des Nervus peroneus

Report of a case of an intraneural ganglion in the peroneal nerve. Reviewing the literature this rare case of peroneal nerve palsy is discussed. The therapy consists in an operative decompression of the nerve by excision or incision of the ganglion cyst.

Tendon transfers in radial nerve palsy.

Radial nerve palsy results in a lack of extrinsic extensors of the wrist, fingers and thumb. The degree of dysfunction depends on the level of trauma to the radial nerve. If the wrist is not stable there is a loss of prehensile grip. Patients have great difficulty picking up large or heavy objects. In high radial nerve palsy the loss of triceps function can cause additional problems. Based on our knowledge of anatomy and biomechanics, radial nerve function can be restored sufficiently. The indications, preoperative planning, technique of transposition and postoperative managment are explained.

TFCC lesions. Diagnosis and therapy.

Lesions of the TFCC may have degenerative or post-traumatic causes. Distal radioulnar joint as well as the ulnocarpal joint can be affected. Patients present with ulnar-sided wrist pain especially in forearm rotation. Therapy depends on the degree of lesions and additional pathology. Wrist arthroscopy offers a certain diagnostic tool. In addition, adequate therapy can be realized. After failed arthroscopic therapy, ulnar shortening osteotomy reduces ulnar load significantly.

The importance of the distal radioulnar joint for reconstructive procedures in the malunited distal radius fracture.

Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignement of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.

[The compression glove--a useful tool in hand surgery]. / Der Kompressionshandschuh--ein nützliches Hilfsmittel in der Handchirurgie.

Edema of the hand of no matter which cause prevents adequate active finger motion. Persistent swelling may lead to secondary shrinkage of collateral ligaments and fibrosis of paratenon. A custom made compression glove has proven to be an effective tool in reducing edema and preventing secondary damage. It has been useful in treating posttraumatic or postoperative edema and trophic disturbances of the hand.