[Diagnostics and classification of distal radius fractures]. / Diagnostik und Klassifikation der distalen Radiusfraktur.

Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X­ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

[Experiences with arthroplasty of the basal joint of the thumb : The"mini-hip" gains ground]. / Erfahrungen mit Endoprothetik am Daumensattelgelenk : Die "Mini-Hüfte" auf dem Vormarsch.

The complex kinematics of the saddle joint has been a challenge in the development of trapeziometacarpal prostheses. The introduction of the dual-mobility design increases the range of motion and limits strains on the cup fixation. Therefore, rates of loosening and dislocation have been markedly reduced. Furthermore, several studies showed a similar relief of pain, range of movement and grip strength compared to the results of resection arthroplasty. The preservation of the length of the first ray as well as the more stable and functional joint can be favourable in younger and active patients. Further investigation is needed to determine whether or not those higher demands affect long-term survivorship. The high grade of patient satisfaction, the shorter recovery time and the safe surgical technique motivates considering the implantation of a total endoprosthesis with a dual-mobility cup as an attractive alternative to resection arthroplasty in the operative treatment for trapeziometacarpal osteoarthritis.

Corrective osteotomy after malunited distal radius fractures.

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

The distal radial decompression osteotomy for ulnar impingement syndrome.

INTRODUCTION: The decompression of the distal radioulnar joint (DRUJ) is performed by ulnar translation of the radial shaft proximal to the sigmoid notch, i.e. detensioning of the distal part of the interosseous membrane (DIOM) while containment of the DRUJ is achieved by closed wedge osteotomy of the radius. The osteotomy shortens the radius which entails detensioning of the triangular fibrocartilage complex (TFCC). SURGICAL TECHNIQUE: Facilitating the modified Henry approach to the distal palmar radius a radial based wedge osteotomy is applied. The proximal osteotomy is proximal to the ulnar head and distal osteotomy is proximal to the sigmoid notch to prevent iatrogenic impingement. Ulnar translation of the radial shaft is performed to loosen the DIOM. The closed wedge osteotomy reduces radial inclination which will foster containment of the DRUJ. CONCLUSION: Distal radial decompression osteotomy of the DRUJ preserves DRUJ function while relieving painful impingement. Further surgical interventions are not compromised in case of failure.

Prospective study on harvesting autologous bone grafts from the anterior iliac crest using a new specialized reamer.

The iliac crest remains the most frequent donor site for bone harvesting. Despite the surgical access to the iliac crest being relatively simple and the operation being carried out regularly, there are frequent complications. Therefore, a new, manual iliac crest reamer (R group) was compared to the classical harvesting of a corticocancellous bone graft by means of an oscillating saw (Con group) in a prospective study on 80 consecutive patients having hand surgery. Follow-up time was 3 months. Operation time and incidence of hematomas, seromas, and paresthesias in the R group were significantly shorter and less, respectively, than in the Con group. Pain at harvest site measured with the visual analogue scale (VAS) at 5 days, 6 weeks, and 12 weeks postoperatively was significantly less in group R as well. The utilization of the iliac crest reamer allows bone graft harvest in a relatively quick and simple operation with relatively few complications but with the limitation in that the maximum diameter of a bone cylinder that it can harvest is 20 mm.

Ulnar shortening osteotomy with a premounted sliding-hole plate.

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.

Proximal interphalangeal joint replacement with pyrolytic carbon prostheses.

OBJECTIVE: Prosthetic joint replacement to reduce pain and maintain function of the proximal interphalangeal joint. INDICATIONS: Symptomatic arthritis of the proximal interphalangeal joint with preservation of the collateral ligaments, sufficient bone support, and intact or at least reconstructable extensor tendons. CONTRAINDICATIONS: Lack of stability, e. g., as a result of rheumatoid arthritis or destruction of the ligaments caused by an accident. Nonreconstructable extensor tendons. Florid or chronic infection. Lack of patient compliance. SURGICAL TECHNIQUE: Dorsal approach to the proximal interphalangeal joint. A triangular tendinous flap with pedicle, based distally on the insertion of the medial band, is lifted up, leaving the lateral bands intact. The joint surfaces are resected while maintaining the palmar plate and the collateral ligaments. The trial prosthesis is fitted, its position is checked, and the final unconstrained prosthetic components are inserted using a press-fit technique. The dorsal aponeurosis is reapproximated. RESULTS: 20 patients were treated for posttraumatic or idiopathic arthritis with 24 pyrolytic carbon PIP prostheses, and a follow-up examination was carried out after an average of 15 months (6-30 months). Surgical management was changed from arthroplasty to arthrodesis in three cases. For the remaining prostheses, an average range of motion of 50 degrees was achieved for the proximal interphalangeal joint. On the visual analog scale (VAS; 0: no pain, 10: incapacitating pain), the patients suffered few symptoms (VAS: 0-3). 80% of patients said they were satisfied with the outcome of the operation. In three cases (one infection, two dislocations) the prostheses had to be removed and arthrodesis performed. Migration of the distal components was observed on the radiographs in five cases, and of the proximal components in four cases, although this did not have any effect on the functional parameters. The development of a painless noise ("squeaking") was noticed in nine out of 21 prostheses. However, as with prosthetic migration, this did not cause any functional deficits.

Special aspects of wrist arthritis management for SLAC and SNAC wrists using midcarpal arthrodesis: results of bilateral operations and conversion to total arthrodesis.

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilateral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis experienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: I to 4). A mean arc of wrist extension and flexion of 53 degrees on the right and 49 of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed partial arthrodesis at rest and by 46% at stress on the visual analog scale andfrom intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain activities, 55%felt considerably and 15% strongly limited in daily life. However, all but two patients were satisfied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and preserved valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.

Minimal invasive treatment for scaphoid fractures using the cannulated herbert screw system.

Internal fixation of scaphoid fractures avoids the problems associated with prolonged plaster immobilization and, at the same time, allows an early return to activity for these mostly young patients.Internal fixation of the scaphoid is greatly facilitated by the use of specially designed headless bone screws, such as the Herbert bone screw, originally developed specifically for internal fixation of the scaphoid; furthermore, the advent of cannulated scaphoid screws has made closed (percutaneous fixation) stabilization of the scaphoid a reality. Indeed, this method has now become the treatment of choice for the majority of acute scaphoid fracture, bringing with it all the advantages of internal fixation without the disadvantages of open surgery.However, the success of closed treatment is also dependent on an accurate assessment of the fracture, and for this reason, we now advocate the routine use of computed tomography preoperatively. Because of the complex, 3-dimensional shape of the scaphoid, simple x-rays alone are inadequate, whereas computed tomography, parallel to the long axis of the scaphoid, allows excellent visualization of the fracture and any associated deformity, which must be corrected at the time of surgery.We describe here our method of treating acute scaphoid fractures, and we report the outcome of minimally invasive fixation.

Ulnar shortening osteotomy with a new sliding-hole plate.

Ulnar shortening osteotomy represents a common procedure for surgical treatment of the ulnar impaction syndrome but is still associated with complications like malrotation, angulation, or malunion because of incomplete closure of the osteotomy gap. Therefore, the authors developed a special 7-hole compression plate that allows fixation of the ulna before the osteotomy is carried out to prevent rotation. With this plate, a shortening of up to 10 mm is possible and the compression holes allow closure of the osteotomy gap. The plate has been used in 23 ulnar shortening cases at their center with good results. The authors describe the technique and report their results of ulnar shortening with this device.