Risk factors for reoperation in primary hand infections: a multivariate analysis.

INTRODUCTION: Severe hand infection might cause severe morbidity including stiffness, contracture and possibly amputation. The purpose of this study was to analyse the current epidemiology of adult acute hand infections in a European Hand Surgery Centre and to identify risk factors for secondary surgery. MATERIALS AND METHODS: We retrospectively analyzed a cohort of 369 consecutive patients with primary infection of the hand that were admitted to our department and required operative treatment. The following variables were recorded: demographics, medical history, cause and location of infection, laboratory values, cultured microorganisms and reoperation rate. Univariate logistical regression was used to identify variables associated with reoperation and backward selection was applied to identify the final multiple variable model. RESULTS: The mean age at the time of operation was 50.5 years (SD 16.1, range 19-91) and 65.6% of patients were male. Sharp cuts or lacerations were the most common cause (29.0%) for hand infections. 81 different species were cultivated and in 47 patients (12.7%), the cultures were positive for more than one organism. Staphylococcus aureus was the most common cultured organism (19.5%). There were relatively few cases of methicillin-resistant Staphylococcus aureus (2.2%). 80 patients (21.7%) needed more than one operation. We identified three risk factors for reoperation in a multivariate analysis: an elevated value of C-reactive protein at the time of admission, involvement of multiple sites and bacterial growth in culture. CONCLUSION: The rate of infections with MRSA in this European cohort was lower compared to reports from the USA. Thus, hand surgeons should choose their empiric antibiotic therapy depending on their patient population. The knowledge of risk factors for severe hand infections might help surgeons to identify patients at risk for additional surgery early.

Ulnar shortening osteotomy as a treatment of symptomatic ulnar impaction syndrome after malunited distal radius fractures.

A malunited distal radius fracture can lead to symptomatic ulnar impaction syndrome, which is a common cause for ulnar-sided wrist pain. If conservative treatment fails and symptoms persist after an arthroscopic ulnocarpal debridement, ulnar shortening osteotomy (USO) is the treatment of choice. Since the first USO described by Milch in 1941 after a malunited Colles fracture, many techniques have been described varying in surgical approach, type of osteotomy and osteosynthesis material used. Many studies demonstrated good to very good functional results after USO, reporting, however, a delayed union or non-union rate up to 18%. A modern, low profile, locking plate showed in our short-term study very good functional results and no implant-associated complications, in particular no non-union.

Practicability of a locking plate for difficult pathologies of the scaphoid.

INTRODUCTION: Headless compressions screws are the most implanted devices for scaphoid fractures and nonunions. For cases when screw osteosynthesis is not possible, a special locking plate for scaphoid reconstruction has been developed. The purpose of this study was to evaluate the safety and practicability of this device for difficult scaphoid pathologies. MATERIALS AND METHODS: Between March 2010 and December 2014, 20 patients (age range 16-59 years) were treated with scaphoid locking plate osteosynthesis. In 17 cases it was due to scaphoid nonunion or delayed union and in three cases to treat a complex multi-fragmentary fracture of the scaphoid. Most of the initial fractures were located either in the proximal third (n = 9) or the middle third (n = 8) of the scaphoid. RESULTS: Mean follow-up was 14.6 ± 8.9 months (range 2-30 months). All three scaphoid fractures (100%) showed bony healing in the CT scan after 2.7 ± 0.6 months. 15 of 17 (88.2%) patients with scaphoid nonunion demonstrated bony healing in the latest CT scan at an average of 6.2 ± 8.1 months (range 2-11 months) after scaphoid reconstruction. Range of motion (extension/flexion) was 104° ± 18.4° (range 80°-150°) and about one third less than the unaffected side. The average grip strength averaged 38.2 kg on the operated side and 44.1 kg on the unaffected side after surgery. 13 plates (65%) had to be removed due to impaction of the plate or protrusion of the screws. CONCLUSIONS: This new locking device for scaphoid reconstruction seems to be a safe, useful and reliable tool in the treatment of difficult nonunions or multi-fragmentary scaphoid fractures. The practicability is convincing and satisfying fusion rates can be accomplished. However, most patients require hardware removal. We recommend using this plate as a rescue option when a stable osteosynthesis is necessary for the healing process and screw fixation has already failed or is not possible.

[Diagnostics and treatment of acute scaphoid fractures]. / Diagnostik und Therapie frischer Skaphoidfrakturen.

BACKGROUND: Fractures of the scaphoid bone are common but can easily be overlooked in standard X­rays. Inadequate diagnostics and therefore inappropriate treatment of scaphoid fractures often leads to problems in healing with formation of non-union and painful osteoarthritis of the wrist. OBJECTIVE: This review summarizes the current practical recommendations in the diagnostics and treatment of acute scaphoid fractures. METHODS: An analysis and review of selected literature including the current S3 guidelines were performed. RESULTS: The main statements are that in cases of a clinically suspected scaphoid fracture, staged diagnostics including radiographs, computed tomography (CT) and when necessary magnetic resonance imaging (MRI) should be applied to confirm or exclude a fracture. Further treatment in the case of a fracture is planned according to a CT-based classification. There are fracture types that can be treated either conservatively or operatively and there are other fracture types that always require operative fixation. The operative technique depends on the exact fracture geometry. For osteosynthesis, cannulated headless compression screws are mostly used.

Results after arthroscopic treatment of central traumatic lesions of the triangular fibrocartilage complex.

INTRODUCTION: Injuries of the triangular fibrocartilage complex (TFCC) are of high clinical relevance; however, the clinical evidence for treatment is poor and long-term results are rarely published. The purpose of this study was to evaluate the clinical outcome of symptomatic central traumatic lesions of the TFCC (Palmer 1A) following arthroscopic debridement. MATERIALS AND METHODS: Between 2007 and 2013, 87 patients were arthroscopically diagnosed with Palmer 1A lesion and accordingly treated with debridement. Follow-up was available for 43 patients. Activities of daily living (ADLs) were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Pain perception was evaluated with visual analogue scale (VAS 0-10). Grip strength and wrist motion were assessed with conventional techniques using a Jamar dynamometer and a goniometer. Patient satisfaction was assessed using a questionnaire at follow-up. RESULTS: Mean follow-up was 42.5 months (range 5-70). The mean age of the patients (22 male and 21 female) at time of surgery was 41 ± 15.9 years. No major complication occurred during surgery and follow-up. The DASH score (preoperatively 49.8 ± 19.3 vs. postoperatively 14.1 ± 17.9, p < 0.05) and pain perception (VAS: preoperatively 7.2 ± 2.0 vs. postoperatively 1.4 ± 1.6, p < 0.05) improved significantly. Grip strength was satisfactory after surgery (19.6 ± 13.1). Ulnar deviation improved significantly from 29.3 ± 10.4° to 35.6 ± 8.3° (p < 0.05) and wrist flexion improved from 53.8 ± 18.9° to 67.4 ± 12.9° (p < 0.05). Wrist extension, radial deviation, pronation and supination did not change significantly after surgery. Improved symptoms were reported by 41/43 (95.3%) patients and 40/43 (93%) patients would have had the same procedure again knowing the final outcome. Six of 43 patients (15%) had an ulnar plus variance. None of these needed ulnar shortening. CONCLUSIONS: Central traumatic TFCC lesions can safely be treated by arthroscopic debridement. We showed a sustained pain relief with significantly improved quality of life (DASH score) and wrist motion at follow-up. This resulted in a high patient satisfaction and acceptance of the procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, level IV.

[Endoprostheses of the distal radioulnar joint]. / Endoprothetik am distalen Radioulnargelenk.

BACKGROUND: A stable distal radioulnar joint (DRUJ) is mandatory for the rotation and load transmission in the forearm and wrist. Salvage procedures such as the Darrach operation, Bowers arthroplasty, and the Kapandji-Sauvé procedure include the potential risk of dynamic radioulnar instability and impingement, despite stabilizing techniques addressing the soft tissues. PROSTHESES: In an attempt to stabilize the distal forearm mechanically following ulnar head resection, various endoprostheses have been developed to replace the ulnar head. These prostheses can be used for secondary treatment of persistent complaints and unsatisfactory results after ulnar head resection, but also in the primary treatment of osteoarthritis of the DRUJ. Based on promising results concerning improvement in pain, range of motion, and grip strength, with proper indications ulnar head prostheses should be considered as a valuable treatment option for osteoarthritis of the DRUJ.

[Primary intervention in Dupuytren's disease]. / Primäreingriff beim Morbus Dupuytren.

Partial aponeurectomy as the state-of-the-art treatment in Dupuytren's disease is indicated when minimally invasive forms of treatment, such as needle aponeurotomy or percutaneous collagenase injection, are not possible due to the advanced stage of the disease or the morphology of the contracture. Even in earlier stages of Dupuytren disease partial aponeurectomy has advantages in comparison to minimally invasive forms of treatment. These advantages are lower recurrence rates as well as less persistent residual contractures, especially in the proximal interphalangeal joint.

[(Partial) fusion of the wrist : Indications and surgical procedures]. / (Teil­)Arthrodesen am Handgelenk : Indikationen und chirurgische Therapien.

Carpal bone fusions for secondary reconstruction are still indispensable despite state of the art diagnostic tools and modern treatment techniques for wrist lesions. The former fusions stabilize the wrist and enable sufficient residual carpal mobility. Pain can be reduced significantly by arthrodesis of destroyed joints and the progress of osteoarthritis may be stopped or delayed. This review presents commonly used fusions with their inherent indications, contraindications and complications.

[Fractures of the thumb ray]. / Frakturen des Daumenstrahls.

Fractures of the first thumb ray are common and need accurate differential treatment to restore gripping hand functions. Displaced fractures of the distal and proximal phalanx of the thumb are often treated with screws or Kirschner wires. Stable fractures can also be treated non-operatively. Fractures of the base of the first metacarpal should be differentiated into extra-articular Winterstein fractures and intra-articular Bennett or Rolando fractures. Traction forces by the abductor pollicis longus tendon regularly lead to displacement of the shaft of the first metacarpal; therefore, these fractures usually require reduction and fixation. Good functional results can be achieved by operative treatment. Fractures of the trapezium are rare. If they are displaced, operative treatment is recommended to prevent osteoarthritis of the first carpometacarpal joint.

A review of thrombosis and antithrombotic therapy in microvascular surgery.

Despite a remarkable expansion of microsurgery, there is still no international consensus about routinely used prophylactic antithrombotic agents. Most treatment regimens still use aspirin, heparin (low-molecular-weight and unfractionated heparin) or colloids (hydroxyphenylacetate 6%/dextran); however, clear evidence for the clinical benefit of an ideal administration regimen or one agent over the other has not yet been established. Instead of searching for the one regime that fits all, an increasing number of reviews from different disciplines describe multistep approaches that optimize what has been shown to be most promising. This includes the use of antithrombotic agents, proper risk assessment, secondary prevention and professional training to optimize microsurgical skills. In this review, we describe factors included in traditional approaches and also emphasize the value of good surgical technique, which while recognized by all to be one of the most important factors for success, receives less emphasis in reviews describing thrombosis prophylaxis in microvascular surgery.

[Treatment of distal radioulnar joint osteoarthritis]. / Die Behandlung der Arthrose des distalen Radioulnargelenks.

The distal radioulnar joint (DRUJ) plays a key role in stable forearm rotation. The main stabilizer of the DRUJ is the triangular fibrocartilaginous complex (TFCC). If the integrity of the DRUJ is disturbed, commonly after distal radius fractures, osteoarthritis may develop. For the surgical treatment of osteoarthritis, different techniques are available and in most cases salvage procedures (Darrach, Bowers and Sauvé-Kapandji operations) are performed which generally promise reasonable results but include the potential risk of radioulnar instability which can lead to pain and weakness. Soft tissue stabilizing techniques have only limited success rates. In an attempt to mechanically stabilize the distal forearm following ulnar head resection various endoprostheses have been developed to replace the ulnar head. The prostheses can be used for the secondary treatment of failed ulnar head resection but can also achieve good results in the primary treatment of osteoarthritis of the DRUJ.

The significance of conventional radiographic parameters in the diagnosis of scapholunate ligament lesions.

OBJECTIVE: Although in widespread clinical use, evidence of the diagnostic accuracy of radiographic parameters for the diagnosis of scapholunate ligament injuries is scarce. The objective of this study was to evaluate the scapholunate (SL) angle, radiolunate (RL) angle and SL gap as diagnostic parameters for these lesions. METHODS: Eight hundred forty nine patients, who underwent wrist arthroscopy at our institution because of wrist pain were included in a retrospective analysis. In all patients the SL angle, RL angle and SL gap were measured on preoperative radiographs. These parameters were correlated with the actual finding of the SL ligament during arthroscopy. Optimal test thresholds were calculated as well as sensitivity, specificity and the likelihood ratios of each parameter. RESULTS: All three parameters proved useful in statistical analysis. The optimal cut-off points for diagnosing lesions of the SL ligament were calculated as 62.5° for the SL angle, 12.5° for the RL angle and 2.5 mm for the SL gap. SL angles had the greatest specificity (0.93). CONCLUSIONS: We were able to validate plain radiographs as a reliable tool in the work-up of patients with suspected SL ligament injuries. However, wrist arthroscopy remains the gold standard in diagnosing and treating these lesions.

[Applications of free lateral arm flap for hand and forearm defect reconstruction]. / Einsatzmöglichkeiten des freien lateralen Oberarmlappens zur Defektdeckung an Hand und Unterarm.

BACKGROUND: The purpose of this retrospective study was to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand. PATIENTS AND METHODS: The data of 21 patients who underwent defect coverage of the forearm and hand with the free lateral arm flap between 2002 and 2010 were analyzed. The mean patient age was 48 years (range 17-78 years). The results concerning defect origin, flap size, pedicle length, operative time, revision of the anastomosis or other complications, donor site morbidity and length of hospital stay were evaluated. RESULTS: In 6 cases the defect was on the forearm and in 15 on the hand. The majority of defects were infections or chronic wounds. The overage flap width ranged from 3 to 8 cm and the length from 5 to 20 cm. Revision of the anastomosis was only necessary in one case and flap survival rate was 100%. In all patients primary closure of the donor site was possible without complications during the healing procedure. CONCLUSION: The results underline the good reliability of the free lateral arm flap with a satisfactory aesthetic appearance excellent tissue quality and frequent primary donor site closure.

[Chronic osteitis of the lower extremities. An interdisciplinary treatment concept]. / Chronische Osteitis der unteren Extremität. Interdisziplinäre Behandlungskonzepte.

INTRODUCTION: The purpose of this investigation was the retrospective analysis of patients with delayed infections, chronic posttraumatic osteitis of the lower extremities and free-flap coverage after radical debridement of bone and soft tissue. METHODS: From the time period 1994-2003 a total of 22 patients including 4 females and 18 males were investigated. In 16 patients treatment was carried out on the lower leg and in 6 patients the foot was treated with subsequent free-flap coverage. In 14 cases the latissimus dorsi muscle was used, in 5 cases the gracilis muscle, in 2 cases parascapula flaps were used and in 1 case the serratus anterior muscle. The average age of the patients was 43 years (range 17-63 years) and grouping was according to the HOST classification. Functional outcome was evaluated by a standardized questionnaire (Funktionsfragebogen Hannover FFbH-OA 2,0), quality of life and social reintegration by non-standardized questionnaires. RESULTS: In the cases investigated the following results could be achieved: full leg activity 55%, leg pain while walking 73%, special footwear 68%, normal gait 55%, positive quality of life and social reintegration 55%, port activities 36% and reemployment 45%. CONCLUSION: According to the results of this study the quality of life of patients with chronic osteitis of the lower leg is in general satisfying. In order to improve quality management and cost reduction in public health an interdisciplinary treatment concept of plastic and orthopedic surgeons should be established for complex fracture management as this is the most effective tool in treating chronic osteitis.

[Operative versus conservative treatment of non-displaced fractures of the scaphoid bone. Results of a controlled multicenter cohort study]. / Operative vs. konservative Therapie nichtdislozierter Skaphoidfrakturen. Ergebnisse einer kontrollierten multizentrischen Kohortenstudie.

PURPOSE: Within a prospective, multicenter cohort study we investigated whether operative treatment of scaphoid bone fractures leads to earlier return to previous activity levels. METHODS: Only isolated, acute, complete, stable and non-displaced fractures of the mid-third of the scaphoid bone were included. A total of 94 patients with the same number of fractures were recruited. In the operative group, fractures were fixed with a cannulated screw and had postoperative splint immobilization for a maximum of 1 week. In the conservative group a short arm cast was applied until fracture union was achieved. Both groups were followed for 6 months. RESULTS: By 15 weeks patients receiving surgical treatment had returned significantly earlier to their full time work and home activities and achieved significantly better results for functional status, pain, and overall satisfaction. However, after screw fixation, complication rates concerning union and secondary operative management were higher. CONCLUSION: Operative treatment primarily facilitates earlier return to previous activity levels, as well as better functional status, less pain and higher patient satisfaction, but conservative treatment seems to be safer and associated with a lower complication rate.

Long-term results and the Disabilities of the Arm, Shoulder, and Hand score analysis after modified Brooks and D'Aubigne tendon transfer for radial nerve palsy.

PURPOSE: Radial nerve damage results in substantial functional limitations of the upper extremity. No detailed data exist regarding long-term results, patient satisfaction, and professional and social reintegration after tendon transfer for irreparable damage to the radial nerve. In this retrospective study, we investigated these data through the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. METHODS: Between 1995 and 2006, 77 patients underwent a modified Brooks and d'Aubigne surgical technique for radial nerve palsy in our department. In 19 cases, the flexor carpi radialis muscle was used as a donor instead of the flexor carpi ulnaris muscle. The mean follow-up period was 60 months (range, 24-150 months); motion of the wrist and finger joints and pinch-grip power were compared with the healthy side. We assessed the limitation in pursuing daily activities using the DASH score. RESULTS: Wrist extension averaged 73% of the contralateral side, whereas the value for movement of digital extension was 32% and for thumb abduction in the palmar direction it was 80%. The power grip was reduced to 49% and the pinch grip was reduced to 28%. The mean DASH score was 15 +/- 9, the symptom score mean was 15 +/- 7, and the working score mean was 12 +/- 10. The mean total DASH score was 16 +/- 10. The proportion of patients who remained employed after surgical treatment was 89%. CONCLUSIONS: Functional results, adequate patient satisfaction, and sufficient professional and social reintegration can be achieved after modified Brooks and d'Aubigne tendon transfer. Accordingly, the tendon transfer offers an important alternative-possibly the procedure of choice-to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important.

[New bone-ligament-bone transplant from plantar plates of the toes and possible use in reconstruction of the scapholunate ligament. An anatomical study]. / Neues Knochen-Band-Knochen-Transplantat aus plantaren Platten der Fusszehen und die mögliche Anwendung in der SL-Band-Rekonstruktion. Eine anatomische Studie.

BACKGROUND: Various treatment options have been proposed for reconstruction of the scapholunate ligament. However, none of these methods prevent patients with scapholunate instability from developing wrist arthritis. This study was performed to investigate a new bone-ligament-bone autograft from the plantar plate of the toes for suitable reconstruction of the scapholunate interosseus ligament. The anatomical properties and the technical feasibility were investigated. METHODS: The plantar plates of the metatarso-phalangeal joints and the proximal interphalangeal joints of the 2nd-5th toes were examined in 20 cadaver feet and measurements such as length, thickness and width were recorded. RESULTS: The average lengths of the plantar ligaments of the proximal interphalangeal joint were 0.63 cm (D3) and 0.62 cm (D4), respectively and were therefore found to be similar to that of the scapholunate ligament. Bone-ligament-bone autografts of the plantar plates were designed and intercalated between the scaphoid and lunate bones and, contrary to all previous methods, not simply superimposed upon them. CONCLUSIONS: It can be concluded from the data that this new graft of the proximal interphalangeal joint of the 3rd and 4th toes can be a suitable replacement for the scapholunate ligament.

[Surgical treatment of ulnar impaction syndrome : Ulnar shortening osteotomy through the ulnopalmar approach using a low-profile, locking plate]. / Die operative Behandlung des Ulna-Impaction-Syndroms : Ulnaverkürzungsosteotomie mit einer winkelstabilen, Low-profile-Platte über einen ulnopalmaren Zugang.

OBJECTIVE: Extra-articular shortening of the distal ulna in order to decompress the ulnocarpal joint. INDICATIONS: Congenital or posttraumatic, symptomatic ulnar impaction syndrome. CONTRAINDICATIONS: Osteoarthritis or deformation of the distal radioulnar joint. SURGICAL TECHNIQUE: Exactly defined oblique osteotomy in the distal third of the ulna using the saw guide, closing of the osteotomy gap using the compression spindle, osteosynthesis with the locking plate. POSTOPERATIVE MANAGEMENT: Palmar forearm thermoplastic cast or splint for 3 weeks, load bearing after bony union. RESULTS: Between June 2016 and March 2018 ulnar shortening was performed in 17 patients using the new locking plate. In all, 15 patients were reevaluated with complete follow-up data. Postoperatively patients experienced significant pain reduction (Visual Analog Scale 0-10) by 65% (7 before and 2.5 after surgery; p < 0.05) and a significant improvement of function (Disabilities of Arm, Shoulder and Hand 0-100) by 49% (47 before and 24 after surgery; p < 0.05). Bony union was observed in all patients after a mean time of 4 months. Overall patient satisfaction was high.

[Palmar angular stable plate fixation of nonunions and comminuted fractures of the scaphoid]. / Palmare winkelstabile Verplattung von Pseudarthrosen und Trümmerfrakturen des Kahnbeins.

OBJECTIVE: Stabilization of comminuted fractures and nonunions of the scaphoid with an angular stable low-profile scaphoid plate. INDICATIONS: Scaphoid nonunions with a large palmar defect, second and third surgical procedure after previous stabilization by headless compression screw (HCS). Comminuted fractures of the scaphoid that cannot be sufficiently stabilized by screws. CONTRAINDICATIONS: Radio- and midcarpal osteoarthritis, small proximal pole fragments, fragmentation of the proximal pole. SURGICAL TECHNIQUE: The scaphoid is accessed by a palmar approach. After correcting the DISI (dorsal intercalated segment instability) deformity of the lunate and humpback deformity of the scaphoid, the reduction is secured by temporary Kirschner wires. The nonunion is debrided and the bone defect filled with cancellous bone graft. Subsequently the scaphoid plate and the angular stable screw are positioned in the order to place three screws in the proximal and distal fragment of the scaphoid. Comminuted fractures of the scaphoid are fixated by temporary Kirschner wires, then the plate is positioned in the same way as nonunions. POSTOPERATIVE MANAGEMENT: Comminuted fractures and nonunions of the scaphoid are immobilized by a below-elbow cast or thermoplastic splint with inclusion of the thumb for 8 weeks. No heavy work, high-risk or contact sport activities for 12 weeks. Plate removal is recommended after 6 months or after bony healing. RESULTS: By stabilizing scaphoid nonunions with a plate, high union rates with good clinical outcome can be achieved if the indication is correct.

TGF-beta antisense oligonucleotides modulate expression of matrix metalloproteinases in isolated fibroblasts from radiated skin.

BACKGROUND: Transforming growth factor-beta (TGF-beta) has been identified as an important component of wound healing. Recent developments in molecular therapy offer exciting prospects for the modulation of wound healing, specifically those targeting TGF-beta. The purpose of this study was to analyze the effect of TGF-beta targeting on the expression of matrix metalloproteinases (MMPs) in fibroblasts isolated from radiation-induced chronic dermal wounds. MATERIALS AND METHODS: The expression of MMPs in tissue samples from radiation-induced chronic dermal wounds was investigated by immunohistochemistry and microarray technique. The effect of TGF-beta targeting using antisense oligonucleotides on the expression of MMPs in isolated fibroblasts was analysed by ELISA and multiplex RT-PCR. RESULTS: Immunohistochemical investigation and microarray analysis demonstrated an increased expression of MMP protein and mRNA in tissue samples from radiation-induced chronic dermal wounds compared to normal human skin. Antisense TGF-beta oligonucleotide treatment significantly down-regulated MMP secretion in vitro. CONCLUSION: TGF-beta antisense oligonucleotide technology may be a potential therapeutic option for the inhibition of proteolytic tissue destruction in radiation-induced chronic wounds.