[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers]. / Fingerrekonstruktion durch Transplantation der zweiten Zehe nach traumatischem Verlust sämtlicher Finger.

PURPOSE: To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits. METHOD: Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed. RESULTS: A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment. CONCLUSION: Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.

[Comparison of functional results after reconstruction of the thumb]. / Vergleich funktioneller Ergebnisse nach Daumenrekonstruktion.

Between 1980 and 2000, 26 pollicizations of the index finger and 32 transplantations of the second toe were performed for reconstruction of the thumb after traumatic loss. Twenty-three patients with index finger pollicization and 26 patients with second toe transplantation could be reviewed after an average follow-up of 6.4 years. Vascular complications occurred in two toe transplantations and one index finger pollicization. One transplanted toe was lost after vascular complications. Mobility of the interphalangeal joints was reduced after both procedures. Pinch grip was achieved in 20 of 23 patients after pollicization and 20 of 26 patients after second toe transplantation. Sensitivity was better after pollicization. The most common complaints were cold intolerance after both procedures. Fourty of 49 patients would have the operation again, nine patients would refuse thumb reconstruction.

[Therapy of the peromelic form of symbrachydactyly by double second-toe transplantation]. / Die Behandlung der peromelen Form der Symbrachydaktylie durch zweifache freie Zehentransplantation.

From 1989 to 2001 eleven children with the peromelic type of symbrachydactyly underwent a staged double second toes transplantation for restoration of two finger rays. The second toe of the feet were transplanted first to the small finger position and in the second step to the thumb position. One failure occurred in the first toe transplantation and another developed a venous thrombosis with partial necrosis and eventually a useless ray. Eight children were reviewed retrospectively in a mean follow-up of 5.3 years. The ability to pinch was restored in four children. In all patients without complications the function of the hand improved and the sensitivity was good.

[Operative treatment of vulnerable scars and deep soft-tissue defects of the thumb with a free toe pulp neurovascular flap]. / Die Deckung ausgedehnter instabiler Narben und tiefer Haut-Weichteildefekte an der Daumenkuppe mit der Grosszehen-Pulpa-Lappenplastik1.

Because of the capability of opposition, the thumb is the most important digit of the hand. In case of deep soft-tissue defects of the pulp, it is necessary to reconstruct the palmar surface of the distal phalanx of the thumb using tissue with good sensibility. Between 1982 and 1998 at the Department of Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftliche Unfallkrankenhaus Hamburg, we used a free toe pulp neurovascular flap for reconstruction of the pulp of the thumb in nine patients. All flaps healed without complications. Indications, operative techniques, and results of this procedure are described.

[Anatomy of the dorsal mid-hand arteries--anatomic study and review of the literature]. / Anatomie der dorsalen Mittelhandarterien--Anatomische Untersuchung und Literaturübersicht.

By dissections of 20 cold-preserved hands, we investigated the dorsal metacarpal arteries (DMA) with regard to reliability, origin and anastomoses. The first dorsal metacarpal artery showed a trifurcation with three vessels: Ramus ulnaris (A. metacarpalis dorsalis I), Ramus medialis and Ramus radialis (A. ulnodorsalis pollicis). The DMA II to IV were observed medially in their respective intermetacarpal spaces. The A. metacarpalis dorsalis V was unreliable in reaching the skin of dorsal proximal phalanges as in the DMA IV. Most reliable for reaching the skin of dorsal proximal phalanges were the radial arteries--first, second and third dorsal metacarpal arteries. The dorsal digital arteries originate close to one another at the level of the metacarpophalangeal joints. There was an increase of epifascial position, from radial to ulnar. Irregular palmar intermetacarpal anastomoses were found proximal to the ligamentum metacarpale transversum profundum but nearly consistently in the web space.

[Covering defects of the basal finger area by pedicled flaps anastomosed to the doral metacarpal arteries]. / Deckung von Defekten an den Fingergrundgliedern durch distal an den dorsalen Metakarpalarterien gestielte Lappen.

Between 1993 and 1998, 12 distally based dorsal metacarpal artery flaps were used to cover defects of the fingers and palm. All flaps were raised from the dorsum of the hand. Eleven flaps allowed direct closure of the donor site area; one case required a full-thickness skin graft. Nine flaps healed uneventfully. Distal marginal flap necrosis occurred in three cases. All of these were used to cover defects at the distal part of the middle phalanx.

Callus distraction in the hand skeleton.

From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and fingers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and fingers is a feasible operative technique leading to a promising improvement of function.

[Comparison of various evaluation measures for assessment of treatment success after scaphoid injuries]. / Vergleich verschiedener Bewertungsmassstäbe zur Beurteilung des Behandlungserfolges nach Kahnbeinverletzungen.

Different evaluation scores have been developed in order to assess treatment outcome of carpal injuries. The available scores are not comparable and differ in type and number of parameters. This is a retrospective study of 100 patients who presented with a fracture or a pseudarthrosis of the scaphoid from 1983 to 1997. The Cooney and the Meine scores were compared with our own score. While the Cooney score and the newly developed score show an equal distribution of results in all categories, the score of Meine led to an overall better outcome assessment. The comparative evaluation of the different scores shows that the combination of only a few well defined parameters is sufficient for assessing the treatment outcome of carpal injuries.

[Persistent scaphoid pseudarthrosis after surgical treatment: results of repeated bone transplantation]. / Persistierende Kahnbeinpseudarthrose nach operativer Behandlung: Ergebnisse der erneuten Knochenspanplastik.

From 1984 to 1993, 30 patients with persistent scaphoid non-union despite bone grafting procedures underwent additional reconstructive surgery. Twenty-five patients were followed-up between one and eleven years after revision with a mean follow-up time of 4.8 years. Fifteen patients had bone graft procedures alone, ten patients had additional internal fixation with the Herbert screw or Ender plate. At follow-up, scaphoid union was achieved in 16 patients (64%), 19 patients had arthritic changes of the radiocarpal joint. Only patients with scaphoid union showed satisfactory functional results. Five patients with failed revision surgery needed further operations for chronic wrist pain, including three wrist arthrodeses.

Ilizarov distraction-lengthening in congenital anomalies of the upper limb.

Nine patients underwent Ilizarov distraction-lengthening for congenital anomalies. All were late cases and had undergone other procedures. In five radial club hand patients with very short forearms, we achieved an average 5.8 cm increase in length with each distraction cycle. In two patients with symbrachydactyly of the cleft hand type, we achieved pinch grip between a radial and an ulnar digit by lengthening the short ray. Another case of the monodactyly type in which we tried to lengthen three transplanted proximal toe phalanges ended in failure. A soft tissue distraction was attempted in a case of camptodactyly but failed. We report the problems we encountered and suggest some solutions.

[Surgical treatment of scaphoid pseudarthrosis--long term outcome with the Herbert screws]. / Die operative Behandlung der Kahnbeinpseudarthrose--Langzeitergebnisse mit der Herbert-Schraube.

Between 1984 and 1993, 131 scaphoid nonunions were treated with iliac crest bone grafting and the Herbert-screw. 105 patients were followed between one and ten years with an average followup period of 4.5 years. Bony union was achieved in 93 patients with improvement of range of motion and grip strength. In 14 patients with DISI-instability, the angulation deformity was incompletely corrected with an average reduction of the scapho-lunate angle of eleven degrees. Limited athritic changes at the radial styloid were noted in 58%, intercarpal in 25% of the patients. Most frequent reasons for persistent nonunion were technical problems with the Herbert-screw.

[Reconstruction of thumb through continuous lengthening of the first metacarpus.]. / Daumenrekonstruktion durch kontinuierliche Verlängerung des ersten Mittelhandknochens.

GOAL OF SURGERY: Reconstruction of the amputated thumb through continuous distraction with an Ilizarov ring fixator. INDICATIONS: Traumatic loss of thumb at the level of the proximal half of the proximal phalanx. CONTRAINDICATIONS: Insufficient soft tissue coverage of stump. Stiff saddle joint. POSITIONING AND ANAESTHESIA: Tourniquet. Brachial plexus or general anaesthesia. SURGICAL TECHNIQUE: Installation of a ring fixator. Incomplete osteotomy at mid shaft of first metacarpus with chisel and completion through osteoclasia by twisting the chisel. Preserve palmar periosteum. Deepening of first web space if necessary after removal of external fixator. Use of Z-plasty and proximal transfer of adductor pollicis insertion. POSTOPERATIVE MANAGEMENT: After 1 week continuous lengthening 0.7 mm/day in 3 daily increments. After removal of fixator plaster cast for 2 weeks. POSSIBLE COMPLICATIONS: Improper installation of fixator. Incomplete osteotomy. Too rapid or too slow distraction. Pin tract infection. Deep infection. RESULTS: Over a 2 year period 10 lengthenings. Average follow-up 23 months (10 to 36 months). Average gain in length 38.1 mm. Average length of treatment 163 days. Deepening of web space in 7 patients. Force of grasp 64% of opposite side. Pin tract infection: 4, too early removal of fixator: 1, revision of scar: 1 and correction of stump: 1. All patients were satisfied with the result but for scar at web space.

["Secondary" chondrosarcoma of the hand. Case report and review of the literature]. / Das "sekundäre" Chondrosarkom der Hand. Fallbeschreibungen und Aufarbeitung der Literatur.

Rapid growth of a painful and often recurrent bone tumor of the hand, is suspicious of low malignant chondrosarcoma, even despite previous histological identification as an enchondroma. The difficulty of differential diagnosis of enchondroma and chondrosarcoma is demonstrated in two cases and discussed in a review of the literature.

[Lengthening osteotomy with the Ilisarow fixator]. / Verlängerungsosteotomie mit dem Ilisarow-Fixateur.

From 1991 to 1993, 23 distraction lengthenings were performed using the Ilisarow external fixator. It could be demonstrated that significant lengthening was possible without bone transplantation with the exception of two cases. In one further case, non-union resulted. Further complications were five pin infections, four loosenings of the apparatus, and in one case difficulties with the scar on the amputation site. The Ilisarow external fixator demonstrated stability and variability in its possible applications.

[Initial experiences with the Ilisarov method on the hand bones]. / Erste Erfahrungen mit der Ilisarow-Methode am Handskelett.

From 1 July 1991 to 1 July 1992, 23 patients were treated using an Ilisarov distraction apparatus. The apparatus was used for callus distraction in 13 patients, and for closed fracture treatment, for generating longitudinal pressure in the treatment of fractures, for corrective osteotomy and for soft tissue distraction in 10 patients. Callus distraction in the hand has advantages over conventional techniques. Furthermore, the Ilisarov technique has its merits in certain fractures of the hand.

[Computerized tomography of the hand with high resolution technique]. / Computertomographie der Hand in hochauflösender Technik.

The results of 175 high-resolution computed tomography (CT) scans of the hand and wrist are analysed and compared to the results of conventional radiographs. Advantages of the procedure can be demonstrated when assessing pathological changes within the complex three-dimensional structure of the hand and wrist, and in the analysis of articular surfaces. In some cases, fractures and dislocations of the distal radioulnar joint and the carpal bones were missed in conventional radiographs. In cases of scaphoid fracture and nonunion, CT scans give valuable additional information surpassing the possibilities of conventional radiographs. For instance, bone healing after bone grafting can be better evaluated with a CT scan. Furthermore, preoperative planning is simplified, when tumors and cysts of the carpal bones can be located precisely using computed tomography.

[Hamulus fracture: a frequently unrecognized injury. Presentation of diagnosis and therapy based on two case reports]. / Die Hamulusfraktur: Eine häufig unerkannte Verletzung. Darstellung der Diagnostik und Therapie anhand zweier Fallbeispiele.

Fractures of the hook of the hamate are rare injuries of the hand. They are caused by direct trauma to the palm, however there are some cases without history of trauma. While physical examination is often suspicious of fracture, standard X-ray films can fail to demonstrate the fracture. Bone scans show an increased uptake in the ulnar region of the wrist. The carpal tunnel view or computed tomography confirm the diagnosis. Operative treatment is recommended. Simple excision of the hook, bone grafting or internal fixation are possible procedures. The diagnostic problems are demonstrated in two case reports.