[Two-Stage Reconstruction in Bony Finger Joint Defects - Long-Term Results]. / Zweizeitige Arthrodese bei knöchernen Fingergelenkdefekten ­ Langfristige Ergebnisse.

BACKGROUND: Bony defects in finger injuries and infections impose high demands on their treatment due to the close anatomic relationships. Ideally, the injuries are entirely treated in emergency care. Due to the mechanism of the accident, contaminated and compromised soft tissues are often present and set limits to single-stage treatment. We present the long-term subjective and functional results after two-stage reconstruction of bony finger joint defect injuries. PATIENTS AND METHODS: Over a period of 15 years, a total of 40 patients with 43 fingers were treated due to a defect injury in the phalanges. Initially, the finger was stabilised with Kirschner wires after debridement. After consolidation of the soft tissue, the bone was reconstructed in a subsequent operation by interposition of an iliac crest graft. Complications occurred in 9 patients. Twenty-five patients with 27 fingers were followed up for 10.3 years. Range of motion, length of the affected finger, and grip force, each in relation to the contralateral extremity, were recorded. In addition to a subjective assessment of the global result, the daily function was determined by means of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Significant differences compared with the contralateral extremity (p<0.05) were found in length (70 mm; 91.0%) and total mobility of the affected finger (95°; 46.0%), hand span when the thumb was involved (202.5 mm; 93.4%), and power grip when one of the fingers was injured (30 kg; 84.1%). The DASH score was 4.2 points (0-55.8). Subjectively, 88% of patients were satisfied with the treatment outcome. CONCLUSION: In case of contaminated and compromised soft tissues, the two-stage treatment of bony defect injuries in finger joints by arthrodesis of the joint is a reliable treatment strategy. In the long run, it results in a very satisfactory function of the hand in everyday life although significant differences have been measured compared with the contralateral extremity.

Anatomical principles of ankle denervation - An update.

BACKGROUND: Denervation is a surgical option in ankle arthrosis when conservative therapy has failed. Sectioning all joint branches is essential for its success. The locations of the articular branches of the saphenous (Sa), tibial (Ti), sural (Su), superficial (Ps) and deep peroneal (Pp) nerves are specified. METHODS: In 16 cryopreserved specimens, the courses of the nerves were prepared. Their articular branches were identified, and their respective locations documented by using a new reference system. RESULTS: The articular branches to the ankle ranged from 5 to 30 cm measured from the foot sole. The Sa should be transected at 22.5 cm, the Su at 20 cm, and the Pp at 15 cm. The Ti should be skeletonized up to 25 cm. Epifascial dissection of the Ps is to be performed below 15 cm. CONCLUSION: The study specifies the joint branches of the ankle in an intraoperatively reproducible reference system and thus minimizes the required skin incisions.

[Keeping the big picture in Terror-MASCAL-A new hospital concept]. / Überblick im Terror-MANV ­ ein neues Klinikkonzept.

BACKGROUND: Two key positions have been defined for the in-house management of patients in the context of a terrorism-related mass casualty incident (Terror-MASCAL). The senior triage coordinator (LArS) categorizes the injured according to injury severity using algorithms. The central operational and medical coordinator (ZONK) disposes and prioritizes the injured for treatment measures, considering the injury severity and the available treatment capacities. The dynamics and complexity of a Terror-MASCAL combined with the high number of patients requires comprehensible documentation. MATERIAL AND METHODS: The evaluation of an incident exercise of a Terror-MASCAL revealed deficits in its documentation. Based on the deficits identified, requirements have been defined. The article presents the management and documentation aids of a German national trauma center. RESULTS: The hospital with its currently available resources is abstractly represented via the Trauma Tactics Board (TTB). Patients with their individual injuries are represented by identification cards on the TTB. The ZONK can prioritize and dispose further treatment based on the information about the available resources and the patient-specific injury pattern. The patient registry continues to document the patient's other medical findings. Important external and internal information is noted in an event register. The entire documentation process on the TTB is documented by camera. CONCLUSION: Documentation aids are required to fulfil the core tasks of the ZONK. By using the documentation aids, a hospital can prepare for a Terror-MASCAL within a short time. Lack of daily practical application of the documentation aids should be compensated for by regular practice and interdisciplinary exchange of experience.

[Long-Term Results of Extensor Indicis Transposition Following Rupture of the Extensor Pollicis Longus Tendon after Paediatric Forearm Fracture]. / Langzeitergebnisse der Extensor-indicis-Transposition bei Ruptur der Extensor pollicis longus Sehne nach kindlicher Unterarmfraktur.

BACKGROUND: A rare but typical perioperative complication in the surgical treatment of pediatric forearm fractures is injury to the extensor pollicis longus (EPL) tendon. This article presents the long-term results after reconstruction of the EPL tendon with transposition of the extensor indicis (EI) tendon in children and adolescents after surgically treated forearm fracture. PATIENTS AND METHODS: Over a period of 15 years, 22 children up to the age of 16 were treated with EI transposition analogous to adult care. In a follow-up examination, the range of motion of the finger and thumb joints, retropulsion of the thumb and index finger, abduction and opposition were examined. In addition, hand span and strength in the gross, key, and point grasp were measured. Subjective complaints were questioned and the DASH score was assessed. RESULTS: Rupture of the EPL tendon is a rare complication, accounting for 1% of all surgically treated paediatric forearm fractures. 15 patients with an average age of 10.9 years could be followed up for an average of 66.5 months after transposition of the EI tendon. Significant differences were found in reduced mobility of the metacarpophalangeal joint of the thumb, isolated extensor strength of the index finger, a reduced span between the thumb and index finger in palmar abduction, and reduced strength in the pointed grip. Subjectively, the differences between the sides were not noticed by the patients and their parents in everyday life. CONCLUSIONS: Transposition of the EI tendon for reconstruction of a ruptured EPL tendon as a rare complication after paediatric forearm fracture does lead to a measurable and significant reduction in index finger mobility on the affected side in the long term, but without subjective limitations of the children.

Der Einfluss der simulierten Endgelenksversteifung auf die Bewegung und Kraftentwicklung des Fingers.

PURPOSE: Distal interphalangeal joint (DIPJ) arthrodesis is a well-proven therapy for osteoarthritis in the DIPJ. Since the upper limb is effectively a linked chain which is moved by interlinked, joint-overlapping muscle-tendon units, impacts on movement and force patterns are expected to occur in response to arthrodesis. In this context, a real-time quantitative analysis has not been performed to date. MATERIAL AND METHODS: Finger motion and force development during grasping were dynamically measured and quantitatively analyzed in 19 healthy volunteers with a simulated DIPJ arthrodesis using a TUB (Technische Universität Berlin) sensor glove during fist closure and evaluating two types of force grips compared with the physiological grip. RESULTS: Typical motion patterns were found. During physiological fist closure, the average flexion angle was 71.5° in the metacarpophalangeal joint (MPJ), 76.8° in the proximal interphalangeal joint (PIPJ) and 37.3° in the distal interphalangeal joint (DIPJ). With DIPJ arthrodesis, the flexion angle decreased to 49.6° in the PIPJ, whereas it increased slightly to 77.3° in the MPJ. During force grip I, the average physiological flexion angles were 18.3° in the MPJ, 39.6° in the PIPJ and 42.6° in the DIPJ. With simulated DIPJ arthrodesis, the flexion angle in the MPJ increased to 28.4°, whereas it decreased to 25.2° in the PIPJ. Force grip II yielded physiological flexion angles of 30.9° in the MPJ, 36.6° in the PIPJ and 29.0° in the DIPJ. In response to simulated DIPJ arthrodesis, the angle in the MPJ increased to 34.4° while it decreased to 23.3° in the PIPJ. The forces measured with force grips were almost equally distributed under physiological conditions. In response to simulated DIPJ arthrodesis, the average decrease in the measured force of a finger was no more than 1.4%. CONCLUSION: This study was the first to introduce a quantitative analysis of grasping with simulated DIPJ arthrodesis. Based on this analysis, the study demonstrates the dynamic interaction of the finger joints as well as force patterns on the individual finger rays of the hand in real-time.

[Ulnar Shortening Osteotomy - Two Weeks of Immobilization Sufficient]. / Ulnaverkürzungsosteotomie ­ Zwei Wochen Ruhigstellung ausreichend.

BACKGROUND: Diaphyseal ulnar shortening osteotomy (USO) as surgical treatment of ulnar impaction syndrome is standardized nowadays with good to very good results. In contrast, a wide spectrum of different postoperative treatment regimens can be found in the current literature. The results after USO with modern, angular stable implants with immobilization for 2 weeks are presented. PATIENTS AND METHODS: A retrospective database analysis identified 49 patients (31 women, 18 men, mean age 37.6 years) with a total of 51 USO over a 13-year period and were followed up for 73.5 (15.9-192.9). All USO were obliquely sawed and stabilized with palmar locking implants. The wrist was immobilized postoperatively in 30° extension in a dorsal forearm splint for 2 weeks. RESULTS: All USO showed load-stable consolidation signs after an average of 7.0 (SD 1.9; 4.9-14.1) weeks. Wrist range of motion was significantly improved in extension/flexion from 107.6° (60-155) preoperatively to 123.7° (80-160) postoperatively and in ulnar/radial deviation from 55.1° (25-90) to 60.8° (30-90) (p<0.05). Pain level was significantly reduced from 3.2 (0-8) to 0.1 (0-2) at rest and from 7.3 (4-10) to 1.2 (0-9) under weight bearing (p<0.01). A total of 5 complications (9.8%) were noted. Nonunion was not found. CONCLUSION: By using angular stable implants to stabilize a USO, the duration of immobilization can be reduced to 2 weeks without compromising bone healing.

[Corrective Osteotomy of malunited Fractures of the Base of the first Metacarpal Bone]. / Die Korrekturosteotomie an der Basis des ersten Mittelhandknochens nach in Fehlstellung konsolidierter Fraktur.

PURPOSE: In this study, the results after corrective osteotomy of the base of the first metacarpal bone are presented. PATIENTS AND METHODS: There were 24 malunion following a fracture of the base of the first metacarpal, these included 19 Bennett's fractures, 3 Rolando fractures, and 2 Winterstein fractures. The time between the corrective osteotomy and the initial trauma averaged 16 (range, 4 to 66) weeks. The Bennett and Rolando fractures had an average step-off of 2.3 (range, 0 to 4) mm, as well as gaps between 0.9 and 5.4 mm in the basal articular surface of the first metacarpal. There was a subluxation in 16 patients. Patients with Rolando or Winterstein fractures showed an axis deviation of the first metacarpal ranging from 31° to 57°. Two of the patients with Rolando fracture showed a step-off of the articular surface of 1 and 3 millimetres, respectively. Screw osteosynthesis was carried out 10 times, K-wire osteosynthesis 13 times, and once, both procedures were combined. One osteotomy was performed with use of a plate osteosynthesis. RESULTS: The corrective osteotomy in patients with Bennett's fracture improved the radial abduction on average from 37° to 49° and the palmar abduction on average from 37° to 47°. Thirteen patients presented a congruent articular surface postoperatively. A step-off in the articular surface between 0.5 and 2.2 millimetres remained in 6 cases. In one patient the subluxation could not be completely corrected. In two cases a trapezectomy was required due to the remaining displacement in the joint and a post-traumatic osteoarthritis. The mobility after Rolando and Winterstein fractures improved on average from 31° to 41° for radial abduction and from 32° to 43° for palmar abduction. Congruent joint surfaces as well as repositioning of the first metacarpal was seen in all patients, only one patient showed a persisting axis deviation of 35° postoperatively. All patients returned to work. CONCLUSION: The study shows that posttraumatic malunion of the base of the first metacarpal can be treated effectively by corrective osteotomy resulting in good outcomes, if degenerative changes have not occurred, while alternative treatment methods remain to be performed.

[Secondary flexor tendon reconstructions - how good are they?] / Sekundäre Beugesehnenplastiken ­ Wie gut sind sie?

BACKGROUND: Secondary reconstructions of flexor tendons are nowadays seldom - due to developments in primary repairs of flexor tendon. They are however indicated in complex cases. The results of a tertiary, supraregionally operating hand centre are presented. The results are compared with recent and historic published results. PATIENTS AND METHODS: During a period of 11 years and with a total of 644 flexor tendon repairs, there have been 52 secondary flexor tendon reconstructions: 7 single staged reconstructions, 16 tendon transpositions and 29 two staged reconstructions. A total of 39 patients have been evaluated retrospectively using the system of Buck-Gramcko. RESULTS: Excellent to good results have been achieved in 60 % of the single staged reconstructions. Functional = excellent to good results are found in 75 % of the transpositions. 50 % of the two staged reconstructions obtained a functional result. In total 58.5 % of the secondary flexor tendon reconstructions achieved a functional result according to the system of Buck-Gramcko. CONCLUSIONS: Secondary flexor tendon reconstructions make up about 7.5 % of all flexor tendon injuries. The functional results have changed little during the last decades and relevant improvement appears to be impossible. In comparison to primary suture of flexor tendons, the results are disappointing. The objective is to further optimize the primary repair of flexor tendons and consequently to reduce the need for secondary reconstructions.

Altered expression of Fas receptor on alveolar macrophages and inflammatory effects of soluble Fas ligand following blunt chest trauma.

Blunt chest trauma impairs the outcome of multiply-injured patients. Lung contusion induces inflammatory alterations and Fas-dependent apoptosis of alveolar type 2 epithelial (AT2) cells has been described. The Fas/Fas ligand (FasL) system seems to exhibit a proinflammatory potential. We aimed to elucidate the involvement of the Fas/FasL system in the inflammatory response after lung contusion. Chest trauma was induced in male rats by a pressure wave. Soluble FasL concentrations were determined in bronchoalveolar lavage fluids and alveolar macrophage (AMΦ) supernatants. Alveolar macrophages and AT2 cells were isolated to determine the surface expression (FACS) of Fas/FasL, the mRNA expression (reverse transcriptase-polymerase chain reaction) of Fas, FasL, TNF-α, IL-6, and IL-10 and to measure the release of IL-6 and IL-10 after culture with or without stimulation with FasL. After chest trauma, FasL concentration was increased in bronchoalveolar lavage fluid, and AMΦ supernatants and Fas and FasL protein were downregulated on AMΦs and unchanged on AT2 cells. The mRNA expression of Fas was increased in AMΦs and AT2 cells and that of FasL only in AMΦs isolated after lung contusion. Fas ligand stimulation further enhanced IL-6 and suppressed IL-10 release in AMΦs after trauma.The results indicate that the Fas/FasL system is activated after chest trauma, and FasL is associated with the inflammatory response after lung contusion. The proinflammatory response of AMΦs is enhanced by FasL stimulation. Both AMΦs and AT2 cells seem to contribute to the mediator release after lung contusion. These results confirm the importance of the Fas/FasL system in the inflammatory response after chest trauma.