[Revision surgery after carpal tunnel release using a posterior interosseous artery island flap]. / Revisionschirurgie des karpaltunnelsyndroms - ergebnisse der behandlung mit der dorsalen vorderarmlappenplastik.

PURPOSE: The aim of this study is to evaluate the results of fasciocutaneous posterior interosseous artery island flaps in the treatment of recurrent or persistent carpal tunnel compression syndrome (CTS). PATIENTS AND METHODS: From 1997 to 2006, 14 patients (8 women, 6 men, ages ranging from 26 to 77 years with a mean age of 55.7 years) have been operated for recurrent or persistent CTS, or for a neuropathic pain syndrome. All patients were treated with a posterior interosseous island flap following neurolysis of the scarred median nerve. The patients were evaluated pre- and postoperatively using a pain visual analogue scale and the DASH score. Sensibility, motor dysfunction, pain and success of the treatment were classified as good, better or bad. RESULTS: Mean follow-up of the patients was 23.8 months (1.7 to 93.5 months). The pain evaluation showed a statistically significant improvement (p < 0.005) decreasing from a mean value of 6.7 to 1.5. The DASH score was also statistically significantly improved postoperatively (p < 0.005). The best results were observed in patients without extensive preliminary median nerve damage. The duration of symptoms before re-operation did not influence the outcome. Seven patients demonstrated good, five improved and two patients maintained poor results. The two patients with poor results suffered from extremely scarred and injured median nerves following previous carpal tunnel surgery. CONCLUSION: Protective coverage of the median nerve by use of a fasciocutaneous island flap after failure of carpal tunnel release provides a good gliding tissue cover and reduces the risk of adhesions between the nerve and the surrounding tissues after previous surgery. While this protection of the nerve can reduce painful symptoms it does not guarantee total pain relief in all patients. Pain relief and functional recovery strongly depend on the preexisting condition of the median nerve.

Optogenetically stimulating intact rat corticospinal tract post-stroke restores motor control through regionalized functional circuit formation.

Current neuromodulatory strategies to enhance motor recovery after stroke often target large brain areas non-specifically and without sufficient understanding of their interaction with internal repair mechanisms. Here we developed a novel therapeutic approach by specifically activating corticospinal circuitry using optogenetics after large strokes in rats. Similar to a neuronal growth-promoting immunotherapy, optogenetic stimulation together with intense, scheduled rehabilitation leads to the restoration of lost movement patterns rather than induced compensatory actions, as revealed by a computer vision-based automatic behavior analysis. Optogenetically activated corticospinal neurons promote axonal sprouting from the intact to the denervated cervical hemi-cord. Conversely, optogenetically silencing subsets of corticospinal neurons in recovered animals, results in mistargeting of the restored grasping function, thus identifying the reestablishment of specific and anatomically localized cortical microcircuits. These results provide a conceptual framework to improve established clinical techniques such as transcranial magnetic or transcranial direct current stimulation in stroke patients.

Tibial nerve mistakenly used as a tendon graft. Reports of three cases.

We describe three patients in whom the tibial nerve was used, in mistake for the plantaris tendon, to repair a ruptured calcaneal tendon. The tendon repair was successful in all cases, but despite attempted reconstruction of the nerve, no patient had any motor recovery although two regained some protective sensation.

Long-term results of radioscapholunate fusion following fractures of the distal radius.

Fifteen patients with radioscapholunate (RSL) fusion for traumatic lesions of the radiocarpal junction, whose short-term results have been previously reported, were reassessed after an average follow-up time of 8 years. Five patients had undergone wrist fusion because of non-union or early progressive arthritis. Of the ten wrists with retained mobility, eight continued to function satisfactorily. Two wrists were painful for reasons other than secondary midcarpal arthritis. Patient satisfaction was comparable in both groups with the wrist score better for wrists with residual motion. The survival of RSL partial wrist fusion corresponded inversely with the number of preceding operations and the range of motion before partial fusion. Secondary midcarpal arthritis, if present, arose early and was well tolerated. Failures were strongly linked to technical mistakes and complications.

Kienböck's disease, early stage 3--height reconstruction and core revascularization of the lunate.

Early stage 3 Kienböck's disease has been treated by inner débridement, recontouring, height reconstruction, bone grafting and core revascularization of the lunate; additional procedures included temporary external fixation of the wrist and/or shortening osteotomy of the radius in selected cases. 26 patients, representing an uninterrupted series of 28 procedures, were followed-up for an average of 6.7 years (range 2.5-9.3 years) with periodic clinical and radiographic evaluations until they reached the final comprehensive assessment that included trispiral tomography and MRI. Every patient was subjectively improved, pleased with the result and able to resume his previous job. Pain intensity, rated on a zero to five scale, improved from 2.5 points pre-operatively to a final score of 0.8 points. Wrist motion gained slightly. Grip strength improved significantly. Lunate reconstruction proved successful in 37% of the cases; in an additional 23%, the disease process was stabilized. Carpal height decreased 4.7%; ulnar translation was not substantially altered. Arthrosis increased postoperatively in 55%, remained unchanged in 36% and progressed in 9%. Overall, 43% good and excellent, 43% fair and 14% poor results were observed.

The dorsal middle phalangeal finger flap. Mid-term results of 43 cases.

The dorsal middle phalangeal finger (DMF) flap is a (neuro)vascular island flap based on one palmar proper digital artery, its venae comitantes (and/or a separate dorsal vein) and the dorsal branch(es) of the palmar digital nerve. The main nerve supply of the donor finger is left undisturbed. The flap may be raised on a short antegrade, long antegrade or a retrograde pedicle, and used as a free, arterial and/or venous flow-through or neurovascular flap. In a prospective study (mean follow-up of 50 months), the results of 43 DMF flaps were analysed. All flaps survived, retained patency of their vascular pedicles and fulfilled their goals. Neurovascular flaps provided sensate coverage at the S3+ level with static 2-point discrimination values of about 10 mm. Dissection between the proper digital nerve and the rest of the neurovascular bundle induced a 5% incidence of cold intolerance and a 12% occurrence of S3+ hypaesthesia. Advantages, drawbacks and indications of DMF flaps are outlined.

Corrective osteotomy for post-traumatic malunion of the phalanges in the hand.

Rotation, angulation, deviation, shortening or a combination of deformities can occur due to phalangeal malunion and can lead to impairment of hand function. A historical cohort study of 57 patients who had phalangeal corrective osteotomies for posttraumatic malunion between 1978 and 1990 was undertaken. 59 rotational, radial/ulnar deviation, flexion/extension, length adjustment procedures, and combinations thereof were performed, using rigid internal fixation. Concurrent tenocapsulolysis was done in 50% of the cases. Satisfactory correction was obtained in 76% of the patients. Bony union was obtained in all cases. A net gain in active range of motion was achieved in 89% of the patients. Excellent and good results were obtained in 96% of the patients who had corrective osteotomies for malunion involving only the bone and in 64% of the patients who had corrections for malunion with involvement of multiple structures (P < 0.01).

Chronic post-traumatic radial instability of the metacarpophalangeal joint of the finger. Long-term results of ligament reconstruction.

Chronic painful post-traumatic instability of the radial collateral ligament complex of the metacarpophalangeal joint of a finger was treated by tendon graft reconstruction in 24 patients. Seventeen patients (20 joints) were available for a retrospective study at a mean follow-up time of 105 months. Eighty percent of the joints showed excellent or good results, with relief of pain, return of adequate stability, a near normal range of motion and absence of degenerative changes.

Rigid internal fixation of basilar fractures of the proximal phalanges by cancellous bone grafting only.

Ten patients with 13 basilar metaphyseal impaction fractures of the proximal phalanges of the fingers were treated with "rigid internal fixation" by bone grafting alone. When retrospectively reviewed at a mean follow-up of 32 months, bone healing had occurred without any relevant secondary displacement of the fracture fragments. The final ranges of motion were good and return to work was quicker than expected.

Vascular leiomyoma in an index finger undergoing malignant transformation.

We report a case of vascular leiomyoma of the pulp of the index finger that recurred twice and underwent malignant change. Ray resection proved to be curative. An extensive literature review is given.

[Arthrogryposis multiplex congenita of the upper extremity]. / Arthrogryposis multiplex congenita im Bereiche der oberen Extremität.

This article is a comprehensive review on arthrogryposis multiplex congenita of the upper extremity. The introduction contains information on definition, etiology, pathogenesis, differential diagnosis and manifestations outside the upper extremity. The main section focuses on the upper limb and expands on epidemiology, patterns of deformity, their natural evolution, on related functional problems, and general principles of treatment. Finally, the various regional deformities are presented and guidelines are given for conservative or operative treatment.

[Mini condylar plate osteosyntheses of the hand]. / Kondylenplättchen-Osteosynthesen der Hand.

The mini condylar plate fixation system is a new method for stable internal metaphyseal bone fixation about the MP and PIP joint areas of the hand. Indications for its use are rigid stabilization of fractures, osteotomies, and bony components of composite tissue transfers. The device should be used in deference to other techniques when early active range of motion is pursued. Its best use is in the face of combined injuries, or osteotomies with tenolysis/capsulotomy. The advantages of this implant's design permit stabilization of small epiphyseal fragments with minimal interference of joint function and perhaps a reduction of irritation of the extensor aponeurosis. Disadvantages include the need for careful preoperative planning because of this implant's small size and unforgiving tolerances of application. The data is included for the first 87 consecutive cases of its use. Despite the institution of range of motion therapy within five days in 77% of the cases, there were no nonunions. Two cases of delayed union were successfully treated by addition of cancellous bone grafts without revision of the fixation devices. Problems included malalignments (three cases), infection (two cases), and soft tissue coverage (four cases). Aseptic necrosis of bone is associated with metacarpal head fractures and is seen with the use of this implant in treating such intraarticular fractures. The final digital performance was analysed but has not been presented because of the multiplicity of the associated joint, tendon, vascular, nerve, and skin involvement.

[Is panarthrodesis the gold standard in wrist joint surgery?]. / Ist die Panarthrodese der Goldstandard der Handgelenkchirurgie?

In order to determine the value of panarthrodesis, 109 cases have been reviewed. Relevant complications occurred in 36%, whereof 20 were serious entailing reoperations. The procedure was most rewarding in patients with inflammatory arthritis which were mostly painfree and regained full strength, whereas in cases following trauma and avascular necrosis of the lunate, only 56% were painfree, and only 6% achieved contralateral strength. In comparison with 52 cases which had undergone procedures preserving wrist motion, the results were not different with regard to pain relief and strength, whereas in the patients treated accordingly, a functional amount of wrist motion could be preserved.

[Acute vascular disorder as a complication of replantation and revascularization of the digital area]. / Akute Durchblutungsstörungen als Komplikationen von Replantationen und Revaskularisationen im Digitalbereich.

This study on vascular complications in digital replantation and revascularization covers the six-year experience of a universitary replantation center. The material comprises 143 patients with 67 replantations and 137 revascularizations. Inadequate circulation was observed in 21.6% of the cases, or 17.6% of the digits. In digital replants, during or following the initial surgery, significant vascular complications were encountered in 28 (42%) of the replanted thumbs and fingers. Of these, seven digits (10.4%) presented with irreparable vascular damage and were amputated without salvage attempts. Single or repeated microvascular revisions saved 13 (two thirds) of the remaining digits. The survival rate of this group was thus raised to 78%. In digital revascularization, the vascular complication rate was much lower. In 137 digits, eight developed complications (6%). One of these was accepted as a failure; of seven reinterventions, five proved successful. The over-all survival rate was 98% in this group. To the factors known to determine survival following replantation and revascularization, those governing the ability to offset vascular complications must be added. In this respect, the analysis of our data revealed additional statistically significant prognostic elements: the decision for or against surgical reintervention, the location of the thrombosis relative to the arterial or venous side, the type of injury and the timing of revisional surgery. Other parameters, such as the age of the patient, the experience of the surgeon, or the type of initial vascular reconstruction were not statistically relevant. In our experience, repeated attempts at microvascular salvage in face of circulatory complications of digital replantations or revascularizations are worthwhile.

[Snapping palmar drawer phenomenon of the wrist: a physiologic or pathologic study finding?]. / Das schnappende palmare Schubladenphänomen des Handgelenkes: Ein physiologischer oder pathologischer Untersuchungsbefund?

In the examination of a wrist, when this is held in neutral position and moderate ulnar deviation, a substantial palmar drawer translation combined with a snap can be elicited. The sign is most evident in about 15 degrees of ulnar deviation, while it is negative in the neutral position, in radial deviation or in maximal ulnar deviation. The translation and the snap have been consistently demonstrated in normal wrists and are therefore considered physiologic. The knowledge of this impressive phenomenon seems important for differential diagnosis when assessing the stability of a wrist; its clinical and cineradiographic picture are described.

[Microsurgical and histological observations in schwannoma of peripheral nerves]. / Mikrochirurgische und histologische Beobachtungen bei Schwannomen peripherer Nerven.

From 1986 to 1991, eight patients with benign schwannomas (neurilemomas) of peripheral nerves underwent tumor resection. In six of eight cases, microsurgical dissection revealed one or several nerve fascicles "disappearing" in the center of the schwannoma. Therefore, these fascicles had to be removed along with the tumor. This observation contradicts the current opinion that enucleation of benign schwannomas is usually straightforward and possible without fascicular damage. Interestingly, the resection of fascicles did not create additional neurological deficits. For functional reasons, partial nerve grafts bridging the resulting fascicular defects were considered appropriate in two cases. Tumors of peripheral nerves should be treated by surgeons familiar with microsurgical operative techniques.

[How reliable is the posterior interosseous artery island flap? A review of 88 patients]. / Wie zuverlässig ist die distal gestielte A. interossea posterior-Lappenplastik? Eine retrospektive Analyse von 88 Patienten*

The distally-based, reverse posterior interosseous flap can be used to reconstruct soft-tissue defects in the region of the hand, provided there is an intact anastomotic network of the posterior and anterior interosseous system at the wrist. Between 1986 and 2000, 88 flap procedures were planned. Anatomical variations were recorded in 21 patients (24 %), in five of which the flap could not be harvested. In the remaining 16 patients, flap dissection was more difficult due to anatomical variations. There was a complication rate of 23 %, including haematoma, congestion, infection or technical errors, which resulted in flap necrosis of variable degrees in 11 patients (13 %). In case of haematoma, flap loss could be reduced by early revision surgery. There was no statistical correlation between anatomical variations and complications or flap loss. Secondary flap corrections, including defatting and remodelling, were commonly performed in due course. Knowing the limitations of the posterior interosseous flap, fasciocutaneous flaps are considered ideal to reconstruct soft-tissue defects or contractures of the thumb web and the dorsal hand because of good tissue matching. Fascial flaps are a good option for palmar defects or to wrap around neurolyzed nerves.

The dorsal middle phalangeal finger flap.

A versatile one-stage neurovascular flap from the dorsum of the middle phalanx of the finger is described. The flap is based on one proper digital artery, the venous network about its adventitia and the dorsal branches of the proper palmar digital nerves bilaterally. The characteristics of the flap include a size up to 3 by 6 cm, an arterio-venous pedicle up to 12 cm in length, an arc of rotation around the superficial palmar arch, discriminative sensibility, and comparably low donor morbidity. The flap may be transposed on its vascular pedicle with or without nerve suture. Furthermore it is ideally suited as a thin and pliable flow-through flap in digital replantation/revascularization. Finally, it may be utilized as a free neurovascular flap.

[Comments on vascular pedicled nerve transplantation in the area of the upper extremity]. / Anmerkungen zur vaskulär gestielten Nerventransplantation im Bereiche der oberen Extremität.

This article describes the vascular anatomy of several nerves of the upper extremity with a view of their potential use as pedicled, vascularized nerve grafts.

[Ring avulsion injuries: improved indications for replantation]. / Ringavulsionsverletzungen: Verfeinerte Indikationsstellung zur Replantation.

Based on experiences with 12 replantations of ring avulsion injuries, an additional classification of type III avulsions (Urbaniak, 1981) is proposed, according to the level of injury of the neurovascular bundles. If this lies proximally (III P), microsurgical reconstruction is usually straightforward and the prognosis generally good; in distal lesions (III D), however, uncorrectable segmental devascularization can occur, which may be detrimental to survival or ultimate function.