Commentary on "Does ultrasonography contribute significantly to the diagnosis of carpal tunnel syndrome?" by A. Zyluk, I. Walaszek and z. Szlosser.

The diagnosis of carpal tunnel syndrome diagnosis can be made based on the history and clinical findings in most of the cases, but in doubtful cases, electrophysiological tests and ultrasound can provide additonal and useful information.

Prospective study on complications following a lower body lift after massive weight loss.

BACKGROUND: Lower body lift procedures are in high demand following the increase of massive weight loss patients. As surgical complication rates in this patient group are generally high, patients need to be prepared for risk factors and complications in lower body lift surgery. The aim of this study was to identify the complications and possible risk factors of a lower body lift as concrete data for this procedure are limited. METHODS: A prospective study on 50 consecutive patients who underwent a lower body lift procedure was performed. Measures included co-morbidities and complications. Risk factors assessed included patient age, gender, highest lifetime body mass index (BMI) (BMI max), current BMI, excess weight loss (EWL), type of weight loss and nicotine consumption. RESULTS: There were 50 patients (44 females, six males) with a mean age of 41±10.8 years and a mean EWL of 86.4±15.6%. Mean BMI max was 49.5±10.5 kg m(-2), current BMI was 27.8±4.0 kg m(-2). A total of 35 (70%) patients developed at least one complication. Five patients (10%) suffered a major complication that necessitated surgical revision. Wound dehiscence occurred in 30 patients (60%), followed by seroma in 17 patients (34%). A surgical complication was directly related to BMI max (p=0.02) and age of the patient at the time of surgery (p=0.03). CONCLUSIONS: The overall complication rate following a lower body lift was 70%, which is comparable with that known for high-risk patient groups. The most important risk factors are BMI max and age of the patient (Clinical trial registration number (ISRCTN): NCT01551862).

Four-corner arthrodesis--does the source of graft affect bony union rate? Iliac crest versus distal radius bone graft.

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

[Ulna shortening osteotomy using a new 7 hole gliding plate. Results from 73 cases]. / Die Ulnaverkürzungsosteotomie mit der neuen 7-Loch-Gleitplatte. Ergebnisse von 73 Eingriffen.

BACKGROUND: Ulna shortening osteotomy is a common procedure for the surgical treatment of ulna impaction syndrome, but it is still associated with complications such as rotation malalignment, and delayed or non-union due to of incomplete closure of the osteotomy gap. METHODS: We have developed a 7-hole titanium compression plate that provides fixation of the ulna before the osteotomy is carried out. With this plate, which has been in use for 4 years, a shortening of up to 10 mm is possible using two gliding holes, with the compression holes enabling the closure of the osteotomy gap. We report the results of 70 patients undergoing 70 ulna shortening procedures, with a follow-up of between 5 and 18 months. Two patient groups underwent follow-up clinical examination as well as completing the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for evaluation. RESULTS AND CONCLUSIONS: There was no occurrence of delayed or non-union. The DASH score averaged 19 points in the prospective and 23 points in the retrospective group, representing a good functional result with only minor impairment. This study indicates that ulnar shortening using this gliding compression plate and performing an oblique osteotomy is associated with a minimal complication rate and highly satisfactory clinical outcome.

[Is a differentiated treatment depending on the degree of severity justified in cubital tunnel syndrome?]. / Ist eine unterschiedliche Behandlung bei verschiedenen Schweregraden des Sulcus nervi ulnaris-Syndroms sinnvoll?

BACKGROUND: Cubital tunnel syndrome is the second most common chronic nerve entrapment of the upper extremity, yet both diagnosis and staging of the severity of the progression of the disease rely mostly on the keen observation and interpretation of clinical signs and symptoms. To be valid, a staging system must correlate well with the known pathophysiological mechanisms of chronic nerve compression, have objective parameters available to quantify differing degrees of sensory and motor dysfunction, and finally must allow different therapeutic consequences. PATIENTS AND METHODS: In this study we have prospectively evaluated 44 patients who presented with the clinical diagnosis of cubital tunnel syndrome. Quantitative Sensory Testing was performed using a computer-assisted testing system (Sensory-Management Services L. L. C., Baltimore). Classic two-point discrimination, one point pressure threshold, pinch and grip strength were measured. Progression of disease was staged according to the gradual loss of sensory and motor function. After an average of 15 months postoperatively, ulnar nerve function was re-evaluated using the same parameters and outcome measured with the modified Bishop rating scale. RESULTS: The results of this study indicate that 100 % of patients in the moderate group had a good and excellent outcome, whereas only 74 % of the severe group were rated as good and excellent with 17 % moderate and 9 % poor outcome.

[Scaphoid fractures--operative or conservative treatment? A CT-based classification]. / Kahnbeinfrakturen--wann operativ, wann konservativ? CT-basierte Klassifikation.

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

[Significance of electroneurographic parameters in the diagnosis of chronic neuropathy of the ulnar nerve at the elbow]. / Die Wertigkeit elektroneurographischer Messparameter in der Diagnostik der chronischen Ulnarisneuropathie am Ellenbogen.

PURPOSE: Ulnar neuropathy at the elbow (UNE) is the second most common compressive neuropathy of the upper limb. Besides clinical evaluation, electrodiagnostic studies are usually applied to confirm the diagnosis. However, there are certain limitations to the diagnosis of UNE by electrodiagnostic studies. In a prospectively performed study we compared the diagnostic value of the electrodiagnostic parameters to the symptoms and the clinical parameters for different degrees of sensory and motor dysfunctions. METHODS AND MATERIALS: Between 2001 and 2003, 38 patients (mean age 53.9 +/- 8.8 years, 19 men and 19 women) were treated at our institution for UNE. For 34 (89%) patients complete electrodiagnostic studies were performed and for 25 patients there was also an electrodiagnostic evaluation of the asymptomatic contralateral arm. According to the symptoms and clinical parameters (grip and pinch grip, two-point discrimination), the patients were assigned to three stages (mild, moderate, and severe). Electrophysiological measurements for each stage were compared with one another. The diagnostic value for each electrophysiological parameter was evaluated in comparison to the normal limits of the "Deutsche Gesellschaft für Neurologie (DGN)" and the "American Association of Electrodiagnostic Medicine (AAEM)". RESULTS: In the 34 symptomatic arms the mean values for motor nerve conduction were: conduction velocity (MNCV) = 41.2 +/- 11.6 m/s; velocity change above-to-below-elbow segment = 12.8 +/- 7.7 m/s; CMAP = 9224 +/- 5514 microV; dL = 3.24 +/- 0.82 mg. For the moderate stages of nerve compression (n = 11) the mean values are: MNCV = 42.5 +/- 12.7; velocity change MNCV = 13.2 +/- 6.8; CMAP = 11 890 +/- 4750; dL = 2.97 +/- 0.57; for severe nerve compression (n = 23): MNCV = 40.6 +/- 11.0; change MNCV = 12.7 +/- 8.3; CMAP = 7948 +/- 5358; dL = 3.37 +/- 0.8. The difference for each parameter between the symptomatic and asymptomatic contralateral arm was statistically significant (p < 0.05) as it was for the difference of the parameters of the group with severe nerve compression in comparison to the asymptomatic arm. In the comparison of the moderate stage group with the asymptomatic arm there was only a significant difference for MNCV and there was no significant difference between the moderate and the severe group. In our study the calculated sensitivities for the electrodiagnostic studies were 76% for all symptomatic arms, 64% for the moderate group, and 83% for the severe nerve compression group. In all patients the MNCV was the most sensitive parameter. CONCLUSION: Electrodiagnostic studies were only able to reveal 3/4 of all patients with an affection of the ulnar nerve and only 2/3 of the patients with a moderate stage of ulnar nerve compression. Although important for the further therapy, a differentiation between a moderate and severe degree of nerve compression was not possible.

[The posttraumatic carpal collapse--long-term results after midcarpal fusion]. / Der posttraumatische karpale Kollaps--Längerfristiger Verlauf nach mediokarpaler Teilarthrodese.

PURPOSE: Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid. METHOD AND MATERIAL: 37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically. RESULTS: The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain. CONCLUSION: Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.