ACE inhibitors, angiotensin receptor blockers and endothelial injury in COVID-19.

BACKGROUND: COVID-19 is caused by the coronavirus SARS-CoV-2, which uses angiotensin-converting enzyme 2 (ACE-2) as a receptor for cellular entry. It is theorized that ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) may increase vulnerability to SARS-CoV-2 by upregulating ACE-2 expression, but ACE-I/ARB discontinuation is associated with clinical deterioration. OBJECTIVE: To determine whether ACE-I and ARB use is associated with acute kidney injury (AKI), macrovascular thrombosis and in-hospital mortality. METHODS: A retrospective, single-centre study of 558 hospital inpatients with confirmed COVID-19 admitted from 1 March to 30 April 2020, followed up until 24 May 2020. AKI and macrovascular thrombosis were primary end-points, and in-hospital mortality was a secondary end-point. RESULTS: AKI occurred in 126 (23.1%) patients, 34 (6.1%) developed macrovascular thrombi, and 200 (35.9%) died. Overlap propensity score-weighted analysis showed no significant effect of ACE-I/ARB use on the risk of occurrence of the specified end-points. On exploratory analysis, severe chronic kidney disease (CKD) increases odds of macrovascular thrombi (OR: 8.237, 95% CI: 1.689-40.181, P = 0.009). The risk of AKI increased with advancing age (OR: 1.028, 95% CI: 1.011-1.044, P = 0.001) and diabetes (OR: 1.675, 95% CI: 1.065-2.633, P = 0.025). Immunosuppression was associated with lower risk of AKI (OR: 0.160, 95% CI: 0.029-0.886, P = 0.036). Advancing age, dependence on care, male gender and eGFR < 60 mL min-1 /1.73 m2 increased odds of in-hospital mortality. CONCLUSION: We did not identify an association between ACE-I/ARB use and AKI, macrovascular thrombi or mortality. This supports the recommendations of the European and American Societies of Cardiology that ACE-Is and ARBs should not be discontinued during the COVID-19 pandemic.

Osteonecrosis of the Upper Extremity: MRI-Based Zonal Patterns and Differential Diagnosis.

Regarding the upper extremity, osteonecrosis can relate to the humeral head and to any carpal bone, most commonly the lunate (Kienböck's disease), scaphoid (Preiser's disease and nonunion), and capitate bone (osteonecrosis of the capitate head). In children and adolescents, osteochondrosis is an important differential diagnosis at the epiphyses. Appropriate imaging of osteonecrosis depends on knowledge about blood supply, biomechanical load, and bone repair mechanisms. Contrast-enhanced MRI (ceMRI) enables the differentiation of up to three mostly band-shaped zones: necrotic tissue (proximal), hypervascular repair tissue (intermediate), and viable bone (distal). To distinguish between necrotic and repair zones, intravenous gadolinium is recommended in MRI. Osteosclerosis and insufficiency fractures in early and intermediate stages as well as osteoarthritis in advanced stages are best depicted using high-resolution CT (HRCT). The combination of HRCT and ceMRI allows for exact classification of osteonecrosis regarding morphology and viability.

[Scaphoid pseudarthrosis : Complex reconstruction using vascularized bone grafts]. / Skaphoidpseudarthrose : Komplexe Rekonstruktionen mithilfe vaskularisierter Knochentransplantate.

The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.

[Treatment of necrosis of the lunate bone]. / Therapie der Lunatumnekrose.

BACKGROUND: There still is no standard therapy that predictably results in healing of avascular necrosis of the lunate bone. Nevertheless, there exists a wide spectrum of operative treatment options for different stages. OBJECTIVE: This article reviews the treatment options for necrosis of the lunate bone and proposes algorithms based on the age of the patient and condition of the lunate bone and the wrist. METHODS: Surgical treatment options for necrosis of the lunate bone can be divided into relieving or revascularization procedures and salvage procedures. RECOMMENDATIONS: For patients under 20 years old the treatment of choice is prolonged immobilization, in cases of non-response or progression, minimally invasive and relieving procedures are used. In adult patients with limited affection of the lunate bone the first therapeutic approach should also be immobilization. If in progressive disease or advanced stages only the lunate bone is compromised but reconstructable, restoration should be considered. In progressive collapse of a non-reconstructable lunate bone the therapeutic efforts shift to mobility-preserving procedures utilizing still functional articulations of the wrist. If all functional articulations are lost only classical salvage procedures are feasible. CONCLUSION: According to the presented algorithms a stage-dependent therapy of necrosis of the lunate bone is possible. It should not be ignored that there are still no scientific and evidence-based arguments for some of these treatment options. This is also true for maximally invasive procedures, where superiority to more simple procedures have not been proven. Therefore, their application should be restricted and based on an individual decision.

[Free vascularised medial femoral trochlea flap : Indication and technique]. / Freies gefäßgestieltes Femurknochentransplantat bei Skaphoidpseudarthrose : Indikation und Technik.

BACKGROUND: Avascularity of fragments is a common problem in treatment of scaphoid nonunion. Therefore, vascularised bone grafts have gained increasing importance. Especially the free vascularised femoral trochlea flap has become the subject of special interest because of its particular characteristics in the last few years. OBJECTIVES: Indications for and the technique of free vascularised corticocancellous as well as osteocartilagineous femoral trochlea flap are reported according to the author's practice combined with an evaluation of these methods considering current literature. RESULTS: Indications for the free vasscularised corticocancellous femoral trochlea flap include scaphoid nonunion with avascular proximal fragment combined with humpback deformity, previous operations, extensive bone defect, and long standing nonunion. The free vascularised osteocartilagineous medial trochlea flap may replace a destroyed proximal scaphoid pole. The literature reports only a few patients with healing rates between 80 and 100 %. CONCLUSIONS: Both corticocancellous and osteocartilagineous free vascularised medial trochlea flap improve therapeutic options in treatment of difficult scaphoid nonunion. Until now only the results of a few patients have been published. Therefore, a final evaluation will be possible when long-term results in a reasonable number of patients are available.

[Hand injuries in mountain sports]. / Handverletzungen beim Bergsport.

BACKGROUND: Apart from clean cut finger amputations, every kind of hand injury can be seen in mountain and winter sports but only skier's thumb and injuries of the pulley system in sport climbers are seen in a greater number of cases. Nevertheless, these two common injuries as well as the rare frostbite of the fingers are often underdiagnosed or overdiagnosed as well as undertreated or overtreated. PURPOSE: This paper describes the diagnostics and treatment of skier's thumb, injuries of the pulley system in sport climbers and frostbite of the fingers. RESULTS: Before checking the metacarpophalangeal (MP) joint of the thumb for stability, radiographs should be taken to exclude a bony avulsion of the ulnar collateral ligament in skier's thumb. If there is no bony ligament avulsion further diagnostic procedures, e.g. ultrasound, are recommended to prove or exclude a Stener lesion, which is an absolute indication for operative treatment together with a dislocated bony ligament avulsion. To quantify the severity of a lesion of the pulley system ultrasound and magnetic resonance imaging (MRI) are needed. Most lesions of the pulley system can be treated conservatively. Only multiple pulley ruptures or isolated ruptures associated with a lesion of the lumbrical muscles or collateral ligaments require operative treatment. As long as there is no infection amputation should be done as late as possible in frostbite of the fingers because the extent of the frostbite can rarely be correctly estimated. CONCLUSION: Most cases of skier's thumb as well as lesions of the pulley system can be treated non-operatively but precise diagnostics are needed.

[Scapholunate lesions]. / Die skapholunäre Bandverletzung.

Injuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.

Long-term strategies for the treatment of Refsum's disease using therapeutic apheresis.

Refsum's disease is a rare autosomal recessive disorder of fatty acid metabolism. Poorly metabolized phytanic acid accumulates in fatty tissues, including myelin sheaths and internal organs, leading to retinitis pigmentosa, peripheral polyneuropathy, cerebellar ataxia, and renal, cardiac or liver impairment. Dietary restriction of phytanic acid in some cases is not sufficient to prevent acute attacks and stabilize the progressive course. Phytanic acid bound to large low density lipoproteins (LDL) and very low density lipoproteins (VLDL) molecules offers the possibility of extracorporeal elimination by lipid apheresis. We report on the long-term lipid apheresis treatment of four patients with severe Refsum's disease. Retinitis pigmentosa, peripheral polyneuropathy, cerebellar ataxia, anosmia, and sensorineural hearing loss were major symptoms exhibiting a progressive course. Lipid apheresis was performed for 5-13 years without severe complications. Maximum levels of phytanic acid before commencing chronic lipid apheresis were >300 mg/l. During steady state with lipid apheresis, mean phytanic acid before treatments was 87 mg/l and was reduced to 36 mg/l. Mean reduction rate was 59% per treatment. In all patients, abnormal motor nerve conduction velocity with signs of chronic denervation improved, morphological and functional stabilization of eye involvement was observed. Lipid apheresis prevented the extension of the disease to previously unaffected organs in three patients. Extracorporeal elimination of lipoprotein-phytanic acid complexes by lipid apheresis represents a pathophysiologically guided therapeutic approach, resulting in long-term improvement or stabilization of overall rehabilitation in patients with progressive Refsum's disease.

[Long-term results following denervation of the wrist]. / Langzeitergebnisse nach Handgelenkdenervation.

BACKGROUND: This retrospective study examines long-term follow-up results after complete denervation of the wrist. PATIENTS AND METHODS: Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0-100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter. RESULTS: In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73. CONCLUSION: Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.

[Reconstruction of the middle phalangeal base of the finger using an osteocartilaginous autograft from the hamate]. / Rekonstruktion der Mittelgliedbasis am Finger durch ein osteochondrales Transplantat vom Os hamatum.

OBJECTIVE: Restoration of proximal interphalangeal joint stability with preservation of mobility by reconstruction of the middle phalanx base using an osteochondral graft from the carpometacarpal joint surface of the hamate. INDICATIONS: Acute and older isolated destruction of the palmar middle phalanx base >25%. CONTRAINDICATIONS: Destruction of the head of the proximal phalanx, advanced chondropathia of the head of the proximal phalanx, extensive soft tissue injury with loss of skin coverage at the proximal interphalangeal joint. SURGICAL TECHNIQUE: The fractured middle phalangeal base is debrided and the defect is replaced by a size-matched autograft from the dorsal carpometacarpal hamate osteoarticular surface that is secured in place with miniscrews. POSTOPERATIVE MANAGEMENT: Immobilization for 2 weeks in a below-elbow cast in intrinsic plus position. Subsequent immobilization by a splint including the distal and proximal interphalangeal joint. RESULTS: Healing was achieved in 100% with restoration of joint congruity in 12 of 13 cases and slight subluxation in 1 case. Follow up was possible in 9 cases after 22 ± 16 (5-51) months. The average range of motion in the reconstructed joint achieved 0/9/73°, grip strength 82% of the unaffected side. Of the 9 patients, 5 developed a mild flexion contracture of the proximal interphalangeal joint. The DASH score achieved 4 ± 3 (0-8) points, pain at rest was 1 ± 2 (0-5), pain at exercise 2 ± 2 (0-5) on a visual analogue scale (0-10). All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by using an osteochondral graft from the hamate is a reliable procedure to restore stability and mobility of the joint.

[Experiences with the "short arc motion" protocol for rehabilitation of extensor tendon injuries in zones E and F according to Wilhelm]. / Erfahrungen mit dem Short Arc Motion (SAM)-Schema in der Nachbehandlung isolierter Strecksehnenverletzungen der Zonen E und F nach Wilhelm.

Rehabilitation of extensor tendon injuries in zones E and F (according to Wilhelm) is difficult because of the broad bone-tendon interface favouring adhesions. Therefore RB Evans developed the so called "short arc motion" protocol to improve the results of extensor tendon injuries in zones E and F. This protocol consists of immobilisation of the PIP and DIP joints of the injured finger interrupted by regularly performed limited active motion exercises according to the principle of "minimal active tension". Evans demonstrated superior results using this protocol compared to pure immobilisation. In this study we retrospectively evaluated our results using the "short arc motion" regime in isolated extensor tendon injuries since 2000. 10 patients could be examined with a mean follow-up of 2 years and 5 months after operative treatment of fresh extensor tendon injuries as well as one patient with an old extensor tendon lesion. According to the Strickland-Glogovac formula our patients with fresh extensor tendon lesions had 70.3 % on average which is a good result. Using the Geldmacher score these patients had a mean result of 20.7 points indicating a good result too. With regard to the PIP joint, the mean extension deficit was 8.5 degrees. So our results are good, but not as good as those from Evans. Being aware of the limitations of a retrospective study lacking a control group of patients with traditional aftercare, we will continue to use the SAM protocol in our hospital.

[Mal-united fractures of the distal radius--biomechanics and operative treatment options]. / Die fehlverheilte distale Radiusfraktur--Biomechanik und operative Behandlungsmöglichkeiten.

Despite all progress in the treatment of distal radius fractures, malunion is still one of the most common complications. It may be true that not all non-anatomically aligned fractures of the distal radius are causing disabilities. However, most patients with a distal radial malunion complain about loss of wrist motion and forearm rotation, loss of grip strength, and pain. These complaints should lead to a sophisticated clinical examination and a careful evaluation of the radiographs of the wrist, and - if needed - to further investigations. Treatment options are procedures solely aimed to diminish pain, procedures aimed to improve wrist and forearm function without restoration of the anatomic relationships, and procedures aimed to restore the anatomy of the wrist joint, especially corrective osteotomy of the radius. Radial corrective osteotomy improves significantly wrist and forearm function, grip strength, and diminishes pain. The clinical results are as good or better than the radiological results.

Radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease.

We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4-17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0-52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients. LEVEL OF EVIDENCE: Therapeutic IV.

[Specific Characteristics of Trigger Finger in Children]. / Besonderheiten des schnellenden Fingers im Kindesalter.

BACKGROUND: Trigger finger in children is a rare condition with relevant differences to the more frequent trigger thumb in children and the very frequent trigger finger in adults. PATIENTS AND METHODS: In a retrospective analysis of children who underwent surgery for trigger fingers in 2 specialised centres, we evaluated 42 children with a total of 63 trigger fingers. Due to persistent triggering after release of the A1 pulley based on intraoperative findings in 12 children with a mean age of 3.7 years ranging from 0.6 to 10.2 years and a total of 17 trigger fingers, additional measures after the release of the A1 pulley were required, mainly the resection of one limb of the sublimis tendon. In one of these children another simultaneously operated finger required the release of the A1 pulley alone. We performed a retrospective chart review of these patients and evaluated the results after a mean follow-up time of 4.8 years ranging from 1.2 to 11.8 years by phone call. Functional impairments, persistent pain, satisfaction and complications were monitored. RESULTS: All patients treated with A1 pulley release and resection of one limb of the sublimis tendon had excellent results. One patient had a recurrence and another patient developed a contracture of the PIP joint. In both patients, the widening of the tendon sheath had been done by A2 pulley enlargement in addition to the A1 pulley release. CONCLUSIONS: Persistent triggering of a finger following the release of the A1 pulley in a child can be successfully treated by resection of one limb of the sublimis tendon.

[Differential diagnosis of the signal-compromised lunate in MRI]. / Zur Differenzialdiagnostik des "signalkompromittierten" Os lunatum in der MR-Tomographie.

PURPOSE: To define both the underlying pathology and diagnostic criteria in lunates presenting with conspicuous signal pattern in MRI. MATERIALS AND METHODS: The retrospective evaluation of 2940 MRI examinations revealed 203 patients with signal alterations of the lunate. All MRI examinations were performed on 1.5-Tesla platforms using dedicated surface coils and an intravenous contrast agent. To establish a definitive diagnosis, a total of 252 MRI examinations (49 follow-ups), 22 CT examinations and 4 arthroscopic studies were obtained in addition to the obligatory conventional radiographs. RESULTS: Incorporating all clinical data, radiographs and MRI examinations succeeded in assigning a diagnosis in 136 signal-compromised lunates (67.0 %), whereas additional diagnostic procedures or follow-up examinations were required for the definitive diagnosis in 57 cases (33.0 %). The most frequent entities were 51 cases of Kienbock's disease (25.1 %), 47 cases of ulnolunate-(triquetral) impaction syndromes (23.2 %) and 44 cases of intra-osseous ganglion cysts (21.7 %). Other pathologies included 23 degenerative, 19 traumatic and 10 inflammatory changes as well as 9 congenital conditions. For MRI assessment of the altered lunate, the most important parameters were location and morphology as well as involvement of the articular and osseous structures of the carpus. CONCLUSION: The lunate may be affected by different pathological states of the wrist. In total, only one quarter of the signal-compromised lunate represented Kienboeck's disease.

[Zenker's diverticulum. Long-term results after surgical therapy]. / Das Zenker'sche Divertikel. Langzeitergebnisse nach operativer Therapie.

Twenty-one patients were treated for Zenker's diverticulum in the Würzburg University Department of Surgery between 1977 and 1989. Surgery was done in 15 cases (8 single-session resections with myotomy of the upper esophageal sphincter, and 7 resections without myotomy). The postoperative course was uneventful in 73%. Wound infection developed in 2 cases, and suture insufficiency and transient paralysis of the recurrent nerve in one each. In 3 patients, postoperative x-ray prior to release from the hospital revealed retention of contrast medium in a discrete, pocket-like protrusion between the cricoid and the pharynx. Follow-up was done after a mean interval of 4 years (range: 5 months-10.5 years) in 10 of the 15 operated patients. Two of them developed relapses about 1-1.3 cm in size within 8 months and 7 years, resp. Myotomy had not been done in either case. Neither patient had complaints. Esophageal manometry was performed in 6 patients. Resting tone of the upper esophageal sphincter was clearly diminished at 12-30 mm Hg (normal 40-50 mm Hg); maximum contraction pressure was also reduced at 30-75 mm Hg (normal 90-110 mm Hg). However, the decisive factor was the exact temporal coordination of pharyngeal contraction with sphincter relaxation. For this reason it is our unconditional recommendation that myotomy of the upper esophageal sphincter be regarded as an essential step in resection of Zenker's diverticula.

[Preliminary results with Cuénod's osteoligamentoplasty and capsulodesis for treatment of chronic scapholunate dissociation]. / Erste Erfahrungen mit der Osteoligamentoplastik und Kapsulodese nach Cuénod zur Behandlung der chronischen skapholunären Dissoziation.

Until now, the ideal treatment of scapholunate dissociation has not yet been found. Cuénod described an operation with reconstruction of the dorsal part of the scapholunate ligament using a bone-ligament-bone autograft (dorsal trapezoidometacarpal II ligament) and an additional dorsal capsulodesis using the dorsal intercarpal ligament. From December 2000 until January 2002, we operated on twelve patients with symptomatic chronic scapholunate dissociation without signs of osteoarthrosis using Cuénod's procedure. Preoperatively as well as at follow-up patients were evaluated using a traditional wrist score and a DASH-questionnaire in addition to clinical examination. X-rays of both wrists in two planes each and additional stress radiographs were done. All patients had an arthroscopy preoperatively and a CT scan before K-wire removal. The mean follow-up time was twelve months. Clinical follow-up showed good results (traditional wrist score: 77 points; DASH-score: 27 points), but with regard to the good preoperative findings (traditional wrist score: 73 points; DASH-score: 28 points) no significant improvement. Postoperative X-rays showed a correction of static instability in three cases; in four cases we found a recurrent SL gap, which was interpreted as failure of the transplanted ligament. Until now, one patient had to be reoperated by STT-fusion. In our patients, Cuénod's operation showed different results. So, further studies are necessary to find the correct indications for applying this procedure.

[Treatment of difficult scaphoid pseudarthroses by bone transplantation and additional implantation of the second dorsal metacarpal artery using the Fernandez and Eggli technique--report of experiences]. / Behandlung schwieriger Skaphoidpseudarthrosen durch Knochentransplantation und zusätzliche Implantation der zweiten dorsalen Metakarpalarterie in der Technik nach Fernandez und Eggli--Erfahrungsbericht.

One of the procedures for the treatment of scaphoid-nonunion with loss of blood supply to the proximal fragment involves the technique described by Fernandez and Eggli (1995). After resection of the necrotic bone and inserting a corticocancellous bone graft from the iliac crest, the second dorsal intermetacarpal artery is implanted into the proximal fragment of the scaphoid. In our hospital, six patients underwent this procedure from May 1998 to June 2000 because of necrosis of the proximal pole or an unsuccessful previous operation. Union was achieved in five patients. In one case, nonunion persisted and the cystic area increased. The described technique is suitable for improvement of bone healing of the scaphoid in complicated cases. The advantages of this technique lie in the predictable anatomy of the second intermetacarpal artery and the straightforward dissection.

[Comparative outcome assessment of the wrist joint--mediocarpal partial arthrodesis and total arthrodesis]. / Vergleichende Ergebnisbewertung am Handgelenk--mediokarpale Teilarthrodese und Totalarthrodese.

Total wrist fusion still represents the main treatment for severe posttraumatic disorders of the wrist due to longstanding scaphoid nonunion (SNAC-wrist) or scapholunate dissociation (SLAC-wrist). During the last decade, midcarpal fusion has become more and more popular as it preserves motion. The question, however, remained if the preserved motion is of real benefit from a patient point of view, as complete pain relief is rare following this type of limited wrist fusion. The purpose of this study was to compare the outcome of both treatments with the modified Cooney wrist score and the DASH questionnaire. Between 1993 and 1997, 138 patients with progressive carpal collapse were treated either by midcarpal fusion (97) or total wrist fusion (41). Overall satisfaction was high in both groups with 86% (midcarpal fusion) and 84% (total wrist fusion). The traditional wrist score (70 versus 52 points) and the DASH questionnaire (33 versus 45 points) revealed the superiority of midcarpal fusion. The correlation between the wrist score and the DASH was statistically high (p < 0.001), demonstrating the specificity and validity of the DASH questionnaire. Midcarpal fusion is preferable to total wrist fusion for treatment of progressive carpal collapse (SLAC- and SNAC-wrist). The DASH represents a sensitive tool to evaluate the outcome of salvage procedures for treatment of disorders of the wrist.

[Non-traumatically-induced paralysis of the ramus profundus nervi radialis. Aspects of a rare disease picture]. / Die nicht traumatisch bedingte Parese des Ramus profundus nervi radialis. Aspekte eines seltenen Krankheitsbildes.

Both radial tunnel syndrome and posterior interosseous nerve compression syndrome are caused by compression of the posterior interosseous nerve. Posterior interosseous nerve (PIN) compression syndrome is a rare condition--less than 10 percent of our cases of PIN-compression showed signs of palsy--and must be differentiated from tendinous lesions. From 1992 to 1997, we decompressed the PIN using an anterior approach in nine cases because of palsy without a history of trauma. Only one patient was lost to follow-up. Our study indicates that the results of operative decompression of the PIN depend on the time interval between first symptoms of palsy and operation. On the other hand, some cases of posterior interosseous nerve compression syndrome show spontaneous recovery. We recommend operative decompression of the PIN if incomplete palsy worsens or if complete palsy persists for more than 12 weeks.