Quantitative MRI comparison of multifidus muscle degeneration in thoracolumbar fractures treated with open and minimally invasive approach.

BACKGROUND: Minimally invasive pedicle screw fixation has less approach-related morbidity than open screw placement and is allegedly less traumatizing on paravertebral muscles, as there is no requirement to mobilize and retract the adjacent muscle portion. The approach-related long-term effects to the morphology of the paravertebral muscles are unknown. The purpose of this study was to compare the long-term amount of fatty degeneration of the multifidus muscle in patients treated with a classical open or a minimally invasive approach. METHODS: Fourteen Patients meeting inclusion criteria were selected. In all patients a singular fracture of the thoracolumbar spine with a two-level posterior instrumentation was treated, either using an open approach or a minimally invasive approach. All patients underwent quantitative MRI spectroscopy for quantification of the fatty degeneration in the multifidus muscle as a long-term proof for muscle loss after minimum 4-year follow-up. Clinical outcome was assessed using Oswestry Low Back Pain Disability Questionnaire, SF-36 and VA-scale for pain. RESULTS: The minimally invasive approach group failed to show less muscle degeneration in comparison to the open group. Total amount of fatty degeneration was 14.22% in the MIS group and 12.60% in the open group (p = 0.64). In accordance to MRI quantitative results there was no difference in the clinical outcome after a mean follow up of 5.9 years (±1.8). CONCLUSION: As short-term advantages of minimal invasive screw placement have been widely demonstrated, no advantage of the MIS, displaying a significant difference in the amount of fatty degeneration and resulting in a better clinical outcome could be found. Besides the well-known short-term advantage of minimally invasive pedicle screw placement, a long-term advantage, such as less muscle degeneration and thus superior clinical results, compared to the open approach could not be shown.

[Surgical treatment of ulnar collateral ligament injuries of the thumb metacarpophalangeal joint]. / Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk.

OBJECTIVE: Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb. INDICATIONS: Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures. CONTRAINDICATIONS: Abrasions, wound-healing disturbance, skin disease, osteoarthritis. SURGICAL TECHNIQUE: Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury. POSTOPERATIVE TREATMENT: Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months. RESULTS: Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

[Percutaneous screw fixation of non- or minimally displaced scaphoid fractures]. / Perkutane kanülierte Verschraubung nicht- oder minimal-dislozierter Skaphoidfrakturen.

OBJECTIVE: Providing stability and reduction of the period of immobilisation of non- or minimally displaced scaphoid fractures using a minimally invasive technique. INDICATIONS: Scaphoid fractures of the types A2, B1 and B2 (Herbert's classification) with no or minimal displacement, along with a patient's request for early functional treatment. CONTRAINDICATIONS: Relative contraindications: significant dislocation of the fracture, scaphoid cyst or a too proximal fracture, concomitant fractures of the wrist. Absolute contraindications: pseudoarthrosis, luxation fractures. SURGICAL TECHNIQUE: Minimally invasive percutaneous screw fixation using a double threaded screw. POSTOPERATIVE MANAGEMENT: Postoperative immobilisation in a plaster cast with a thumb inlay for 1-3 weeks until swelling and pain subside. Followed by active physiotherapeutic exercise, however no pressure on the hand for 6 weeks after surgery. RESULTS: Seventy patients with a non- or a minimally displaced scaphoid fracture were treated between 2005 and 2011. We used percutaneous screw fixation as the therapy technique. A total of 57 patients (81%) presented for follow-up. Four patients (5.7%) had an unhealed fracture 6 months postsurgery confirmed. One patient needed revision surgery because of a screw that was too long. None of the patients had a postsurgical infection, haematoma or a complex regional pain syndrome. Smoking and putting pressure on the hand too early have been identified as possible risk factors for the unhealed fractures.

[Osteoconductive behaviour of beta-tricalcium phosphate ceramics in osteoporotic, metaphyseal bone defects of the distal radius]. / Osteokonduktive Eigenschaften von Beta-Trikalzium-phosphat in osteoporotischen, metaphysären Radiusdefekten.

BACKGROUND: Surgical treatment of osteoporotic distal radius fractures with locking plates does not completely prevent loss of reduction. Additional bone deficit stabilisation with the use of bone substitute materials is receiving increased attention. Most knowledge on the in vivo behavior of bone substitutes originates from a small number of animal models after its implantation in young, good vascularized bone. PURPOSE: This paper investigates the osteoconductivity, resorption and biocompatibility of beta-tricalcium phosphate as a temporary bone replacement in osteoporotic type distal radius fractures. PATIENTS AND METHODS: 15 bone samples taken from the augmented area of the distal radius of elderly people during metal removal were examined. RESULTS: The material was found to be osteoconductive, good degradable, and biocompatible. Degrading process and remodelling to woven bone seem to require more time than in available comparative bioassays. CONCLUSIONS: The material is suitable for temporary replacement of lost, distal radius bone from the histological point of view.

Complications following palmar plate fixation of distal radius fractures: a review of 665 cases.

INTRODUCTION: Palmar plate fixation of unstable distal radial fractures is quickly becoming the standard treatment for this common injury. The literature reporting complications consists mainly of isolated case reports or small case series. METHOD: Between February 2004 and December 2009 palmar plate fixation was performed in 665 cases. The overall complication rate was 11.3 % (75 complications). Revision surgery was necessary in 10 % (65 procedures). RESULTS: The reasons for revision surgery were: postoperative median nerve compression (22 patients) and secondary dislocation (9 patients). An ulna shortening osteotomy for ulnar impingement syndrome was necessary in eight cases. Intraarticular screw placement occurred in three patients. There were two flexor pollicis longus, one finger flexor and three extensor pollicis longus tendon ruptures. Posttraumatic compartment syndrome of the forearm requiring fasciotomy occurred in four cases. There were three cases of infection. Nonoperative treatment was necessary in nine patients, who developed a complex regional pain syndrome. Hardware failure occurred in three cases. Hardware removal was performed in 232 (34 %) cases. CONCLUSION: Palmar plate fixation of distal radius fractures is a safe and effective procedure. Nevertheless, complications necessitating a second intervention are relatively common. A proportion of these complications is iatrogenic and can be avoided by improving the surgical technique.

[The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects]. / Der distal gestielte adipofasziale Suralislappen zur Rekonstruktion von Defekten der distalen unteren Extremität.

OBJECTIVE: Problematic tissue defects in the distal one-third of the lower leg represent a special challenge for the operative therapy. The distally based adipofascial sural artery flap is a safe and effective modification of the classical fasciocutaneous sural artery flap technique and makes the reconstruction in this problematic area more feasible. The surgical aim is soft tissue reconstruction with local tissue avoiding free tissue transfer. INDICATIONS: Complex or chronic wounds (maximum width of 8 cm) of the distal lower leg with exposed bone, joints, tendons, and/or neurovascular structures, especially in cases of missing skin perforators. CONTRAINDICATIONS: Arterial vascular disease (stage III-IV), especially peroneal artery occlusion. Postthrombotic syndrome with occlusion of the small saphenous vein. Chronic lymphedema. SURGICAL TECHNIQUE: Preparation of the vascular pedicle of the distally based flap (including small saphenous vein, sural artery and nerve), the adjacent crural fascia and the subcutaneous fat without a skin island. The pivot point is about 6 cm cranial to the malleolus lateralis. The flap can be raised proximally up to the heads of the gastrocnemius muscle. After harvesting the flap there will be a change in blood flow direction in the small saphenous vein. The donor site can be closed primarily. The flap is covered with meshed split skin graft at the end of surgery. POSTOPERATIVE MANAGEMENT: Strict elevation of the extremity for 5 days, then flap conditioning. RESULTS: Between 1997 and 2012, this technique was used in 104 consecutive patients with soft tissue defects in the distal one-third of the lower leg. Flap survival was achieved 91 patients. In 2 patients amputation of the lower leg was necessary at the mid tibia level. In 3 cases flap necrosis occurred, requiring free tissue transfer.

Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthoplasty using the split abductor pollicis longus tendon.

OBJECTIVE: Reduction of pain and gain of functionality in symptomatic osteoarthritis of the first carpometacarpal joint. INDICATIONS: Idiopathic, rheumatic, or posttraumatic osteoarthritis of the first carpometacarpal joint. RELATIVE CONTRAINDICATIONS: Poor general condition, poor condition of the hand's soft tissue/skin, chronic regional pain syndrome, current or recent infections of the hand, heavy manual labor (decision on a by-case basis). SURGICAL TECHNIQUE: Supine position, hand pronated or slightly tilted. Upper arm tourniquet (Esmarch's method). Loupe magnification. Incision over the first extensor compartment. Exposure and incision of the thumb's basal joint. Resection of the trapezium. Exposure of the abductor pollicis longus (APL) tendon. Longitudinal split of the tendon harvesting the distally based ulnar part of the tendon. The split APL tendon is wrapped around the flexor carpi radialis (FCR) muscle tendon, suturing it to the tendon and back to itself. The rest of the split APL tendon is placed into the gap between the scaphoid and the first metacarpal bone, which is followed by wound closure. POSTOPERATIVE MANAGEMENT: Plaster cast (thumb abduction splint) for 4 weeks. Stable commercially available wrist brace for at least 2 more weeks. RESULTS: There were no significant differences between the FCR arthroplasty (Epping's method) and the APL arthroplasty (Wulle's technique) regarding pain (visual analog scale), disability/usability (DASH score), or range of motion. Patients who had undergone APL arthroplasty showed significantly better grip and pinch strength. Furthermore, the operating time was significantly shorter and scars were significantly smaller in APL arthroplasty.

Reconstruction of the thumb tip using palmar neurovascular flaps.

OBJECTIVE: Reconstruction of the tip of the thumb using a neurovascular flap. INDICATIONS: Transverse defects of the thumb's tip or large defects of the palmar pulp (max. 2.0-2.5 cm) with exposure of bone and/or tendons. CONTRAINDICATIONS: Extensive crush injury, heavy wound contamination, circulatory disorders, acute infection, very large defects (> 2.0-2.5 cm finger length), circumferential soft tissue defects, and previous defects/operations (relative). SURGICAL TECHNIQUE: Supine position, hand supinated, tourniquet, loupe magnification. Mid-lateral incisions along both sides of the finger running from the defect to the interphalangeal joint (small defect) or proceeding further proximally. Careful elevation of the flap including both neurovascular bundles leaving dorsal branches of the bundles (long fingers only) and the flexor tendon sheath intact. Suture of the flap in either flexion position (i.e., advancement flap) (Moberg) or by creating an island-flap through an additional transverse skin incision along the flap's base (O'Brien). Finally, closure of the defect at the flap's base using a full thickness skin graft, Z plasty, or V-Y plasty. POSTOPERATIVE MANAGEMENT: Plaster cast (finger slightly flexed) for 2 weeks. RESULTS: Reliable method. Good functional results with good sensibility and only minor reduction in range of motion.

[Soft tissue reconstruction of the distal lower extremity using the 180-degree perforator-based propeller flap]. / Die 180º-Propellerlappenplastik zur Defektdeckung im Bereich des distalen Unterschenkels.

OBJECTIVE: Operative technique of propeller flap reconstruction of soft tissue defects in the distal lower extremity. Soft tissue reconstruction of the distal third of the lower extremity with local, reliable perforator flaps avoiding free tissue transfer. INDICATIONS: Complex wounds (maximum width of 6 cm) of the distal lower extremity with exposed bones, joints, tendons, and neurovascular structures. CONTRAINDICATIONS: Arterial vascular disease (stage III or IV), diabetes mellitus, postthrombotic syndrome, venous ulcers, chronic lymphedema, contusion of adjacent soft tissue, previous radiation, and lack of perforators SURGICAL TECHNIQUE: The perforator represents the pivot point around which rotation of up to 180º of the subfascially harvested flap allows closure of the defect. The proximal donor site can be closed primarily up to a width of 6 cm. POSTOPERATIVE MANAGEMENT: Strict elevation of the extremity for 5 days, then flap conditioning. RESULTS: This technique was used for soft tissue reconstruction in 17 patients. In one patient with diabetes, complete flap necrosis occurred, requiring amputation of the extremity. One case of epidermolysis healed without further surgery.

[Propeller flaps: the reliability of preoperative, unidirectional Doppler sonography]. / Propeller-Lappenplastiken: die Reliabilität der präoperativen, unidirektionalen Dopplersonografie.

BACKGROUND: Propeller flaps represent an elegant and reliable method for soft-tissue reconstruction of the extremities and trunk, obviating the need for free tissue transfer. Preoperative localisation of perforators adjacent to the defect is important regarding the pivot point and length of the flap. Most commonly unidirectional Doppler sonography is used. The reliability of this method regarding propellerflaps has not thoroughly been evaluated. The aim of this study is to assess the positive predictive value of this method for planning propeller flaps. PATIENTS AND METHOD: In a total of 68 patients, soft-tissue reconstruction using propeller flaps was planned with unidirectional Doppler sonography. Defects were located on the lower extremity in 48 cases, the buttock area in 15 cases and the trunk in 5 cases. RESULTS: In 12 cases no adequate perforators were located intraoperatively despite a positive Doppler signal. In the lower extremity Doppler produced a false-positive result in 21% of the cases, whereas in the buttock region only 13% false positives result were found. The positive predictive value overall was 82%. When no perforator was located, flap coverage was achieved using the reverse sural artery flap in 6 cases, the free peroneal artery perforator flap in 3 cases, local advancement flaps in 2 cases and skin grafting in 1 case. DISCUSSION: The reliability of unidirectional Doppler sonography is inadequate for localisation and selection of the dominant perforator when planning propeller flaps. A high rate of false-positive results needs to be anticipated especially distally in the extremities. In 18% of cases an alternative surgical plan was required to achieve soft tissue coverage. We recommend using colour duplex sonography for a more reliable preoperative localisation of perforators.

[Aging and the appearance of the hand]. / Alterung und ideale Asthetik der Hand.

The appearance of the hand is clearly secondary to its function. Nonetheless, aging changes on the hands are of considerable importance to many patients. Although rejuvenation of the hand has attracted increased interest in plastic surgery recently, the dermatologists have dealt with this problem for a longer time. Successful rejuvenation requires thorough analysis of the underlying pathophysiology. Hand aging is characterized by dermal and subcutaneous volume loss resulting wrinkle formation. Aging is also associated with increased visibility of tendons and veins as well as age spots and precancerous lesions. Hand rejuvenation aims at successfully reversing this three-dimensional process. The majority of treatment options address only partial aspects of the aging process. Topical treatments are the mainstay of therapy as these changes are most obvious. As patients will mainly seek advice from dermatologist, this field requires increased attention.

A randomised clinical study comparing palmar and dorsal fixed-angle plates for the internal fixation of AO C-type fractures of the distal radius in the elderly.

Current surgical treatments for distal radial fractures include dorsal and palmar plate fixation. We report results of a randomised study comparing these methods for AO C1-3 fractures. The emphasis was placed on the early postoperative functional recovery within the first 6 months as this interval is of decisive importance for elderly patients. Thirty patients with unilateral AO C1-3 fractures were enroled, 15 were treated with a palmar plate and 15 received a dorsal Pi-plate. Results were assessed 6 weeks, 3 months and 6 months postoperatively focusing on functional recovery. The palmar plate group demonstrated significantly better results in range of motion, grip strength and pain.

[Soft tissue coverage of the distal third of the tibia with fasciocutaneous propeller flaps]. / Die Defektdeckung des distalen Unterschenkeldrittels mit perforatorbasierten 180 degrees -Propellerlappen.

BACKGROUND: The distal third of the tibia is often only amenable to free tissue transfer to cover exposed bone, tendons and neurovascular structures. Using relatively constant perforators of the tibial and peroneal vessels, soft tissue coverage can be achieved with so-called propeller flaps. METHODS: 8 patients presenting with post-traumatic defects over the lateral malleolus and the Achilles tendon were included in this study. A propeller flap based on perforators from the peroneal or tibial artery was used to cover the defect. RESULTS: One case of partial flap necrosis was encountered in a diabetic patient. Transient venous congestion of the flap tip was witnessed in two instances, which resolved without further intervention. No other complications occurred. All patients were fully ambulatory within 8 weeks, except for 1 patient, who required a below-knee amputation. CONCLUSION: The propeller flap has proven to be a versatile and elegant method to obtain soft tissue coverage with local tissue. Contrary to conventional rotation flaps, direct closure of the donor site is possible. Patients are not impaired by bulky flaps and may wear normal shoes. Even in the elderly, this flap was successful.

[Body dysmorphic disorder--dysmorphophobia]. / Body Dysmorphic Disorder--Dysmorphophobie.

Body dysmorphic disorder (BDD) is a rare disease. Although described in the last century it was only recently classified in the DSM-IV. BDD is characterized by an excessive concern about an imagined deformity of the body. Establishing the diagnosis of BDD remains to be demanding, yet of utmost importance for the surgeon. Only a timely diagnosis will prevent dissatisfaction of both the patient and the surgeon. In this article, strategies to cope with such patients after diagnosis are described.

[Tumors of the hand -- results of a long-term study]. / Tumoren der Hand -- Ergebnisse einer Langzeitstudie.

This is a report of a long-term study at the Friedrich-Alexander University of Erlangen-Nurnberg, Germany from 1936 to 1994. We divided tumors into three categories, i.e. skin, soft tissue and bone tumors. 4612 tumors were included in the study. Over the course of the study, a dramatic change in the occurrence of single tumors was noticed. While tumor-like lesions have been on the decline, other types of tumors, especially malignant tumors as well as more advanced stages of tumors have become a common occurrence. We will show that particularly larger institutions experience an ever increasing number of advanced tumors requiring individual approaches.

The windblown hand - diagnosis, clinical picture and pathogenesis.

The syndrome of the windblown hand deformity is a complex constellation of malformations affecting not only the head and the feet but also the hands in a quite distinct manner. In the hand, it involves congenital bilateral flexion contracture with ulnar deviation of the metacarpophalangeal joints. The thumb is characteristically adducted (reaching the palm; "thumb-in-palm deformity") with flexion of the MP joint and hyperextension of the IP joint. The etiology is basically unknown. We present two theories based on knowledge derived from the disciplines of evolution biology and embryology. We believe that the atavistic appearance of phylogenetically primitive muscle groups in conjunction with an impaired rotation of the extremities during embryological development account for this malformation syndrome.

Different preparation methods to obtain platelet components as a source of growth factors for local application.

BACKGROUND: Autologous platelet components were recently used as part of tissue-engineering strategies in oral and maxillofacial surgery. Various preparation methods were investigated to define standardized blood bank components and to collect data on the growth factor content of human platelets before and after storage. STUDY DESIGN AND METHODS: Apheresis platelets (AP), buffy coat-derived platelets (BCP), platelets prepared by tube method (TP), and highly concentrated samples prepared from AP and from BCP were evaluated for standard quality criteria of platelet components and for their concentration of transforming growth factor (TGF)-ss1, platelet-derived growth factor (PDGF)-AB, and PDGF-BB. AP were stored for 5 days. On Days 3 and 5, these components and freshly prepared, highly concentrated samples were evaluated for the same measures. RESULTS: Platelet concentration in TP was lower than that in the other groups (p<0.05). However, the concentrations of PDGF-AB, PDGF-BB, and TGF-ss1 were comparable in the three groups. TP showed higher spontaneous CD62 expression than did AP and BCP. The three preparation procedures resulted in significantly different WBC contamination, with the highest levels in TP. For the whole series of measurements, there was a strong correlation between growth factor levels and platelet concentration (p<0.05), which was due to the face that the growth factor content of concentrated platelet samples was tenfold that of AP, BCP, and TP. In TP, the WBC concentration was correlated with PDGF levels (p<0.05). After 5-day storage, the mean levels of PDGF-AB, PDGF-BB, and TGF-ss1 were 57.1, 43.0, and 72.0 percent of the initial values in AP. Overall, multiple regression analysis revealed the following factors influencing the measured growth factor concentrations: platelet concentration, baseline CD62 expression, lactate production, and WBC contamination. CONCLUSION: Various methods enable the preparation of platelet components and of highly concentrated components for local use according to standard blood banking criteria. The obtained components differ, particularly in their WBC content and in vitro platelet activation. These findings are relevant for planning and evaluating further studies of locally usable autologous platelet components.