Superselective angiography of the wrist in patients with Kienböck's disease.

BACKGROUND: Microvascular problems like increased intraosseous pressure or venous congestion may influence the development of Kienböck's disease. We examined if wrist position modifies the blood flow in the nutrient vessels. METHODS: Retrospective analysis of 17 patients with Kienböck's disease who had a superselective microangiography of the radial, ulnar and interosseous artery in different wrist positions under general anaesthesia. We analysed the data with Fisher's exact and Wilcoxon-test. RESULTS: We found vessels that entered the bone, that ended at the bone edge, and that supplied a vascular plexus. The origins were the anterior interosseous artery in 10 of 17 cases, the radial artery in seven cases, and the ulnar artery in five cases. Movement of the wrist could reduce or stop the blood flow. Type of lunate configuration showed no significant influence on the blood supply in neutral position. CONCLUSION: The radial, ulnar, and anterior interosseous artery contribute to the vascular supply of the lunate bone in different combinations. Wrist movement can reduce blood flow to the lunate bone.

The medial femoral trochlea flap with a monitor skin island-Report of two cases.

In this report, we present two cases of the bony reconstruction with the medial trochlea (MFT) flap including a skin island that was used to monitor the perfusion of flap in the postoperative period. Between March 2013 and April 2015, we performed surgery on two patients who suffered from scaphoid and talus non-union after trauma and initial treatment by osteosynthesis. A skin island (1 cm × 1 cm and 3 cm × 1 cm, respectively) was included with the osseous flap (1.6 cm × 1 cm × 1 cm and 2 cm × 3 cm × 2 cm, respectively) to assess the perfusion of the flap. The design of the skin island was based on either the saphenous artery perforator or a cutaneous perforator of the descending genicular artery. Both flaps remained viable throughout the postoperative period, and there were no donor site complications. After a follow-up of 36 and 11 months, bony union was observed in both patients with a high degree of satisfaction. Thus, a MFT flap with a skin island could be a tool to assess the perfusion of the flap in the early postoperative period. © 2016 Wiley Periodicals, Inc. Microsurgery 37:431-435, 2017.

Titanium template for scaphoid reconstruction.

Reconstruction of a non-united scaphoid with a humpback deformity involves resection of the non-union followed by bone grafting and fixation of the fragments. Intraoperative control of the reconstruction is difficult owing to the complex three-dimensional shape of the scaphoid and the other carpal bones overlying the scaphoid on lateral radiographs. We developed a titanium template that fits exactly to the surfaces of the proximal and distal scaphoid poles to define their position relative to each other after resection of the non-union. The templates were designed on three-dimensional computed tomography reconstructions and manufactured using selective laser melting technology. Ten conserved human wrists were used to simulate the reconstruction. The achieved precision measured as the deviation of the surface of the reconstructed scaphoid from its virtual counterpart was good in five cases (maximal difference 1.5 mm), moderate in one case (maximal difference 3 mm) and inadequate in four cases (difference more than 3 mm). The main problems were attributed to the template design and can be avoided by improved pre-operative planning, as shown in a clinical case.

The impact of stereo-visualisation of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and Neer classifications in the assessment of fractures of the proximal humerus.

We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification. These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus.

The NHS and the law. Off the record.

To be found guilty of employing doctors not registered with the GMC is every personnel director's nightmare, says Paul Honigmann.