[Hemitrapeziectomy of the carpometacarpal joint of the thumb]. / Hemiresektionsarthroplastik am Daumensattelgelenk.

BACKGROUND: Hemiresection arthoplasty or partial trapeziectomy of the carpometacarpal joint of the thumb is a surgical option in stages 1-3 according to Eaton-Littler classification. Preservation of the intact scaphotrapeziotrapezoidal (STT) joint and maintenance of the length of the thumb is the advantage of this technique. TECHNIQUE: Technically, partial trapeziectomy is only slightly more complex compared to trapeziectomy with or without suspension. An interposition of autologous or allogeneic material is recommended; suspension arthroplasty is also possible in almost all common variants. Despite these theoretical advantages, this technique has not proven advantageous in practice, neither in terms of function nor in terms of time, compared to other techniques. The great advantage of partial trapeziectomy, however, is the wide range of options for revision surgery in the case of persistent complaints. RESULTS: The risk of proximalization of the thumb due to an inadequate interposition is generally minor and is usually caused by implant sintering. This can easily be compensated for by implanting a larger graft. Persistent instabilities are the most common cause of persistence of symptoms and can usually be remedied by autologous or allogeneic suspension arthroplasty. In addition, the entire range of endoprosthetics is also possible with a previous spare resection of the trapezium and the possibility of a complete trapeziectomy remains in any case. The obvious theoretical advantages of arthroscopic hemitrapeziectomy need to be confirmed in practice in future.

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment.

BACKGROUND: We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma. METHODS: Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses. RESULTS: We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later. CONCLUSIONS: The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious. LEVEL OF EVIDENCE: III.

[Recurrence of septic arthritis of the wrist by Pseudomonas aeruginosa due to colonization of a central venous indwelling catheter]. / Rezidiv einer septischen Arthritis des Handgelenks durch Pseudomonas aeruginosa bei Besiedelung eines zentralvenösen Verweilkatheters.

A diabetic patient, wearer of a port and with a history of gonarthritis due to Pseudomonas aeruginosa presented with subacute arthritis of a wrist. After a protracted interval P. aeruginosa was detected by microbial culture from the explanted port and the affected joint. This case shows that in patients with unclear arthritis of the wrist, a history of septic arthritis with P. aeruginosa and risk factors for hematogenous spread, a recurrent infection should be excluded. The treatment consisted of explantation of the port, débridement with synovectomy of the joint and adequate antibiotic treatment.

[The scaphoid and rheumatoid arthritis : Classification by retrospective X­ray analysis]. / Das Skaphoid bei Rheuma : Klassifikation anhand einer retrospektiven Röntgenanalyse.

BACKGROUND: Early destruction of the wrist in rheumatoid arthritis is common and often progressive. Even in times of improved and standardized medical treatment this cannot always be prevented. OBJECTIVES: A limited range of motion, pain, reduced grip-force, and aesthetic deficits of the wrist can impair the daily life of patients. There is an additional risk for destruction of the surrounding soft tissue and adjoining joints of the upper extremity. RESULTS: Destruction of wrist in rheumatoid arthritis is multifactorial and is localized in many different structures of the wrist. In this context, scaphoid and periscaphoid structures are of interest. Data were gathered in a retrospective study of the wrist X­rays of patients with rheumatoid arthritis. The possible consequences for operative options are described.

[Scaphoid pseudarthrosis : Indications for avascular iliac crest or radius bone grafts]. / Skaphoidpseudarthrose : Indikationsbereiche für das avaskuläre Beckenkamm- oder Radiustransplantat.

BACKGROUND: Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques. OBJECTIVE: Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures? METHODS: Evaluation of current literature and expert opinions RESULTS: Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures. CONCLUSIONS: As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.

[Operative options for rectification after failed osteosynthesis of the distal radius]. / Operative Rückzugsmöglichkeiten nach fehlgeschlagener Osteosynthese des distalen Radius.

BACKGROUND: Even in an era of clear improvements in implants and standardized treatment procedures, abortive osteosynthesis after distal radius fractures is not an uncommon complication. DIAGNOSTICS: Although not every malunion of the radius leads to complaints, affected patients often suffer from limitations in movement, reduction in strength, pain and aesthetic deficits. Following thorough clinical and imaging diagnostics a selection from the possible treatment options must be made taking the results obtained from the diagnostics into consideration. THERAPY: Operative possibilities are available for reconstructing the anatomical features as accurately as possible, functional improvement without correction of the malunion, pain reduction alone and combined procedures. CONCLUSION: Despite abortive osteosynthesis of distal radial fractures there are possibilities for anatomical reconstruction, retention of mobility and pain reduction. Taking the pathological deformities into consideration, the highest priority should be given to reconstructing the anatomical joint conditions as accurately as possible, even when the conservative treatment options were unsuccessful.

[Fracture of the dorsal distal phalanx or the so-called bony extensor tendon avulsion]. / Die dorsale Endphalanxbasisfraktur oder der sog. "knöcherne Strecksehnenausriss"

Fractures of the distal phalanx are common. According to the histological results of Hoch et al., the term bony extensor tendon avulsion is not correct; instead, the description fracture of the dorsal distal phalanx should be used. Many therapeutic options for these fractures are described in the literature. Decision-making for operative treatment should not only be based on X-rays.Good functional results are mentioned in the literature after conservative treatment of larger bony fragments. The mid- and long-term results of remodelled joints that are mostly not in anatomically correct positions can only be determined in prospective studies. Indications for operative treatment are dorsal distal phalanx fractures with a distal finger joint subluxation or in cases of widely rotational malposition of the bony fragment. The osteosynthesis has to respect the extensor aponeurosis.

[Diagnosis of lunotriquetral instability]. / Diagnostik der lunotriquetralen Instabilität.

BACKGROUND: Lunotriquetral dissociation with rupture of the lunotriquetral ligament and the radiolunotriquetral and the radiodorsal ligament is usually recognized late. Cinematography, arthrography, magnetic resonance imaging and arthroscopy are the diagnostic procedures. Treatment includes nonoperative methods in the case of incomplete lesions but also closed reposition with temporary LT arthrodesis and open ligament repair. In many cases, definitive LT arthrodesis may become necessary. It is the aim to develop a diagnostic algorithm on the base of retrospective analysed data. MATERIAL AND METHODS: From January 1998 to July 2003, 97 cinematographies of the wrist were performed, 22 with the question for a dynamic or static VISI deformity as a sign for lunotriquetral instability. This group of patients was analysed retrospectively to evaluate the diagnostic reliability. Based on these datas, a diagnostical algorithm was established for prospective investigations. RESULTS: The combination of cinematography, arthrography and magnetic resonance imaging suspected lunotriquetral instability in ten cases so that an arthroscopy was arranged. This way LT-lesions were verified in nine cases. The mean interval between accident and first contact with our institution was five months. CONCLUSIONS: The management of lunotriquetral injuries is complicated by the long time from trauma to definitive diagnosis. A combination of refined clinical and apparative investigations can lead to a reliable diagnosis.

Scaphoid fracture and scaphoid pseudarthrosis.

Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixtion. The operative treatment of non-unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.

[Follow-up of scaphoid pseudarthroses and scaphoid fractures after Herbert screw implantation in the extremities--MRI (low-field MRI)]. / Verläufe von Skaphoidpseudarthrosen und Skaphoidfrakturen nach Herbert-Schrauben-Implantationen in der Extremitäten-MRT (Niederfeld-MRT).

From January 1993 to September 1996, 59 patients with a scaphoid nonunion (38 times mid/distal third, 21 times proximal third) and 21 patients with a scaphoid fracture (17 times mid/distal third, four proximal third) underwent surgery in our clinic. Fractures of the scaphoid were treated by Herbert screw fixation. The operative treatment of nonunions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. In all cases, an MRI of the carpus in a low-field MRI was carried out pre-operatively in addition to standard X-ray examination. Post-operatively, all patients were again controlled by MRI within defined intervals. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. It was possible to depict the entire scaphoid and to determine the signal intensities of the proximal and distal fragments after Herbert screw fixation due to reduced artefacts on T1-weighted images in all cases. 41 patients with scaphoid nonunion and five patients with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment compared to the distal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction.

[An algorithm for reconstruction of soft tissue defects of the distal lower leg, ankle and heel]. / Algorithmus zur Rekonstruktion von Weichteildefekten am distalen Unterschenkel, Sprunggelenk und Rückfuss.

AIM: The purpose of the study was to establish an algorithm for the reconstruction of soft tissue defects of the distal lower leg, ankle and heel. METHOD: 81 patients presenting with soft tissue defects in these regions underwent flap coverage. The average age was 44.1 years. Small defects (up to 4 x 4 cm) were covered by local flaps. The neurovascular sural flap was the predominant flap procedure for medium size defects (up to 10 x 15 cm). Free flaps were used for larger defects or in cases of stenosis or occlusion of the peroneal artery. Femoro-crural bypasses were performed in three cases to improve peripheral arterial perfusion. RESULTS: The reconstructive goals were achieved in 95% of the cases by performing reconstruction according to the established algorithm. Minor complications occurred in 29.6% of the cases. CONCLUSION: The results appear to be very good considering a patient population with complex and predominantly contaminated wounds. A preoperative angiography represents an important part of the algorithm for flap reconstruction to detect abnormal arterial vascular conditions and thus to plan vascular reconstruction prior to or simultaneously with free flap coverage. Additionally, a non-patency of the peroneal artery represents a contraindication for sural flaps.

[Using prostaglandin E1 in microvascular reconstruction of the upper extremity after acute trauma]. / Die Anwendung von Prostaglandin E1 bei mikrovaskulären Rekonstruktionen der oberen Extremität nach Akuttraumen.

The operative treatment of hand and upper extremity trauma with injury of main vessels becomes a daily standard work in trauma and microsurgical replantation centers. The techniques of vessel and soft tissue reconstruction are well known. The outcome of the replantation depends on various factors. Main influences are the intraoperative status of the vessel wall and the unobstructed flow in the vessel after the operation. Another factor for successful replantation is the homeostasis of the patient. It can be influenced by many drugs which are applied according to a replantation schema. Aim of this therapy is the correction of the rheologic properties of a patient. In a patient group of 25 treated with Prostaglandin E1 (Prostavasin) we observed better wound healing with a 80% rate of successful replantation and microvascular vessel reconstruction.

[Scaphoid fracture and scaphoid pseudarthrosis]. / Skaphoidfraktur und Skaphoidpseudarthrose.

Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixation. The operative treatment of non-unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.

[Free vascularized bone transplantation in the extremities]. / Freie, vaskularisierte Knochentransplantation im Bereich der Extremitäten.

There is a growing trend today which calls for reconstructing the loss of bigger bone parts in the area of extremities in a suitable manner. The microvascular bone transplantation for bridging bone defects is--admist other procedures--a distinct enrichment to preserve the extremities. This method of transplantation has the capability of surviving within a weakened transplant bed. Because of this capability one inevitably wants to know the criteria which determine the biological behaviour of the transplants. Furthermore, it is essential to known how this criteria can be best managed, considering the different indications and locations. The bone healing and bone hypertrophy of 81 patients who received vascularised bone transplantations have been examined with respect to different parameters. As the positive capacities of the vital transplants are almost exclusively dependent on the actual supply with blood, angiography have been undertaken during three months after surgery. 71 patients with a patent anastomosis after surgery have been evaluated. Differences in bone healing of the vascularised transplants have been observed in regard to the following parameter:--The tumor group showed a better rate of bone healing than those patients with trauma and congenital tibiapseudarthrosis.--The bone healing results of the group of younger patients were better than those of the group of older patients. Moreover the transplants without a history of infection were better compared with transplants with a history of infection. Clear differences of the fibula hypertrophy behaviour have been observed with respect to the following parameters: upper extremities < lower extremities, thigh < lower leg, longer transplants < shorter transplants, group of older patients (35-60 years) < group of younger patients (1-18 years), plates < screws.

[Surgical and conservative treatment distal phalangeal fractures]. / Operative und konservative Behandlung der Endphalanxfrakturen.

Fractures of the distal phalanx are common. Injuries often include the surrounding soft tissues especially the nail bed and nail plate. The therapy must be done under consideration of fracture type and soft tissues. The result depends on the type of the fracture and the surrounding structures. After operative and conservative therapy, radiologically unsatisfying results and longer rehabilitation times are common.

Treatment of femoral head necrosis with vascularized iliac crest transplants.

The development of microsurgical methods has allowed for the use of vascularized bone transplants in the treatment of femoral head necrosis, particularly for Stages II, III, and IV according to the Association Internationale de Recherche sur la Circulation Osseuse classification system. Eighty patients with avascular necrosis of the femoral head were treated with vascular pedicled iliac crest transplant, perfused by the circumflexed ilium profunda artery between 1988 and 1996. On average, the postoperative followup was 5 years. Evaluation was based on the Harris hip score, and clinical and radiologic examination. Clinical results according to the Harris hip score were good or excellent in 86.6% of the patients. Radiologic appearance during the followup remained stable in 56.1% of the patients according to the classification system of the Association Internationale de Recherche sur la Circulation Osseuse. These findings are compatible with the findings of other studies in which vascularized bone transplants were used and approximately 50% of the patients with Stages II, III, and IV, according to the classification of the Association Internationale de Recherche sur la Circulation Osseuse had an unchanged stage of disease 5 to 6 years after the procedure.