Torque acting on biodegradable magnesium screws during intramedullary insertion into a metacarpal bone - a biomechanical study.

Recently, biodegradable implants made from magnesium (Mg) alloys have been developed to obviate the need for later implant removal. Mg-based cannulated compression screws (CCS) are ideal for intramedullary screw (IMS) fixation of metacarpal fractures. The present study aimed at investigating the torque acting on Mg-based CCS at failure and at intramedullary metacarpal insertion. The devices were CE certified Magnezix 2.7 and 3.2 mm CCSs (Syntellix®, Hannover, Germany). Torque at failure was measured in a synthetic bone model using a standardized polyurethane foam block. In a second assessment, insertional torque was measured in ten cadaveric metacarpal bones. Mean torque at failure for the 2.7 mm and 3.2 mm CCSs was 42.8 Ncm (±1.9 Ncm) and 63.0 Ncm (±2.2 Ncm), respectively. In the human cadaver model, the torque distribution curve at metacarpal insertion showed three peaks. The highest reached 53.6% of the lowest torque at failure measured in the synthetic bone model for the 3.2 CCS (31.4 vs. 58.6 Ncm). The mean difference between peak torque at metacarpal insertion and torque at failure was 38.3 Ncm (99% CI [33.6, 43.0 Ncm], p < 0.0001). In terms of torque load, Mg-based CCSs are suitable for IMS fixation of metacarpal fractures. Biodegradable implants may represent an important improvement of this treatment method; confirmation by in-vivo studies is needed.

Intramedullary screw fixation of metacarpal and phalangeal fractures - A systematic review of 837 patients.

Intramedullary screw (IMS) fixation is increasingly used as an alternative treatment option in metacarpal and phalangeal fractures of the hand. However, this technique is currently the subject of controversy among hand surgeons. The aim of this systematic review was to gain insight on radiological, functional and patient-rated outcomes reported in literature. A comprehensive literature search of PubMed, Embase, CENTRAL and CINAHL databases was conducted on March 1st, 2021. All studies reporting on fracture union, complications, and functional and patient-rated outcome in IMS fixation of metacarpal and/or phalangeal fractures were selected. Two prospective and 16 retrospective cohort studies were included, encompassing a total of 837 patients with 958 fractures (693 metacarpal, 222 proximal phalangeal and 43 middle phalangeal). Mean surgery duration was 26.4 min (range 5-60 min). Union was ultimately achieved in all fractures in a mean of 5.7 weeks (range 2-12 weeks). The procedure-related complication rate was 3.2%. The most frequently reported complication was limitation of joint motion, occurring in 2.0% of cases. Incidence of other complications, including loss of reduction, infection and screw protrusion did not exceed 1%. Overall mean total active motion averaged 243° and grip strength reached 97.5% of the contralateral side. The Disabilities of the Arm, Shoulder and Hand (DASH) score averaged 3.7 points. Duration of sick leave was 7.3 weeks. According to the findings of this systematic review, IMS fixation is a time-saving and safe minimally invasive solution for both metacarpal and phalangeal fractures, with a low rate of complications and promising functional and patient-rated results.

Ulnar Variance in Scaphoid Fractures: Retrospective Analysis of 182 Cases.

BACKGROUND: Literature provides little and controversial evidence regarding the influence of ulnar variance (UV) on the incidence of scaphoid fractures. The aim of this retrospective study was to assess UV in a large number of patients with acute scaphoid fracture in comparison to a control group of the same population. METHODS: During a two year period, 182 patients with acute scaphoid fractures (fracture group) and 182 ethnicity-, gender- and age-matched patients with wrist contusions (control group) were treated in three non-university hospitals. Using standardized digital wrist radiographs, UV values were measured by means of the method of perpendiculars by two independent examiners. The UV values of the fracture group were then compared to the UV values of the control group. RESULTS: Analyses of the agreement between the two raters resulted in a good to excellent inter-item correlation of 0.89, with a high intra-class coefficient of 0.93 (95% confidence interval: 0.87-0.95). Mean (SD) UV value was -0.82 mm (1.77) in the fracture group and 0.27 mm (1.44) in the control group. Paired sample t-test showed a significant difference between the two groups (p < 0.0001). CONCLUSIONS: According to this study, patients with scaphoid fractures are significantly more likely to show a negative UV than matched patients with wrist contusions.

Lucerne cast - LuCa: Functional conservative treatment of extra-articular fractures of the proximal phalanges of the fingers (with video).

Most extra-articular fractures of the proximal phalanges (P1) of the triphalangeal fingers can be treated conservatively with good results. Prerequisites for successful fracture treatment are intact soft tissue without any lesions of the extensor hood and stable initial fracture reduction. The key to functional conservative treatment of P1 fractures is to immobilize the metacarpophalangeal joints in flexion, resulting in equilibrium of flexor and extensor forces across the fracture site, which converts these inherently unstable fractures into relatively stable fractures. Precise initial application of the cast and regular follow-up of the patient is essential for successful treatment. By means of an instructional video, an overview of the equipment required is given, and the correct application of a Lucerne Cast is illustrated step-by-step.

[Treatment of an osteo-fascio-cutaneous defect of the femur with a serial connected flow-through free-flap]. / Therapie eines osteo-fascio-cutanen Femurdefektes mit in Reihe geschalteter Durchflusslappenplastik.

Covering large osteo-fascio-cutaneous defects after debridement often calls for elaborate soft tissue reconstruction. Large tissue loss or structural damage that requires distinct repair is rarely coverable by a single conventional flap. Here, we report the case of serial flap coverage using sequentially connected fibular and latissimus dorsi free flaps.

[Bilateral Instability of the Interphalangeal Articulation of the Thumb in Hajdu-Cheney Syndrome]. / Instabilität der Daumenendgelenke beidseits bei Hajdu-Cheney-Syndrom.

We present the case of a 52-year-old lady suffering from Hajdu-Cheney syndrome, a rare hereditary disease, which was referred to our clinic on the basis of progressive instability of the interpalangeal articulations of both thumbs. Even if acroosteolysis of the distal phalangeal bones is typical for this disease, to the best of our knowledge the interphalangeal instability has not been described before.

[An immobilising malignant phyllodes tumour of the breast]. / Immobilisierendes malignes Cystosarcoma phylloides der Brust.

Phyllodes tumours of the breast are rare occurrences, but they can reach huge dimensions. Descriptions of tumours whereby the women are immobilised as a consequence of the size of the tumour, are hard to find in the literature. In this presentation we show a case of a woman in otherwise healthy condition with a giant phyllodes tumour of her left breast. Because of the weight of the tumour, the patient could not leave her bed for more than 6 months.

[Long-term outcome after surgical treatment of breast asymmetry: analysis of the patient's perspective in 51 cases]. / Langzeitresultate nach chirurgischer Behandlung von Brustasymmetrien aus Sicht der Patientinnen: Eine Analyse von 51 Fällen.

INTRODUCTION: Literature provides 3 studies only investigating the long-term outcome after surgical correction of breast asymmetry. The goal of this study was to analyse from a patient's perspective, which factors influence postoperative satisfaction most. PATIENTS AND METHODS: All patients undergoing surgical treatment for breast asymmetry between 2000 and 2009 were included. With help of the visual analogue scale the patients conducted a subjective assessment of their own long-term result using the following parameters: overall satisfaction, symmetry, size, shape, scarring and sensitivity. Anthropometric measurements of the breasts followed. RESULTS: 51 patients (80% follow-up) were seen 2-11 (mean 5±2.5) years postoperatively. The following mean values were recorded for overall satisfaction 8.31 (±1.91), symmetry 7.86 (±2.25), size 8.42 (±1.93), shape 8.12 (±2.03), scarring 7.82 (±1.94) and sensitivity 7.92 (±2.19). Overall satisfaction increased significantly with good scores for the parameters symmetry [p=0.01] and shape [p=0.048]. Neither size [p=0.46] nor scarring [p=0.69] nor sensitivity [p=0.34] had a statistically significant influence on overall satisfaction. Furthermore, overall satisfaction did not depend on the surgical technique, preoperative size, preoperative asymmetry, age of the patient at time of surgery, period of time between the operation and the assessment, resected weight (absolute and difference between left and right) or on postoperative symmetry of the nipple areola complex. CONCLUSION: In our patients, long-term overall satisfaction after surgical correction of breast asymmetry was primarily dependent on symmetry and shape. Size, scarring and sensitivity did not have a statistically significant influence on postoperative overall satisfaction. This also applied to preoperative size, preoperative extent of asymmetry, age of the patient at time of surgery, surgical technique and the time span between the operation and the assessment.

[The interesting case: unilateral hypoplasia of the breast in Becker nevus syndrome]. / Der interessante Fall: einseitige Hypoplasie der Brust bei Becker Nävus Syndrom.

The Becker nevus syndrome is defined by the association of a Becker's nevus with ipsilateral breast hypoplasia and/or musculoskeletal disorders. There are only a few dozen case reports in the literature. We here present the case of a 20-year-old female patient who was treated in our clinic due to a breast asymmetry.

Semi-occlusive dressing for the treatment of fingertip amputations with exposed bone: quantity and quality of soft-tissue regeneration.

Nineteen fingertip amputations with exposed bone were treated with a semi-occlusive dressing. The quantity and quality of the regenerated soft tissue was examined. In all 19 fingers there was sufficient uncomplicated healing such that secondary surgical procedures were not needed. At follow-up 6-18 months after the injury, soft tissue thickness around the bone of the distal phalanx measured 6.0 mm (SD 1.6) on the palmar aspect (opposite side 7.0 mm (SD 0.8)) and 4.2 mm (SD 1.7) distally (opposite side 4.5 mm (SD 0.8)). The two-point discrimination was 4 mm (SD 2) (opposite side 3 mm (SD 1)). The skin healed almost without scarring and the dermal ridges reformed. The regeneration of the soft tissue thickness to almost 90% of its former extent is higher than we expected.

[One-stage reconstruction of facial defects after tumor resection with the Integra system]. / Integra zur einzeitigen Defektdeckung nach Tumorresektion im Gesichtsbereich.

BACKGROUND: In 2010 excellent aesthetic results after basal cell carcinoma excision and one-stage coverage with Integra without split thickness skin graft (STSG) were published in a series of 10 Asian patients. Our aim in this study was to verify these results in a series of Caucasian patients and evaluate this procedure as a possible new standard. PATIENTS AND METHODS: 6 patients with facial basal cell carcinoma were treated by regular excision with 3 mm safety margins and one-stage coverage with Integra without STSG, followed by a clinical evaluation and fotodocumentation. RESULTS: In 3 patients local infection occurred with a complete loss of the Integra. 2 out of these 3 patients showed an unaesthetic scar and are considering another surgical approach for correction. The other 3 patients had an uneventful course, unfortunately 2 out of these patients (67%) developed an unaesthetic scar as well and are also considering surgical correction. CONCLUSION: Because of aesthetically unsatisfactory results and high infection rates we abandoned this procedure after 6 patients only. Our standard remains excision with 3 mm safety margins, histological analysis and one-stage repair with local facial flaps.

[SPECT/CT in diagnostics of the hand joint]. / SPECT/CT in der Handgelenkdiagnostik.

CLINICAL/METHODICAL ISSUE: Hand and wrist pain remains a diagnostic challenge, both for hand surgeons and for radiologists. Especially chronic wrist pain is often hard to localize clinically and further cross-sectional imaging is often indispensable. STANDARD RADIOLOGICAL METHODS: The well-established standard for non-invasive diagnostic imaging in chronic wrist pain is magnetic resonance imaging (MRI). METHODICAL INNOVATIONS: Recently, state-of-the-art single photon emission computed tomography/computed tomography (SPECT/CT) systems have been introduced into the diagnostic array for musculoskeletal conditions. Besides morphological data SPECT/CT also provides metabolic information. PERFORMANCE: SPECT/CT allows an exact detection and precise anatomical mapping of different pathologies of the wrist, which is often crucial for therapy. ACHIEVEMENTS: In patients with chronic wrist pain, SPECT/CT is more specific than MRI. It is also beneficial in patients with posttraumatic conditions and metal implants and may serve as a problem-solving tool in difficult cases. PRACTICAL RECOMMENDATIONS: It is considered that SPECT/CT imaging is useful if MRI results are equivocal or present no clearly leading pathology. A primary examination with SPECT/CT seems to be a reasonable option for patients with certain bone pathologies, metal implants and non-specific wrist pain.

Extra-articular fractures of the proximal phalanges of the fingers: a comparison of 2 methods of functional, conservative treatment.

PURPOSE: For nonsurgical treatment of fractures of the proximal phalanges of the triphalangeal fingers, different dynamic casts have been described. The main principle behind these casts is advancement and tightening of the extensor hood, caused by a combination of blocking the metacarpophalangeal joints in flexion and actively flexing the proximal interphalangeal joints. In contrast to established treatment protocols using functional forearm casts, the Lucerne cast allows for free mobilization of the wrist joint. The purpose of the current multicenter study was to compare the results of conservative, functional treatment using 2 different methods, either a forearm cast or a Lucerne cast. METHODS: Over a 2-year-period, a prospective, randomized, multicenter study was conducted at 4 hospitals in Switzerland. Clinical and radiological results of 66 consecutive patients having 75 extra-articular fractures of the proximal phalanges were recorded through a minimum follow-up of 3 months. Intra-articular and physeal fractures, pathological fractures, open fractures, concomitant injuries of the tendons or collateral ligaments, and accidents more than 7 days before presentation were excluded from the study. RESULTS: Radiographically, there were no statistically significant differences between the 2 groups in terms of palmar apex angulation and radial or ulnar angulation. There were no differences in total active range of finger motion. Wrist joint motion at the time of cast removal was statistically superior in patients treated with Lucerne cast. However, there were no significant differences in wrist joint motion at 12 weeks of follow-up. CONCLUSIONS: The clinical and radiological results achieved with the Lucerne cast are comparable to those of established treatment. Well-reduced, minimally angulated, or nonangulated fractures of the proximal phalanges of the fingers can be effectively treated using functional casts without immobilizing the wrist. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis: long-term follow-up.

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22-28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.

[The influence of ulnar variance on the healing of scaphoid fractures]. / Einfluss der Ulnavarianz auf die Kahnbein-Frakturheilung.

The recent literature shows that a negative ulnar variance could pose a risk factor for scaphoid fractures.The aim of the current study was to determine whether the ulnar variance also affects the healing of a scaphoid fracture.2 cohorts of 50 patients each, with either a scaphoid fracture or a non-union, were retrospectively compared. The ulnar variance was measured on the X-rays using the Gelberman method.The average value of the ulnar variance in patients with a scaphoid fracture was -1.0 mm. The negative ulnar variance was measured in 64% of the patients. In the second group with scaphoid non-union, the average value of ulnar variance was -0.8 mm. The negative ulnar variance was similarly high, in 68% of the patients. Our results demonstrated almost identical values in both groups with regard to ulnar variance or its distribution, neutral, negative or positive, without statistical significance.Thus, we can exclude the negative ulnar variance as a risk factor for the development of non-union in cases of scaphoid fractures.

[Piezoelectric osteotomy in hand surgery: the autologous osteocartilage transplantation for joint reconstruction]. / Piezoelektrische Osteotomie in der Handchirurgie: autologe osteokartilaginäre Transplantation zur Gelenksrekonstruktion.

This article demonstrates the use of this piezoelectricsurgical device during an autologous osteocartilage transplantation in which the head of the phalanx of a finger is reconstructed from part of the phalanx condyle of a toe.

[Reconstruction of isolated axillary nerve lesions: clinical and electrophysiological long-term results]. / Rekonstruktion isolierter Läsionen des N. axillaris: klinische und elektrophysiologische Langzeitresultate.

PURPOSE: The purpose of this retrospective study was the clinical and electrophysiological assessment of long-term results following surgical treatment of isolated axillary nerve lesions. PATIENTS AND METHOD: 10 patients, who underwent axillary nerve reconstruction using a nerve graft (80%) or a neurolysis alone (20%), with a follow-up period of 6.7 years (1.6-10.8 years) on average, were included in the study. In addition to the clinical examination, we examined reinnervation by electrophysiological methods and analysed their correlation to clinical results. RESULTS: 30% of the patients had muscle strength of M5 and full active range of motion of 180°, 40% reached M4 and averaged 170° (80-180°), 30% of the patients M3 and 65° (40-90°). In patients with M5, muscle compound action potential averaged 40% of the contralateral side (21-62%), in patients with M4 36% (29-58%), and in patients with M3 7% (3-11%). Good results were associated with younger patient age, a short delay prior to the operation and neurolysis alone (indicated by intraoperative electroneurography). CONCLUSION: The good results confirm our treatment algorithm for isolated axillary nerve lesions by neurolysis alone or reconstruction with autologous nerve transplantation. Measurement of compound muscle action potential is a valuable addition to difficult clinical assessment, as its amplitude enables quantification of axillary nerve recovery.

[Extraarticular proximal phalangeal fractures of the hand: Functional conservative management using the Lucerne Cast (LuCa) - a preliminary prospective study]. / Frühfunktionell-konservative Behandlung extraartikulärer Grundgliedfrakturen der Hand mit dem Luzerner Cast (LuCa) - Eine prospektive Pilotstudie.

AIM: The purpose of our prospective study was to document the clinical and radiological results of conservative-functional treatment of extraarticular proximal phalangeal fractures without immobilisation of the wrist. METHODS: The Lucerne Cast (LuCa) resembles a circular metacarpal brace leaving bare both flexion creases, the rascetta and the distal palmar flexion crease. Dorsally, the brace expands to beyond the proximal interphalangeal joints, fixing the metacarpo-phalangeal joints in an intrinsic plus position, thus causing the extensor aponeurosis to tighten and to move distally. Clinical and radiological results of 15 consecutive patients with a total of 20 fractured proximal phalanges were prospectively recorded through a minimum follow-up of 3 months. RESULTS: Fracture consolidation was achieved in all patients, with nine cases showing a dorsal angulation of 2 °-16°. A slight radial or ulnar deviation, respectively, was present in four cases (3 °-5°). Radiologically, a minor rotational deformity of 5° in supination was found in 3 cases. At a follow-up of 12 weeks, a mean total range of active motion (summation of active range of motion in all three finger joints, TAM) of 240° (minimum 200°, maximum 290°) was achieved. CONCLUSIONS: The results of our prospective clinical trial are comparable to those of already established treatment protocols. Since the Lucerne Cast allows free mobilisation of the wrist joint, the cast is comfortable to wear and may have relevance in the treatment of disabled patients, who only can be mobilised with crutches or walkers.

[Glomangiomatosis on the hand. A case report]. / Glomangiomatose der Hand. Ein Fallbericht.

Glomus tumours are solitary benign lesions most frequently located subungually on fingers and toes. In the rare case of a glomangiomatosis, the typical glomus cells are found on the altered vessel wall of the angiomatosis. Due to the rarity of this disease, no therapeutic golden standard has been mentioned in the literature, and a conservative treatment is usually adopted. The case of a 20-year-old craftsman with congenital, painful glomangiomatosis on his left dominant hand, progressively limiting the functionality of this limb, is reported. Two years after unsuccessful partial tumour resection, a surgical treatment based on radical tumour resection in terms of a finger amputation was performed. The 1-year follow-up showed no signs of pain for the patient.