[Fractures and Non-Unions of the Scaphoid: Our preferred surgical Approaches]. / Skaphoidfrakturen und -pseudarthrosen: Unsere Wahl des Zugangs.

This article describes our algorithm for approaching and fixing scaphoid fractures and non-unions.

[Incisions in surgical Treatment of Dupuytren's Disease]. / Zugänge bei Operationen einer Dupuytren'schen Kontraktur.

Therapeutic options to treat Dupuytren`s disease vary considerably. Nevertheless, limited fasciectomy remains the method of choice in advanced disease. Correct incisions are of crucial importance in this kind of surgery.With the inclusion of relevant literature, we present principles of correct incisions and our personal approach in different stages of the disease. History and a subtle clinical examination are essential to plan the surgery. Important details are quality of skin and extent and characteristics of pathological tissue. Generally accepted basic incisions are longitudinal incisions with subsequent Z-plasties and Zig-Zag-Incisions with several modifications. Extensive deficit of skin necessitates local flaps. In the palm we prefer an ulnar-based flap design and in special cases a Z-plasty. Depending on the extent of the disease, various combinations of these basic techniques are necessary. Incisions must respect general principles in hand surgery, allow exposition of the pathological tissue, utilise mobile parts of skin for usage as flaps and respect vascularisation of resulting flaps.In complex cases, individualised incisions or general hand surgical principles and correction of the resulting skin deficit are crucial elements necessary for successful surgery. By sticking to these principles, experienced hand surgeons can implement different solutions.

[Revision surgery after resection arthroplasty of the CMC-1 joint using the extensor carpi radialis longus muscle tendon]. / Revisionsoperation nach Resektionsarthroplastik des Daumensattelgelenkes unter Verwendung der Sehne des M. extensor carpi radialis longus.

OBJECTIVE: Resuspension of the first metacarpal bone using the extensor carpi radialis longus muscle tendon. Prevention of contact between the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Preservation of motion. INDICATIONS: Pain after preceeding resectional arthroplasty due to proximalisation of the first ray. Radiologically demonstrated contact between the base of the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Instability of the first ray at the site of the suspension. CONTRAINDICATIONS: Proven specific reasons: neuropathical complaints and dysaesthesia in the region supplied by the superficial branch of the radial nerve, tendinitis of the flexor carpi radialis tendon etc. SURGICAL TECHNIQUE: Distalisation of the first ray after mobilisation and debridement at the base of the first metacarpal bone with resection of scar tissue, Resection of the pre-existing tendon plasty and contouring the base of the first metacarpal bone with removal of osteophytes. Interposition of tendon material between the base of the first and second metacarpal bones. POSTOPERATIVE MANAGEMENT: Immobilisation in a forearm cast including the thumb metacarpophalangeal joint for 6 weeks. RESULTS: Of 21 patients treated using this procedure, 15 (13 women, 2 men, average age 59 (51-70) years) were evaluated retrospectively on average 4 (2-10) years postoperatively. Opposition of the thumb was nearly normal. Grip strength and strength of pinch grip did not differ significantly from the contralateral side. Pain at rest and exercise (evaluated by a visual analogue scale from 0-10) was postoperatively significantly reduced. On plain X­rays the distance between the base of the first metacarpal bone and the distal scaphoid pole was significantly increased as a sign of a successful distalisation. Ultimately, 12 patients postoperatively returned to work, 10 to their original occupation. No patient required additional procedures.

[Scaphoid non-union: Experience from more than 280 reconstructions using a medial femur condyle bone graft]. / Kahnbeinpseudarthrose: Erfahrungen aus mehr als 280 Rekonstruktionen mit einem vaskularisierten Knochenblock aus der medialen Femurkondyle.

BACKGROUND: Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences. PATIENTS AND METHODS: Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable. RESULTS: In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions. CONCLUSIONS: These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations.

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.

Interrater-Reliabilität bei der Beurteilung von Skaphoidfrakturen in CT-Aufnahmen des Skaphoids in der Ebene des Handgelenkes vs. in der Ebene der langen Achse des Skaphoids.

BACKGROUND: Because of its form, size and position, the scaphoid is known to be the foundation stone of the carpus, with an exceptionally important biomechanical function. Therefore evaluation of fracture morphology is essential. Experts already agree that computed tomography (CT scan) in the long axis of the scaphoid is the best approach for diagnosing scaphoid fractures, but also for therapy planning. But this method is hardly a standard in most hospitals and studies showing superiority of this technique for therapy planning are non-existent. HYPOTHESIS: The purpose of this retrospective study was to test if the interobserver reliability for the evaluation of scaphoid fracture morphology in CT scans in the long axis of the scaphoid is greater than in CT scans in the plane of the wrist, and thus more reliable. METHOD: 42 patients with scaphoid fractures had a CT scan in the long axis of the scaphoid (CT-scaphoid). CT reformations along planes relative to the wrist (CT -wrist) were made. Those 84 cases were anonymised and put in a random order. They were presented to 4 clinical observers (2 hand surgeons and 2 radiologists) for fracture evaluation with respect to: localisation, humpback deformity, offset (radial/ulnar and palmar/dorsal) and classification by Herbert. Surgeons have to select a palmar or dorsal approach as well as an open or percutaneous technique. Statistical analysis was made between 2 and 4 observers by an impartial statistician, using Cohen's kappa coefficient, Pearson coefficient, Fleiss' kappa, interclass correlation coefficient (Shrout and Fleiss) and Spearman rho coefficient. RESULTS: In all evaluated parameters, the interobserver reliabilty was higher in the CT scan in the long axis of the scaphoid, although statistical significance was only found for the humpback deformity. CONCLUSION: For evaluation and understanding scaphoid fractures, the CT scan along the long axis of the scaphoid is more significant and reliable than the scan in the plane of the wrist and is therefore preferable.

[Results of the reconstruction of the middle phalangeal base of the finger through an osteochondral autograft from the hamate bone]. / Ergebnisse der Rekonstruktion der Mittelgliedbasis am Finger durch ein osteochondrales Transplantat vom Os hamatum.

OBJECTIVE: The fractured base of the middle phalanx was reconstructed in 13 patients using an osteochondral transplant from the carpometacarpal joint surface of the hamate bone. The goal was to restore joint stability with preservation of mobility. Indications were acute and missed isolated destruction of the palmar middle phalanx base ≥ 30 %. Contraindications were destruction of the head of the proximal phalanx, advanced chondropathy of the head of the proximal phalanx, and extensive soft tissue injury with loss of skin coverage for the proximal interphalangeal joint. SURGICAL TECHNIQUE: In this procedure the fractured middle phalangeal base was debrided and the defect replaced by a size-matched autograft from the dorsal carpometacarpal osteoarticular surface of the hamate bone, which was secured in place with miniscrews. RESULTS: Bone fusion was achieved in 100 % with restoration of joint congruity in 12 of 13 cases and a slight subluxation in one case. Follow-up was possible in 9 cases after 23 (5-51) months. The average range of motion in the reconstructed joint for extension/flexion was 0/9/73°; grip strength was 82 % of the unaffected side. Five out of 9 patients developed a mild flexion contracture in the PIP joint. The DASH score was 6 (0-33) points, pain at rest was 1 (0-5), and pain at exercise 2 (0-6) on a visual analogue scale from 0-10. All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by an osteochondral graft from the hamate bone is a reliable procedure to restore stability and mobility of the joint.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck's disease: first results of an ongoing observational study.

INTRODUCTION: Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease. MATERIALS AND METHODS: Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients. RESULTS: In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0. CONCLUSION: One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

[Stabilization of the scaphoid according to Brunelli as modified by Garcia-Elias, Lluch, and Stanley for the treatment of chronic scapholunate dissociation]. / Die Fesselung des Kahnbeins nach Brunelli in der Modifikation nach Garcia-Elias, Lluch und Stanley zur Behandlung der veralteten skapholunären Dissoziation.

OBJECTIVE: Stabilization of the scaphoid correcting rotary subluxation and replacement of the biomechanically essential dorsal part of the scapholunate ligament for prevention of osteoarthritis. INDICATIONS: Scapholunate dissociation without useful remnants of the ligament and reducible malalignment of the scaphoid. CONTRAINDICATIONS: Fixed scaphoid malalignment. Osteoarthritis (SLAC [scapholunate advanced collapse] wrist). SURGICAL TECHNIQUE: Dorsal approach to the wrist using the flap described by Berger. Correction of rotary subluxation and stabilization of the scaphoid using a distally based strip of flexor carpi radialis tendon, which is created through a separate palmar incision, and fixed to a bone anchor in the lunate through a tunnel from the palmar side of the distal pole of the scaphoid to the origin of the dorsal part of the scapholunate ligament from the scaphoid combined with transfixation of the scaphoid to the capitate and the lunate bone in corrected position using two Kirschner wires (1.6 mm). Additionally, the flexor carpi radialis strip is looped through a split in the dorsal radiotriquetral ligament and fixed to itself. POSTOPERATIVE MANAGEMENT: Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires 8 weeks postoperatively, followed by physiotherapy to improve wrist motion. RESULTS: 14 out of 17 patients were available for a clinical and radiologic examination after a mean follow-up time of 10.5 months (minimum 6, maximum 15 months). Two of these patients had to undergo another operative procedure in the meantime, one partial and the other total wrist fusion. The remaining twelve patients had a mean DASH Score (Disabilities of the Arm, Shoulder and Hand) of 25 (minimum 0, maximum 59 points) and a mean modified Mayo Wrist Score of 80 points (minimum 60, maximum 97 points). Contrary to the good clinical results, the final radiologic examination demonstrated a tendency toward loss of correction compared to the postoperative X-rays.

[Treatment of chronic scapholunate dissociation using Cuénod's bone-ligament-bone autograft]. / Die Behandlung der veralteten skapholunären Dissoziation mittels eines Knochen-Band-Knochen-Transplantats nach Cuénod.

OBJECTIVE: Correction of chronic scapholunate dissociation by replacement of the biomechanically most important dorsal part of the scapholunate ligament using a bone-ligament-bone autograft taken from the carpometacarpal joint II and, additionally, a modified dorsal capsulodesis. INDICATIONS: Nonfixed chronic scapholunate dissociation without useful remnants of the ligament in which loss of the dorsal part of the scapholunate ligament is the crucial pathophysiological moment. CONTRAINDICATIONS: Chronic scapholunate dissociation with fixed deformity. Osteoarthritis. SURGICAL TECHNIQUE: Dorsal incision. Approach to the wrist using the capsular flap described by Berger. Reduction of deformity and temporary transfixation of the scaphoid to the capitate as well as to the lunate. Creation of a trough at the ulnar edge of the dorsal aspect of the scaphoid and another trough at the radial edge of the dorsal aspect of the lunate. Fixation of an exactly fitting bone-ligament-bone autograft taken from the trapezoidometacarpal joint II with 1.2-mm screws into the troughs. Fixation of a part of the dorsal intercarpal ligament which is based on the scaphoid to the lunate using a bone anchor. POSTOPERATIVE MANAGEMENT: Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 8 weeks; removal of Kirschner wires 10 weeks postoperatively; after Kirschner wire removal physiotherapy to improve range of motion. RESULTS: Twelve out of 16 male patients were available for a clinical and radiologic examination after a mean follow-up time of 6.3 years (minimum 1.6, maximum 7.3 years). Clinical results were excellent. The modified Mayo Wrist Score averaged 87 points (minimum 65, maximum 100 points). Eleven patients had an excellent or good result, none of the patients showed a poor result. The DASH Score (Disability of the Arm, Shoulder and Hand) was 13 points on average (minimum 0, maximum 42 points). All patients would have the same operation again. Radiologically, a stretching of the bone-ligament-bone autograft was found in six cases. A symptomatic SLAC (scapholunate advanced collapse) wrist with the need for a salvage operation could not be observed.

[Total wrist fusion using the AO wrist fusion plate]. / Die vollständige Versteifung des Handgelenks mit der AO-Handgelenk-Arthrodesenplatte.

OBJECTIVE: Arthrodesis of the wrist in order to improve functional use of the hand by reducing pain and improving grip strength. INDICATIONS: Painful destruction of both the radiocarpal and mediocarpal joint combined with contraindications to motion-preserving procedures. Conservative treatment insufficient. CONTRAINDICATIONS: Patients who are pain-free and satisfied with a motion-preserving procedure (e.g., Wilhelm's denervation procedure) or conservative management (casting). SURGICAL TECHNIQUE: Dorsal approach to the wrist. Removal of destroyed articular surfaces down to cancellous bone, filling the resulting defects with cancellous bone graft taken either from the the radius or the iliac crest. Stable fixation using the AO wrist fusion plate. POSTOPERATIVE MANAGEMENT: Immediate active motion exercises of the fingers. Below-elbow cast for 2 weeks. 6 weeks postoperatively, X-ray control to judge bony healing. Normal use of the hand in daily life but avoiding pain-provoking activities. RESULTS: 26 (18 men, eight women) of the authors' first patients with arthrodesis of the wrist using the AO fusion plate were reexamined after a mean follow-up time of 18 months (minimum 6, maximum 32 months). The mean modified Mayo Wrist Score was 47 points (minimum 20, maximum 70 points), the DASH Score (Disabilities of the Arm, Shoulder and Hand) averaged 46 points (minimum 4, maximum 81 points). 20 of the 26 patients were satisfied, but not all patients were completely free of pain. Eight out of a total of ten patients (seven men, three women) with a bilateral wrist arthrodesis were reexamined after a mean follow-up time of 66 months (minimum 27, maximum 74 months). The DASH Score was 55 points on average (minimum 38, maximum 73 points). All patients stated that their clinical situation had improved and that they were able to manage their daily activities without help. So it can be concluded that bilateral arthrodesis of the wrist is a valuable option, if all other possibilities are exhausted.