Clinical and radiological midterm outcome after treatment of pilonoidal fracture dislocations of the proximal interphalangeal joint with a parabolic dynamic external fixator.

INTRODUCTION: Several methods treating proximal interphalangeal joint (PIP) fracture dislocations have been established providing early joint mobilization. The aim of this study was to evaluate the clinical and radiological outcome of unstable fracture dislocations of the PIP treated with a parabolic dynamic external fixator consisting of two Kirschner (K)-wires. MATERIALS AND METHODS: Twenty-one patients who sustained a pilonoidal fracture of the PIP joint and were treated with a dynamic external fixator were evaluated retrospectively. The active range of motion, pain level, DASH score, Buck Gramcko Score, and the patient's satisfaction and acceptance were assessed. X-ray images were evaluated for bone healing, joint alignment, and signs of osteoarthritis. RESULTS: Mean PIP joint range of motion was 76°. Patients showed very mild discomfort (mean 0.7), high patient satisfaction (mean 1.9), and a moderate acceptance (mean 2.7). The mean DASH score was 11.6 and the Buck Gramcko score 13. All patients showed bone healing. One patient suffered from a recurrent dislocation, and another a subluxation of the PIP joint while wearing the fixator. Both joints could be corrected by modifying the fixator under image intensifier. Twenty patients (95%) showed a concentric and stable aligned joint. Three patients showed an osteoarthritis stage 0, five stage 1, nine stage 2, three stage 3, and one stage 4 according to the Kellgran-Lawrence Score. CONCLUSION: The use of a parabolic dynamic external fixator constructed from two K-wires restores joint alignment and stability in unstable pilonoidal PIP joint disclocation fractures. It allows immediate PIP joint mobilization to avoid adhesions. Modifications of the radius of the parabolic construct within cases of postoperative malalignment, without anesthesia, can restore joint axis and malalignment. This fixator is a cost-effective alternative, showing a good clinical outcome.

Formyl peptide receptor 2 orchestrates mucosal protection against Citrobacter rodentium infection.

Citrobacter rodentium is an attaching and effacing intestinal murine pathogen which shares similar virulence strategies with the human pathogens enteropathogenic- and enterohemorrhagic Escherichia coli to infect their host. C. rodentium is spontaneously cleared by healthy wild-type (WT) mice whereas mice lacking Muc2 or specific immune regulatory genes demonstrate an impaired ability to combat the pathogen. Here we demonstrate that apical formyl peptide receptor 2 (Fpr2) expression increases in colonic epithelial cells during C. rodentium infection. Using a conventional inoculum dose of C. rodentium, both WT and Fpr2-/- mice were infected and displayed similar signs of disease, although Fpr2-/- mice recovered more slowly than WT mice. However, Fpr2-/- mice exhibited increased susceptibility to C. rodentium colonization in response to low dose infection: 100% of the Fpr2-/- and 30% of the WT mice became colonized and Fpr2-/- mice developed more severe colitis and more C. rodentium were in contact with the colonic epithelial cells. In line with the larger amount of C. rodentium detected in the spleen in Fpr2-/- mice, more C. rodentium and enteropathogenic Escherichia coli translocated across an in vitro mucosal surface to the basolateral compartment following FPR2 inhibitor treatment. Fpr2-/- mice also lacked the striated inner mucus layer that was present in WT mice. Fpr2-/- mice had decreased mucus production and different mucin O-glycosylation in the colon compared to WT mice, which may contribute to their defect inner mucus layer. Thus, Fpr2 contributes to protection against infection and influence mucus production, secretion and organization.

Carpal tunnel syndrome assessment with diffusion tensor imaging: Value of fractional anisotropy and apparent diffusion coefficient.

OBJECTIVES: To quantitatively assess carpal tunnel syndrome (CTS) with DTI by evaluating two approaches to determine cut-off values. METHODS: In forty patients with CTS diagnosis confirmed by nerve conduction studies (NCs) and 14 healthy subjects (mean age 58.54 and 57.8 years), cross-sectional area (CSA), apparent diffusion coefficient (ADC) and fractional anisotropy (FA) at single and multiple levels with intraobserver agreement were evaluated. RESULTS: Maximum and mean CSA and FA showed significant differences between healthy subjects and patients (12.85 mm2 vs. 28.18 mm2, p < 0.001, and 0.613 vs. 0.524, p=0.007, respectively) (10.12 mm2 vs. 19.9 mm2, p<0.001 and 0.617 vs. 0.54, p=0.003, respectively), but not maximum and mean ADC (p > 0.05). For cut-off values, mean and maximum CSA showed the same sensitivity and specificity (93.3 %). However, mean FA showed better sensitivity than maximum FA (82.6 % vs. 73.9 %), but lower specificity (66.7 % vs. 80 %), and significant correlation for maximum CSA, 97 % (p < 0.01), with good correlation for maximum ADC and FA, 84.5 % (p < 0.01) and 62 % (p=0.056), respectively. CONCLUSIONS: CSA and FA showed significant differences between healthy subjects and patients. Single measurement at maximum CSA is suitable for FA determination. Key Points • DTI showed that FA is stronger than ADC for CTS diagnosis. • Single- and multiple-level approaches were compared to determine FA and ADC. • Single-level evaluation at the thickest MN cross-sectional area is sufficient.

Total wrist arthrodesis for septic wrist arthritis and loss of the bony carpus following percutaneous pinning of the fifth carpometacarpal joint: a case report.

We report on a patient who developed septic wrist arthritis with destruction of the entire carpus due to osteomyelitis following percutaneous pinning of a fifth metacarpal base fracture. Arthrodesis was performed using a 6 cm vascularized iliac bone graft. This case report may sharpen the surgeon's awareness of risks in orthopedic surgeries, even though the procedure seems to be rather simple and the patient is young and seems to be healthy.

[Biomechanics of distal radius fractures : Basics principles and GPS treatment strategy for locking plate osteosynthesis]. / Biomechanik distaler Radiusfrakturen : Grundlagenverständnis und GPS-Behandlungsstrategie bei winkelstabiler Plattenosteosynthese.

Fractures of the distal radius are most commonly caused by hyperextension injuries of the wrist. Tensile forces and force vectors, strength of impact, bone strength and soft tissue tension create individually different fracture patterns. Metaphyseal comminution, loss of cortical support, ligament avulsion and shear fragments are defining parameters for fracture instability. The dislocation of the articular fragment follows the force vectors of the extrinsic forearm muscles bridging the joint. The goal-plan-standardized (GPS) treatment strategy has proven to be helpful in choosing the ideal individual treatment. It is based on individual patient demands on wrist function and an analysis of fracture instability in computed tomography (CT) scans. The "goal" is a realistic expectation assessed by patient and surgeon. The "plan" includes a benefit-risk analysis and selection of an appropriate treatment modality. The "standardized treatment" of surgical and follow-up treatment is based on biomechanical knowledge. Locking plate osteosynthesis aims to neutralize dislocating force vectors and to allow early active mobility. Unidirectional instability can be indirectly neutralized by palmar locking plate systems. A multidirectional instability can be addressed by multiple plating following the column theory. Distal shear and avulsion fractures may require a fragment-specific osteosynthesis approach.

Characteristics of secondary arthrofibrosis after intra-articular distal radius fracture.

PURPOSE: The purpose of this study was to assess characteristics of radiocarpal arthrofibrosis after intra-articular distal radius fractures (DRF). PATIENTS AND METHODS: In this study 20 patients who underwent wrist arthroscopy at the time of implant removal after volar plating for intra-articular DRF were included retrospectively. The direction of fibrous tissue formation (FTF) and its rigidity were investigated. The findings were correlated to the course of intraarticular fracture lines seen in the preoperative CT, patient age and AO fracture types. RESULTS: In all patients FTF spanned the radiocarpal joint. Fibrous tissue formations extended from previous fracture gaps to the scapholunate interosseous ligament and/or capsule. Four basic types of FTF (Type 1-4) and two combination types (Type 1a, 2a) were found. Fibrotic fans with dorsal capsular attachment (Type 1, 30 %) and its combination with dorsal capsule obliteration (Type 1a, 40 %) were the most common findings. Mild rigidity was present in 3 (15 %), moderate in 7 (35 %), and severe rigidity in 10 cases (50 %). Fracture lines crossing the radius extensor compartments or interfacet ridge, cartilage defects and C3 fractures showed the highest risk to develop severely rigid fibrous tissue formations. In older patients and in more comminuted fractures the number of rigid fibrous tissue formations was higher. CONCLUSIONS: Fracture severity correlates with the development of rigid intra-articular FTF. In case of rigid FTF with restricted wrist motion arthroscopic debridement may be considered at the time of hardware removal.

Injectable collagenase Clostridium histolyticum as a nonsurgical treatment for Dupuytren's disease.

OBJECTIVE: Nonsurgical treatment of Dupuytren's disease using collagenase Clostridium histolyticum (CCH). INDICATIONS: Metacarpophalangeal (MP) joint (20-100°) and proximal interphalangeal (PIP) joint (20-80°) contractures. CONTRAINDICATIONS: Pregnancy, previous hypersensitivity to collagenase or excipients, anticoagulant use within 7 days prior to treatment. INJECTION TECHNIQUE: CCH injected directly into the Dupuytren's cord weakening the contracted cord. After injection, the patient returns the following day to allow CCH to lyse the collagen within the cord. An extension force is then applied to the involved finger to disrupt the weakened cord. POSTMANIPULATION MANAGEMENT: Use of extension splint at night, movement instructions during the day. RESULTS: A total of 120 patients (107 men; 13 women; mean age 62 years, range 30-84 years) were treated. In 49% the little finger, in 44% the ring finger, in 4% the middle finger, and in 3% the index finger was treated. Full release was achieved in 71%, partial release in 26%, and no change in 3% of patients. The median pretreatment contracture for the MP joint was 37° (range 25-100°) and PIP joint 51° (range 30-97°). At 12 months, the mean contracture for the MP joint was 9° (range 0-25°) and for the PIP joint 21° (range 10-36°). Adverse events observed in 96% of patients for 3 months . No tendon ruptures, anaphylactic reactions, or nerve or ligament injuries observed.

[Hand replantation: differences in functional outcome considering patient age and sociomedical aspects]. / Handreplantation: Unterschiede im funktionellen Ergebnis in Anbetracht von Alter und sozialmedizinischem Aspekt.

By presenting 2 cases of successful hand replantation with similar trauma mechanism, level of amputation and ischaemia time of an 18-year-old female patient and a 48-year-old depressive male patient, the influence of age and sociomedical status on the postoperative outcome is discussed. DASH- (disabilities of the arm, shoulder and hand) score and Biometrics E-LINK power and sensitivity measurement were used to evaluate the outcomes.

[Secondary reconstruction of the digital A2-flexor pulley]. / Sekundäre Rekonstruktion des digitalen A2-Ringbands.

OBJECTIVE: Secondary reconstruction of A2 flexor pulley for after closed rupture. INDICATIONS: Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints. CONTRAINDICATIONS: Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints. SURGICAL TECHNIQUE: A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost. POSTOPERATIVE MANAGEMENT: Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months. RESULTS: Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97 %, the average power grip strength 96 %, the finger pinch strength 100 %, and the average circumference 95 % of the uninjured contralateral side. The Buck-Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.

Ulnar shortening with the ulna osteotomy locking plate.

OBJECTIVE: Ulnar shortening for ulnocarpal unloading using a new device enabling parallel osteotomy, rotation-secured compressive shortening, lag screw placement and hybrid stabilization combined in a solely locking plate construct. INDICATIONS: Idiopathic ulnar impaction syndrome. Posttraumatic radial shortening without major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. CONTRAINDICATIONS: Advanced arthritis of the distal radioulnar joint (DRUJ), DRUJ type III according to Tolat, malunion of the distal radius with major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. SURGICAL TECHNIQUE: Mounting of the UOL plate system on the palmar surface of the ulna using standard ulnopalmar exposure. Two parallel 45° osteotomies are performed using an osteotomy guide followed by rotation secured shortening and compression. Stabilization is gained by inserting an interfragmentary lag screw perpendicular to the osteotomy site and applying locking and compression screws. POSTOPERATIVE MANAGEMENT: Lower arm cast for 4 weeks until radiological signs of bone healing become apparent. To limit negative influence of rotational forces during bone healing, patients were instructed to limit forearm rotation up to 30° in pro-/supination. RESULTS: Sixteen ulnar shortening osteotomies were performed in 15 patients (6 men, 9 women, average age 49 years) and evaluated retrospectively. In 10 cases a trauma-related pathology was the indication for the procedure. The average follow-up time was 53 weeks (range 12-93 weeks). Bone union was observed at a median of 10 weeks (range 6-33 weeks). Overall good clinical results could be achieved with an average shortening of 3.7 mm (range 2.1-16 mm). In this series, there was one nonunion.

Initial shortening and internal fixation in combination with a Sauvé-Kapandji procedure for severely comminuted fractures of the distal radius in elderly patients.

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure. At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O'Brien rating system, eight patients had an excellent, two a good and one a fair result. The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

Severe kyphoscoliosis after primary Echinococcus granulosus infection of the spine.

A primary Echinococcus granulosus infection of the spine involving the vertebrae T8 and T9 of a 6-year-old child was treated elsewhere by thoracotomy, partial corporectomy, multiple laminectomies and uninstrumented fusion. Owing to inappropriate stabilization, severe deformity developed secondary to these surgeries. X-rays, CT and MRI scans of the spine revealed a severe thoracic kyphoscoliosis of more than 100 degrees (Fig. 1) and recurrence of Echinococcus granulosus infection. The intraspinal cyst formation was located between the stretched dural sac and the vertebral bodies of the kyphotic apex causing significant compression of the cord (Figs. 2, 3, 4). A progressive neurologic deficit was reported by the patient. At the time of referral, the patient was wheelchair bound and unable to walk by herself (Frankel Grade C). Standard antiinfectious therapy of Echinococcus granulosus requires a minimum treatment period of 3 months. This should be done before any surgical intervention because in case of a rupture of an active cyst, the delivered lipoprotein antigens of the parasite may cause a potentially lethal anaphylactic shock. Owing to the critical neurological status, we decided to perform surgery without full length preoperative antiinfectious therapy. Surgical treatment consisted in posterior vertebral column resection technique with an extensive bilateral costotransversectomy over three levels, re-decompression with cyst excision around the apex and multilevel corporectomy of the apex of the deformity. Stabilisation and correction of the spinal deformity were done by insertion of a vertebral body replacement cage anteriorly and posterior shortening by compression and by a multisegmental pedicle screw construct. After the surgery, antihelminthic therapy was continued. The patients neurological deficits resolved quickly: 4 weeks after surgery, the patient had Frankel Grade D and was ambulatory without any assistance. After an 18-month follow-up, the patient is free of recurrence of infection and free of neurologically deficits (Frankel E). This case demonstrates that inappropriate treatment--partial resection of the cyst, inappropriate anterior stabilization and posterior multilevel laminectomies without posterior stabilization--may lead to severe progressive kyphoscoliotic deformity and recurrence of infection, both leading to significant neurological injury presenting as a very difficult to treat pathology. Fig. 1 X-rays of the patient showing a kyhoscoliotic deformity. a ap view, b lateral view Fig. 2 CT reconstruction of the whole spine showing the apex of the deformity is located in the area of the previous surgeries Fig. 3 Sagittal CT-cut showing the bone bloc at the apex with a translation deformity Fig. 4 Sagittal T2-weighted MRI image showing the cystic formation at the apex.

[Free vascularised iliac bone graft for Kienböck's disease stage III]. / Freies gefässgestieltes Beckenkamm-Transplantat bei aseptischer Mondbeinnekrose im Stadium III.

PURPOSE: The aim of this retrospective study is to report the clinical and radiological long-term results (follow-up >10 years) after revascularisation of the lunate in Kienböck's disease using a free vascularised iliac bone graft in patients with Lichtman stage III disease. PATIENTS AND METHODS: 23 patients (14 male, 9 female) aged between 17 and 43 years were treated with a free vascularised iliac bone graft. The average follow-up time was 13 (10-15) years. Assessment included active range of wrist motion, grip strength, level of pain, patient disability and functional outcome measured by the DASH questionnaire as well as the Green and O'Brien score. Radiological evaluation included Ståhl index, Youm carpal height index, radioscaphoidal angle, radiolunate angle and integration of the free vascularised bone graft. All long-term results were compared to the preoperative state. RESULTS: In 20 of 23 patients definite osteointegration of the vascularised bone graft was achieved. The average extension-flexion arc increased from 75 degrees to 100 degrees postoperatively and the average ulnar-radial deviation arc increased from 35 degrees to 45 degrees . The grip strength improved from 45 kg to 65 kg postoperatively and the pain level decreased from 65 to 6. Radiologically the average Ståhl index improved to 0.44 (preoperative 0.33), the average Youm index to 0.54 (preoperative 0.51) and the average radioscaphoidal angle to 50 degrees (preoperative 46 degrees ). The mean DASH score was 14.2. The Green and O'Brien score showed 11 (48%) excellent, 5 (22%) good, 4 (17%) fair und 3 (13%) bad results. 3 patients presented with a resorption of the bone graft with ongoing radiological progression of Lichtman stage, reduced range of motion and high pain level. CONCLUSIONS: Free vascularised iliac bone grafts for Kienböck's disease is a reasonable treatment option and the clinical and radiological improvements last for a long period of time. Long-term restoration of carpal height was demonstrated. Progression of disease was prevented in 87% (20 of 23) of patients over a mean time of 13 years. In our hands this technique remains the best option for the treatment of Kienböck's disease stage III.

Free vascularised iliac bone graft for recalcitrant avascular nonunion of the scaphoid.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

[Ten years of hand transplantation experiment or routine?]. / Zehn Jahre Handtransplantation Experiment oder Routine?

In the 20th century the legend of Cosmas and Damian - an extremity being transferred from one person to another - became reality. The first hand transplantation was carried out in 1964 in Ecuador but the hand had to be removed again within three weeks due to rejection. Although he was the first one to be treated with more modern immunosuppressants, the same fate overtook another patient who received a hand from a brain-dead donor in 1998 in Lyon. Since then only 32 persons worldwide have been provided with parts of the upper extremity. The partly published histories of three patients who have had both hands transplanted will be summarised and indication critically assessed once again. It is also stressed how difficult, multi-layered and complex the patient's education is. The patient has to be informed in many conversations beforehand about every stage of therapy but also about possible complications and even rejection. Can the psychological burden/stress while waiting for a donor, the difficult post-operative period, lifelong adherence to a rigorous drug-regimen, the complexity of the whole procedure be made comprehensible to a layman? To replace same with same is the goal of the best-possible reconstructive surgery. It is to hope that through future innovations in the immunosuppressing therapy patients can be offered transplantation of one or both hands as a routine-operation. Until then indication has to be strict and the operation can possibly only be performed in a few centres. Long-time prospects, disadvantages and complications, as well as side effects have to be presented openly.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

The phase diagram of halogens on Pt(110): structure of the (4 × 1)-Br/Pt(110) phase.

When adsorbed on the strongly anisotropic Pt(110) surface Br forms a sequence of (n × 1) structures. In the present study we investigate the (4 × 1) structure by scanning tunneling microscopy, quantitative low-energy electron diffraction and density-functional calculations. We show that the optimal structural model contains essentially the same adsorption sites as the (3 × 1) structure, but with a different preference. The positions of the substrate atom are consistent with a frozen surface phonon of fourfold periodicity, suggesting that the phase diagram can be understood on the basis of a tunable charge density wave (Swamy et al 2001 Phys. Rev. B 86 1299). The structure could also be explained by assuming short-range interactions only, but evidence is presented that adsorbate-adsorbate interactions mediated by quasi-one-dimensional surface resonances play a major role in both cases.

[Subjective impairment after macroamputation of the upper extremity]. / Subjektive Beeinträchtigungen nach Makroamputationen an der oberen Extremität.

BACKGROUND: The subjective outcome following macroamputation of the upper limb was evaluated using the DASH score. PATIENTS AND METHODS: In a retrospective study, 11 patients with stumps of the upper limb following trauma were investigated 5.6 years after injury. Data according to injury pattern, age, gender, level of amputation and DASH score were collected. RESULTS: Included are 2 unilateral and 3 bilateral forearm amputees and 6 patients with upper arm amputation. Only males were seen with a mean age of 32 years. Amputation occurred following polytrauma in 3 cases while in the other 8 cases the amputated limb was unreconstructably mangled. 8 patients wear a prosthesis. 4 (36 %) patients are unemployed. The mean DASH score was 44.8, in bilateral forearm amputees 74.16, in unilateral upper-arm amputees 38.47 and in unilateral lower forearm amputees 43.33. Patients with bilateral amputation showed the greatest functional and social impairment. Mean pain was 40 % of the pain section in the DASH questionnaire and showed no difference with regard to the level of amputation or bilateral injury. All patients are socially integrated. Patients with unilateral amputation rated psychological impairment higher than functional impairment. CONCLUSION: Patients with macroamputation of the upper extremity show high psychological and functional impairment. Pain, deficits in function and still not optimal prosthetic devices result in a high percentage of unemployment.

Cortical motor activation patterns following hand transplantation and replantation.

We studied cortical activation patterns by functional MRI in a patient who received bilateral hand transplantation after amputation 6 years ago. In the early post-operative period, the patient who had had the hand transplantation revealed strong activation of a higher motor area, only weak activation of the primary sensorimotor motor cortex and no activation of the primary somatosensory cortex. At one-year follow-up, a small increase in primary sensorimotor motor cortex activation was observed. Activation of the primary somatosensory cortex was only seen at the 2-year follow-up. Transplantation after long-standing amputation results in cortical reorganisation occurring over a two-year period.

Effect of total intravenous anaesthesia and balanced anaesthesia on the frequency of coughing during emergence from the anaesthesia.

BACKGROUND: The effects of total intravenous anaesthesia (TIVA) and balanced anaesthesia (BAL) on coughing during emergence from the general anaesthesia have not yet been compared. METHODS: Fifty patients, aged 18-60 yr, undergoing elective lumbar disk surgery were randomly allocated to undergo TIVA (propofol-remifentanil) or BAL (fentanyl-nitrous oxide-sevoflurane). Extubation was performed in the knee-elbow position, documented on video, and subsequently evaluated by blinded examiners. RESULTS: There was no difference between TIVA and BAL patients with respect to patient characteristics, proportion of smokers, surgical time, or time of emergence. The median number of coughs was significantly lower in the TIVA group (1, range 0-9) than in the BAL group (4, range 0-20, P = 0.007). Mean maximal heart rate and mean maximal arterial pressure measured during emergence were also significantly lower in the TIVA group (P = 0.009 and P = 0.006, respectively). CONCLUSIONS: During emergence from anaesthesia in the knee-elbow position, TIVA is associated with significantly less coughing and reduced haemodynamic response when compared with BAL.