[Diagnosis and therapy of carpal tunnel syndrome--guideline of the German Societies of Handsurgery, Neurosurgery, Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic, Reconstructive and Aesthetic Surgery, and Surgery for Traumatology]. / Diagnostik und Therapie des Karpaltunnelsyndroms--Leitlinie der Deutschen Gesellschaften für Handchirurgie, Neurochirurgie, Neurologie, Orthopädie unter Mitbeteiligung der Gesellschaften für Unfallchirurgie, Klinische Neurophysiologie und Funktionelle Bildgebung sowie Plastiche, Rekonstruktive und Asthetische Chirurgie.

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

[Synovialectomy of the metacarpophalangeal joints with reconstruction of the radial collateral ligaments -- long-term results in patients suffering from rheumatoid arthritis]. / Synovialektomie der Fingergrundgelenke mit Rekonstruktion der radialen Seitenbänder -- Langzeitergebnisse bei Patienten mit rheumatoider Arthritis.

Rheumatoid arthritis may lead to destruction of MP joints and severe alteration of grip and other hand functions. Due to the improvement in medical treatment, synovialectomy of the MP joints is necessary only in late stages. Most centres prefer alloarthroplasties in late stages, as erosion of the cartilage and loosening of the ligaments have already led to destruction of the MP joints and destabilization of grip functions. We do not use alloarthroplasties as our first choice, but pay special attention to the reconstruction of the radial collateral ligaments. Therefore, the elongated radial ligaments are detached near their origin after synovialectomy of the dorsal aspects of the MP joint. After detachment of the radial ligament, the palmar aspects can be cleaned easily. The radial collateral ligaments are shortened and reinserted dorsally to gain slight supination. This study shows the long-term results of our patients. In a period of ten years, 74 patients (87 hands, 347 MP joints) were reexamined after an average of 55 months postoperatively. The loss of active motion was 18 degrees and ulnar deviation could be reduced from 25 degrees to 7 degrees. 71 % of the joints showed stable ligaments, 14 % loose, 15 % unstable ligaments. We saw recurrence of synovialitis in 18 % (10 % mild, 7 % significant, 1 % severe). Radiographs showed amelioration in 14 % of cases and deterioration in 39 %. There was no correlation between active range of motion, synovialitis and X-rays. Results were constant when compared with exams before and five years after surgery. Our investigation shows good and stable results, which can be easily compared with the outcome of other studies after alloarthroplasty. The main advantage in our procedure is the easy access to all parts of the MP joint, which allows complete synovialectomy. By shortening and reinserting the elongated radial collateral ligament, we achieve a mild supination and amelioration of grip strength. The results are constant in long terms. In case of recurrent synovialitis or loosening of the ligaments any other type of auto- and alloarthroplasties can still be performed.

[Adaptive patterns of the rheumatoid wrist after radiolunate arthrodesis]. / Anpassungsformen des rheumatischen Karpus nach radiolunärer Arthrodese.

OBJECTIVE: The aim of this study was the analysis of long-term carpal changes after radiolunate arthrodesis. METHODS: Pre- and postoperative X-rays of 91 wrists in 78 patients with rheumatoid arthritis, who were treated for carpal instability with a radiolunate arthrodesis, were examined concerning the midcarpal joint and the Larsen grade. The mean follow-up was 60 months. RESULTS: After radiolunate arthrodesis the midcarpal joint space remained unchanged in 28%. In 35% secondary arthritis and in 37% further arthritic destruction occurred. The mean Larsen grade increased from 3.2 to 3.8. Six wrists needed complete arthrodesis 25 to 87 months after the primary procedure and one was treated by total wrist replacement. Adaptive changes of the carpus during progressive disease and in secondary arthritis were recognized. Three types of joint lines could be identified: in 35% of the wrists a "perilunar", in 22% a "radio-midcarpal" and in 3% a purely "midcarpal" joint line. In 40% no specific joint line could be identified. CONCLUSION: After radiolunate arthrodesis the carpus remains unchanged in the long run in nearly a third of cases. But even if secondary arthritis or further arthritic destruction occurs as in the remaining cases, the carpus shows an amazing capacity for adaptation. A new intracarpal joint line may develop or the midcarpal joint re-establishes itself.

[The caput-ulnae-syndrome. Pathogenesis, clinic and therapy]. / Das Caput-ulnae-Syndrom. Pathogenese, Klinik und Therapie.

The ulnar head has a central function in stabilizing the wrist. In the treatment of caput ulnae syndrome, the radiocarpal joint must, therefore, always be considered. The integrity of the ulnar head and TFCC are of major importance for the rheumatoid wrist. Therefore, surgical treatment should be carried out early, and is indicated for drug-resistant synovitis and monarthritis of the wrist. Early synovectomy of the radiocarpal and distal radioulnar joint (DRUJ) can be done as an open procedure or, when extensor tendon synovitis is absent, as an arthroscopic procedure. In most cases, however, treatment of manifest caput ulnae syndrome, sometimes even with rupture of the extensor tendons, is necessary. In these cases, resection of the ulnar head together with a dorsal wrist stabilization is indicated. Less often, arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated. When choosing the procedure, the type and stage of wrist changes have to be considered. The DRUJ usually has to be treated together with the radiocarpal joint. Its isolated treatment is rarely indicated.

A comparison of two indices for ulnar translation and carpal height in the rheumatoid wrist.

The indices for ulnar translation described by Chamay et al. (1983, Annales de Chirurgie de la Main, Vol. 2, pp. 5-17), and Bouman et al. (1994, Journal of Hand Surgery Vol. 19B, pp. 325-329), and for carpal height described by Youm et al. (1978, Journal of Bone and Joint Surgery, Vol. 40A, pp. 423-431) and Bouman et al. (1994) were compared in pre- and postoperative wrist X-rays of 91 patients with rheumatoid arthritis undergoing radiolunate arthrodesis. Both indices described by Bouman had a higher applicability and sensitivity than the Chamay and Youm indices and are recommended for use with the rheumatoid wrist. However false-negative values may result when the Bouman index for ulnar translation is used to follow up radiolunate arthrodesis.

[Complications after midcarpal arthrodesis--attempt to analyse the pitfalls]. / Komplikationen nach mediokarpaler Teilarthrodese--Versuch einer Fehleranalyse.

BACKGROUND: Midcarpal arthrodesis (MCA) with excision of the scaphoid is in our opinion a reliable procedure. Pitfalls and unsatisfactory results can be attributed to technical shortcomings during the operation or to poor indication. PATIENTS AND METHODS: From 1993 to 2001, 64 MCA were performed in 62 patients. Patients' subjective assessment of the results were evaluated according to the clinical records and telephone interviews concerning pain, function and patient satisfaction. Pre- and postoperative standard X-rays were analyzed. RESULTS: Among 27 patients operated because of SNAC wrist, the following severe complications were observed: three painful non-unions, which healed after revision doing the same procedure, one deep infection, treated by complete wrist arthrodesis later on. Among 25 patients operated because of SLAC wrist there was one non-union, treated by complete arthrodesis, two transient dystrophies, one marked malposition of the lunate and two patients with persistent pain without any recognisable reason on X-rays. Among seven patients operated because of SLAC-wrist due to chondrocalcinosis, three had pain correlating to a too proximal position of the triquetrum, one of them together with a malposition of the lunate in the p.a. view. One other patient was dissatisfied without any obvious reason. Among three patients operated because of carpal instability persisting after closed reduction of perilunar dislocation, two had persistent pain also correlating to a proximal position of the triquetrum. One patient operated because of destruction of only the midcarpal joint complained of persistent pain on loading the wrist. The overall non-union rate was 6 %. After treating the complications 14 patients remained with unsatisfactory results, seven of them due to a special preoperative situation, four due to technical shortcomings during surgery. The other patients have been free of pain or much improved and able to work. Optimum results may only be obtained, if the lunate is carefully aligned. CONCLUSION: After SNAC and SLAC without more complex lesions of the carpal ligaments, good results may be predicted, a correct operative technique provided. Chondrocalcinosis is a relative contraindication to MCA.

[STT-arthrodesis versus radial shortening osteotomy for Kienböck's disease]. / STT-Arthrodese versus Verkürzungsosteotomie des Radius bei Lunatumnekrosen Stadium 3 und 4 nach Decoulx.

Thirteen patients treated by STT fusion for Kienböck's disease (five stage 3 a, seven stage 3 b, and one stage 4) and 36 patients treated by radial shortening osteotomy (20 stage 3 a, 16 stage 3 b) were checked after 26 and 83 months average. The active range of motion and grip strength were compared by means of the Cooney score, discomfort and pain by the DASH score. X-rays were compared for the bone structure of the lunate and development or progress of carpal collapse. After STT fusion the active over-all range of motion decreased by about 10 degrees, grip strength improved slightly by approximately 10 %, pain and discomfort improved well. Consolidation of the lunate was seen in ten of thirteen patients. The patients treated with radial shortening osteotomy could all improve their range of motion by about 10 degrees and the grip strength by about 20 %, whereas discomfort and pain persisted in some cases. X-rays showed consolidation of the lunate in cases of eleven patients stage 3 a and twelve patients stage 3 b. Radiological results were not always corresponding to the clinical results and the patients' subjective estimation. A group of eight patients could be followed up after more than ten years; all of them showed excellent results. This may indicate the long-term result for those patients who benefit from radius shortening with early pain relief. We recommend both procedures for stage 3 a and 3 b and suggest to decide from case to case, according to the needs of the patient. Ulna minus variance or the patient's wish to restore full active range of motion indicate radial shortening.

Neurophysiological recovery after open carpal tunnel decompression: comparison of simple decompression and decompression with epineurotomy.

Two hundred and seventy-three patients with carpal tunnel syndrome without advanced neurophysiological changes (distal motor latency below 11 ms) were randomized to treatment by open carpal tunnel release with, or without, epineurotomy. Patients were examined clinically and by nerve conduction studies preoperatively and at 3, 6 and 12 months postoperatively. We found no statistically significant difference between simple decompression and decompression combined with epineurotomy with regard to either the clinical or the neurophysiological outcome.

[The rheumatoid wrist. Pathobiomechanics and therapy]. / Das rheumatische Handgelenk. Pathobiomechanik und Therapie.

A stable and pain-free wrist is a prerequisite for normal hand function. Since the wrist joint is involved early in rheumatoid disease and progress is rapid, operative treatment is of major importance. It is indicated not only for treatment of established osseous changes with instability, deformation, and extensor tendon ruptures but for early treatment of drug-resistant synovitis and monarthritis of the wrist.A considerable number of operative procedures is available: arthroscopic or open synovectomy of the radio- and midcarpal as well as the distal radioulnar joint, possibly with resection of the ulna head, partial arthrodeses, complete arthrodeses,and arthroplasty. When choosing the procedure, type and stage of wrist changes as well as the pathobiomechanic situation have to be considered. The individual course of the disease and patient requirements have to be taken into account.Thus, for long periods of time a pain-free stable wrist can be preserved, albeit sometimes with only limited but functional mobility.

[Results of arthroscopic synovialectomy of the wrist]. / Ergebnisse der arthroskopischen Synovialektomie des Handgelenkes.

In the course of inflammatory rheumatic diseases, isolated synovialitis of the wrist and distal radioulnar joint can be found without simultaneous affection of the extensor tendons. It may be the only manifestation of the disease in the sense of monarthritis or one of few affected sites as in oligoarthritis. With modern medical treatment of disease-modifying drugs, this constellation seems to be more frequent. In this situation, we rather perform arthroscopic synovialectomy than open synovialectomy as long as form and function of the joint are maintained. The distal radioulnar joint may also be approached arthroscopically through the perforation of the TFCC, which is usually encountered. A clinical study was performed to evaluate the results of this procedure concerning function, relief of pain, progression of the disease, and risk of recurrence. Between 1995 and 2000, 22 patients (15 female, 7 male) with an average age of 50 years (range 16 to 74) were operated, in one case both wrists. 19 patients have been reexamined clinically and by X-ray after an average follow-up of 21 months (range 6 to 57 months), three by telephone interview. The results were evaluated according to the Mayo modified wrist score (pain, function, motion, and grip-strength related to the contralateral side) and compared to the preoperative values. In the case of bilateral affection, the score was not applied. Also, the patients' subjective evaluation of the results have been taken into account. Progression of the disease has been checked in the standard preoperative and postoperative X-rays of the wrist graded according to the Larsen scale. Special attention was paid to signs of recurrence. The wrist-score improved significantly from an average of 40 points preoperatively to 69 points postoperatively. Eleven patients estimated their wrists as absolutely good, nine as improved, two as unchanged compared to the preoperative situation. Nine patients reported no pain at all, eleven less pain than before and two no change. 17 patients have been satisfied with the procedure, five not. Radiographic progression of the disease from the preoperative status (Larsen stage 0 to III, exceptionally IV) to postoperative was found in three cases. In 19 cases there was no progression. Recurrence was noted in six cases after an average time of six months; a secondary procedure was necessary in two cases. Wrist motion improved in almost all patients from an average value of extension plus flexion of 83 degrees preoperatively to 99 degrees postoperatively. Conclusion. Arthroscopic synovialectomy of the wrist reduces pain and improves function in most cases. It also improves motion, which is an advantage to the open procedure. Patient acceptance of the procedure is high.

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up.

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.

[What are the indications for arthroscopic repair of ulnar tears of the TFCC?]. / Wann ist die arthroskopische Refixation des Discus ulnocarpalis bei ulnarem Abriss indiziert?

A clinical study was performed to assess the outcome after arthroscopic repair of ulnar tears of the TFCC of the wrist, and to determine which factors are of importance for the results. From 1994 until 1998, in 23 patients an ulnar tear of the TFCC of the wrist was found and treated by arthroscopic repair (average age 32 years, range 16 to 56, 11 female, 12 male). The articular disc was sutured by inside-outside-technique with 2/0 PDS to the floor of the sixth extensor compartment. 14 to 54 months (mean 27 months) after the operation, 21 patients were reexamined. The results were graded according to the Mayo-modified wrist score. Several factors which might be of influence were correlated to the results by crosstabs including preoperative clinical assessment of stability of the distal radioulnar joint (DRUJ), time between trauma and repair, mechanism of injury, associated lesions, details of suturing technique, and the amount of loading of the wrist in daily life. In nine patients, the result was rated as excellent, in five patients good, in four patients fair, and in three patients poor. The average preoperative score was 55.7 points, the average postoperative score was 84 points. The difference was statistically significant as calculated by the paired sample t-test (p < 0.05). In preoperative clinical examinations, 13 DRUJs had been assessed as stable, eight as unstable. In the crosstabulation, a significant correlation was found between excellent results and preoperatively preserved stability of the DRUJ, whereas fair and poor results have often been found with clinically unstable DRUJ. The other factors revealed no correlations with the results. Ulnar tears of the TFCC of the wrist without marked instability of the whole DRUJ can be treated by arthroscopic suturing and satisfactory results can be expected. In case of clinical instability of the joint, it is to be assumed that the lesion extends to structures which cannot be seen and sutured arthroscopically. In these cases, open repair after arthroscopic examination must be considered.

[Functional results of medio-carpal partial arthrodesis with excision of the scaphoid]. / Funktionelle Ergebnisse nach mediokarpaler Teilarthrodese mit Exstirpation des Skaphoids.

Midcarpal arthrodesis with excision of the scaphoid for the treatment of painful carpal collapse has been performed in our hospital since 1993. A clinical study was carried out to evaluate the results and determine special factors, which might influence the results. 26 out of 29 patients operated until 1999 were reexamined after an average follow-up of 27 months. The results were evaluated according to the Mayo-modified wrist score. The DASH score and the pain-disability index (PDI) were calculated postoperatively. Standard X-rays of the wrist were analyzed for alteration of the radio-lunate joint space, the position of the lunate with respect to the radius and the correction of the carpal height as calculated by the Youm index. Carpal collapse was due to scapholunate pathology (SLAC) in 12 cases, long-standing scaphoid nonunion (SNAC) in ten cases, perilunate dislocation, which was only simply reduced, in three cases, and calcium pyrophosphate deposition disease in two cases. The Mayo-modified wrist score improved significantly from an average of 46 points before to 76 points after surgery. The DASH score postoperatively was 22, the PDI 13. All patients reported improvement of their situation after the operation, eight were completely free of pain. The average range of motion from extension to flexion was 64 degrees, which was almost identical to the average preoperative value. The average grip strength before surgery was 24 kg, after surgery 34 kg. There was a correlation between the position of the lunate to the radius in the lateral X-ray and the range of extension. If the lunate was positioned correctly, wrist extension was significantly better. The radiolunate joint space was maintained during the period of observation with only two exceptions. Apparent subchondral sclerosis was seen in most of the cases. It was not possible to restore carpal height completely. Some results after perilunate luxations and one case of calcium pyrophosphate deposition disease were unsatisfactory. Midcarpal arthrodesis with scaphoid excision is a reliable method for treating radioscaphoid arthrosis caused by carpal collapse. Correction of the hyperextended position of the lunate is important to obtain optimum results. In our hospital, a wrist arthrodesis is only rarely performed nowadays, except in the rheumatoid patient.

[Treatment of a radio-ulnar synostosis by resection and interposition of a septofascial flap--a case report]. / Behandlung einer radioulnaren Synostose durch Resektion und Interposition eines septofaszialen Lappens--Eine Fallbeschreibung.

Posttraumatic bone formation between radius and ulna can limit forearm rotation considerably. Recurrence after resection of synostoses is likely to develop if the bony surfaces are not covered by gliding soft tissue that is well vascularised. The interposition of a fascial forearm flap pedicled on the septal vessels of the posterior interosseous artery is suitable for this particular purpose. We report on the case of a spontaneous radioulnar synostosis by cartilaginous exostoses and its treatment by resection and interposition of a vascularised fascial flap. Forearm rotation was restored to normal. Until two years postoperatively there has been no recurrence of the synostosis.

[Long-term outcome of partial alloplastic replacement of the scaphoid bone]. / Langzeitergebnisse nach alloplastischem Teilersatz des Os scaphoideum.

The operative treatment of scaphoid nonunion with a small, sclerotic, or avascular proximal fragment and with accompanying radioscaphoid arthrosis is difficult and often disappointing. Excision of the proximal fragment, styloidectomy, partial replacement of the scaphoid, and insertion of a silicone-rubber lunate prosthesis has been recommended in these cases. From 1980 to 1984, eleven patients (all male, average age 42 [25 to 59] years) with conditions described above were treated by partial replacement of the scaphoid. In one patient, the prosthesis dislocated dorsally and was removed five months later. In another patient, increasing pain at the wrist necessitated a wrist fusion five years after implant replacement arthroplasty. Nine patients remained for evaluation with an average follow-up of 14 years, ranging from 12 to 16 years. Clinical and radiographic studies were performed according to the score proposed by Martini (see p. 153 of this issue). The overall results were satisfactory. The outcome was good in one case, satisfactory in six cases and poor in two cases. The best results could be observed in "subjective estimation" and in "work and sports". The worst results were found in the "X-ray" and "motility" evaluation. In all patients, radiographic and clinical symptoms of silicone synovialitis appeared approximately two years after surgery. This developed adjacent to the implant and later spread throughout the wrist. Simultaneously, carpal collapse and secondary arthrosis of the wrist developed. Only two patients complained of moderate wrist pain at the time of examination. None of the patients desired further treatment. This study shows that in advanced scaphoid nonunion partial replacement of the proximal fragment of the scaphoid with a silicone implant provides long-lasting pain relief and satisfactory hand function. However, progressive carpal collapse (SNAC) and radiocarpal arthrosis developing within four to five years cannot be prevented. Furthermore, severe silicone synovialitis was detected in all patients. Therefore, the procedure was abandoned after 1984.

[Results of Kapandji-Sauvé operation after distal radius fractures]. / Ergebnisse der Operation nach Kapandji-Sauvé nach distalen Radiusfrakturen.

Incongruity of the distal radioulnar joint represents a major problem following malunited fractures of the distal radius. A useful solution is the arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis as described by Kapandji-Sauvé. The results of this procedure are presented and the indication compared to alternative treatment options discussed. Between 1991 and 1997, 19 patients were treated with a Kapandji-Sauvé procedure, for rheumatoid arthritis in seven and for a malunited fracture of the distal radius in twelve patients. All of the patients with a malunion of the distal radius were followed up 5 to 70 months postoperatively by clinical and X-ray examination. For evaluation the protocol by Martini for malunited fractures of the distal radius was used. All but one patient agreed that the operation had been beneficial and would choose to undergo the same procedure again necessary. Mean forearm rotation improved from 99 to 166 degrees. Preoperative pain was reduced in eleven patients. Two patients were completely pain-free and seven noticed pain during heavy load only. Grip strength improved postoperatively in three patients, remained unchanged in four and was diminished in three. In two patients preoperative measurements were not available. Evaluation by the Martini protocol gave three very good, four good, four fair, and one poor result. In one patient, regeneration of the ulna across the resected segment occurred necessitating a secondary excision. This resulted in a return of forearm rotation of 140 degree and good patient satisfaction. Arthrodesis of the distal radioulnar joint with distal ulnar pseudarthrosis reliably reduces pain and improves forearm rotation after malunited fractures of the distal radius. However, it cannot influence pain originating from the radiocarpal joint. Therefore, patients with advanced radiocarpal arthrosis are not suitable for the operation. We consider the procedure to be indicated when the distal radioulnar joint is compromised by the fracture itself or by posttraumatic degenerative arthrosis or when instability or subluxation of the distal radioulnar joint occurs that cannot be corrected. We have not observed persisting problems resulting from instability of the proximal ulna.

Intraepineurial constriction of nerve fascicles in pronator syndrome and anterior interosseous nerve syndrome.

In PS or AINS, if obvious epineurial compression deformity of the median nerve or the AIN is not found at known sites of compression, IeCNF should be considered. IeCNF may occur in one or more nerve fascicles of the median nerve at one of multiple levels in the distal upper arm and proximal forearm. Decompression of the nerve fascicles is achieved by epineurotomy, microsurgical interfascicular dissection, and removal of the constricting outer layer of the perineurium above and below the elbow. Resection of the constricted segments of the nerve fascicles is not necessary. Intraepineurial exploration of the nerve trunk also may be considered if, after surgical decompression of PS and AINS, expected recovery has not occurred and there is no evidence of axonal degeneration.

[Idiopathic arthritis of the finger joints]. / Die idiopathische Arthrose der Fingergelenke.

Degenerative arthritis of the finger joints is a very common disease in middle-aged and elderly patients, in females more frequently than in males. Concerning differential diagnosis rheumatoid arthritis and related conditions, gout, calcinosis, tumors and tumor-like lesions must be considered. Therapy is not necessary in every case. Usually treatment is required if the disease causes pains, joint instability or disabling deformity. Conservative treatment such as diet, physiotherapy, orthotics, local physical and antiphlogistic drug treatment or systemic application of non-steroid antiphlogistics should be preferred. Operative procedures such as removal of osteophytes, arthrodesis or arthroplasty are indicated if conservative treatment fails.

[Closure of rheumatic palmar perforations of the wrist capsule with a flap of retinaculum flexorum]. / Verschluss rheumatischer palmarer Perforationen der Handgelenkkapsel mit einem Lappen aus dem Retinaculum flexorum.

In 53 hands with rheumatoid arthritis, bony spurs of the scaphoid and trapezium were found perforating the capsule of the radial wall of the carpal tunnel. After removal of the spurs, the remaining capsular defect was covered by a flap of the flexor retinaculum. The flap is raised from the flexor retinaculum in a width of approximately 15 mm by parallel transverse incisions and is based radially. Then it is brought down to the defect and sutured to the local ligaments. The blood supply of the retinacular flap is well preserved. The flap provides a reliable cover of the capsular defect as well as a smooth gliding surface for the flexor tendons.