WALANT-Epinephrine injection may lead to short term, reversible episodes of critical oxygen saturation in the fingertips.

INTRODUCTION: Although the WALANT technique's long-term safeness has been demonstrated in many studies, there are only few data investigating its short-term effects on tissue perfusion and oxygen levels. It was hypothesized that, temporarily, critical levels of tissue perfusion may occur. METHODS: Seventeen patients, who were scheduled for different procedures in WALANT technique, were injected with 5-7 ml of 1% Articain containing 1:200,000 epinephrine at the finger base. Capillary-venous oxygen saturation, hemoglobin volume in the capillaries, and relative blood flow in the fingertips were recorded once per second by white light spectrometry and laser Doppler flowmetry before, during and after injection for an average of 32 min. RESULTS: Clinically, no persistent tissue malperfusion was observed, and there were no postoperative complications. Capillary-venous oxygen saturation was reduced by ≥ 30% in seven patients. Critical levels of oxygen saturation were detected in four patients during 13 intervals, each lasting for 132.5 s on average. Oxygen saturation returned to noncritical values in all patients by the end of the observation period. Blood flow in the fingertips was reduced by more than 30% in nine patients, but no critical levels were observed, as with the hemoglobin. Three patients demonstrated a reactive increase in blood flow of more than 30% after injection. CONCLUSIONS: Injection of tumescent local anesthesia containing epinephrine into finger base may temporarily cause a substantial reduction in blood flow and lead to critical levels of oxygen saturation in the fingertips. However, this was fully reversible within minutes and does not cause long-term complications.

Analysis of recurrence and complications after percutaneous needle fasciotomy in Dupuytren's disease.

INTRODUCTION: The partial aponeurectomy for treatment of Dupuytren's contracture represents the gold standard for treatment of Dupuytren's contracture. In selected cases, the alternative is the percutaneous needle fasciotomy (PNF). MATERIALS AND METHODS: Between 2008 and 2018, 80 rays in 64 patients were treated using PNF. 53 patients (68 rays) were reviewed with a mean follow-up of 31 months. RESULTS: The recurrence rate was 18.9%. 49 patients with 62 rays had a totally free extension intra-operatively (92.4%). There were no complications. Only one patient reported a transient dysesthesia (1.8%) in the zone of operation. 86% of all patients would undergo the treatment again, if necessary. Patients were able to return to their job in an average of 5.5 days. CONCLUSIONS: PNF is reliable and relatively simple to perform compared to partial aponeurectomy. Therefore, the PNF could be seen as a serious alternative for selected cases.

Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions.

INTRODUCTION: The diagnostic value of clinical tests and magnetic resonance (MR) imaging for the investigation of triangular fibrocartilaginous complex (TFCC) lesions is not clear due to a lack of clinical data. MATERIALS AND METHODS: We retrospectively analyzed 908 patients who underwent clinical tests and arthroscopy for suspected TFCC lesions at our institution. Further, MR imaging findings concerning the TFCC were gathered. We correlated clinical tests and MR imaging findings with those obtained during arthroscopy, and we calculated sensitivity, specificity, as well as positive and negative predictive values. RESULTS: In the whole cohort, the positive predictive values of all clinical tests were low, ranging from 0.53 to 0.55. The ulna grinding test had the highest sensitivity, but lowest specificity. Sensitivity and specificity of the ulnar fovea sign and magnetic resonance imaging were similar, ranging from 0.73 to 0.76, and from 0.41 to 0.44, respectively. To some degree, the diagnostic value seemed to depend on the Palmer class of TFCC lesion. CONCLUSIONS: According to this study, clinical tests and MR imaging findings are of very limited diagnostic value for the diagnosis of TFCC lesions.

The effect of individual isometric muscle loading on the alignment of the base of the thumb metacarpal: a cadaveric study.

Stability of the thumb carpometacarpal joint relies upon equilibrium between its ligaments, muscular support and joint congruity. We wanted to identify the muscles important in preventing or increasing dorsoradial subluxation of this joint. In ten cadaveric hands, a Fastrak® motion tracking device was used to assess the effects of individual isometric muscle loading on the base of the thumb metacarpal relative to the radius and to the base of the middle finger metacarpal. We found that the first dorsal interosseous muscle caused the least dorsoradial translation and highest distal migration of the base of the first metacarpal, whereas abductor pollicis longus was the primary destabilizer, increasing dorsoradial misalignment. The findings show different impacts of these muscles on joint alignment and stability, which suggests that treatment should be targeted to enhance the action of the primary stabilizing muscle, the first dorsal interosseous muscle.

[Primary adaptive vs. secondary wound closure in hand infections - differences and benefits]. / Primär adaptierende vs. sekundäre Wundverschlüsse bei Infektionen der Hand - Unterschiede und Vorteile.

BACKGROUND: Hand infections are common surgical emergencies. There are still controversial opinions regarding the ideal timing of wound closure after radical débridement of the infection. The aim of this retrospective study was to compare the outcome of primary adaptive and secondary wound closures after operative débridement in patients with hand infections. METHODS: We retrospectively analysed all infections of the hand treated operatively in our hospital in the years 2011 and 2012 with a follow-up of at least 6 months. We included 16 patients with primary adaptive wound closure (PWC) and 12 patients with secondary wound closure (SWC) in this study. The evaluated parameters were the need for re-operations, the length of hospital stay, the overall satisfaction with the treatment, the characteristics of the scar and the mobility of the hand. RESULTS: No patient had to be re-operated after PWC or SWC, respectively. Patients in the PWC group were kept significantly shorter as inpatients in comparison to patients in the SWC group (3.0 days vs. 5.1 days; p=0.048). Overall patient satisfaction with the treatment and the scar was comparable for both groups, as was the re-establishment of the mobility of the treated hand to preoperative levels. CONCLUSION: This study shows that wounds after radical débridement for infection of the hand can be closed primarily adaptive without disadvantages for the patient. The length of hospitalisation is significantly shorter if the wound is closed primarily adaptive, a fact that is important for patient comfort and the socio-economic system. Both, primary adaptive and secondary wound closures generally have good outcomes with possible advantages for primary adaptive wound closures concerning the characteristics of the scar.

Long-term results of dorsal intercarpal ligament capsulodesis for the treatment of chronic scapholunate instability.

The purpose of this study was to assess the clinical and radiological outcomes of dorsal intercarpal ligament capsulodesis for the treatment of static scapholunate instability at a minimum follow-up of four years. A total of 59 patients who underwent capsulodesis for this condition were included in a retrospective analysis after a mean of 8.25 years (4.3 to 12). A total of eight patients underwent a salvage procedure at a mean of 2.33 years (0.67 to 7.6) and were excluded. The mean range of extension/flexion was 88° (15° to 135°) and of ulnar/radial deviation was 38° (0° to 75°) at final follow-up. The mean Disabilities of the Arm Shoulder and Hand (DASH) score and Mayo wrist scores were 28 (0 to 85) and 61 (0 to 90), respectively. After significant improvement immediately post-operatively (p < 0.001 and p = 0.001, respectively), the mean scapholunate and radiolunate angles deteriorated to 70° (40° to 90°) and 8° (-15° to 25°), respectively, at final follow-up, which were not significantly different from their pre-operative values (p = 0.6 and p = 0.4, respectively). The mean carpal height index decreased significantly from 1.53 (1.38 to 1.65) to 1.48 (1.29 to 1.65) indicating progressive carpal collapse (p < 0.001); 40 patients (78%) had radiological evidence of degenerative arthritis. Capsulodesis did not maintain carpal reduction over time. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist.

Scaphoid morphology and clinical outcomes in scaphoid reconstructions.

Scaphoid malunion and carpal malalignment can result after scaphoid reconstruction, if the two fragments are not properly reduced before fixation. However, currently there is no information about which degree of deformity or malalignment can be tolerated without impairing clinical function. The purpose of this study was to investigate the influence of the scaphoid morphology and carpal alignment on clinical outcomes after scaphoid reconstruction. A total of 65 patients with an average age of 29 years were followed-up after a mean period of 45 months. In all patients, osseous union after a first-time scaphoid reconstruction in the middle third had been confirmed. Scapholunate (SL) and radiolunate (RL) angles were obtained on plain radiographs as were intrascaphoid (ISA) and dorsal cortical (DCA) angles and the height/length (H/L) ratio of the reconstructed scaphoid on computed tomography (CT) scans. These parameters were correlated with clinical outcome measures. RL angles correlated significantly with wrist range of motion, grip strength and pain levels, whilst SL angles, ISA, DCA and H/L ratio failed to show significant correlations. Our data suggest that clinical outcome is correlated with correct restoration of bone morphology and carpal alignment. After reconstruction, the RL angle should not exceed 10°.

Revision surgery after trapeziometacarpal arthroplasty.

BACKGROUND: The majority of patients with trapeziometacarpal joint (TMJ) arthritis can be successfully treated with some form of arthroplasty. Residual pain therefore is rather uncommon, but particularly difficult to treat. The aims of this study were to determine the number of patients in need of additional surgery; to identify the most common causes for persistent pain and to establish a treatment algorithm. PATIENTS: Twelve patients (11 females, 1 male) who had undergone secondary surgery after TMJ arthroplasty were retrospectively analyzed at a mean time of 32 months after the primary procedure. Parameters included the indication for secondary surgery, the type of procedure, the ultimate range of motion, residual pain levels, upper extremity function assessed by the DASH score and the distance from the first metacarpal bone to the scaphoid. RESULTS: The overall results were assessed according to the Conolly score. The revision rate after primary arthroplasty at our institution was 2.9%. Most common problems for secondary surgery included mechanical pain due to crepitation of the base of the first metacarpal bone, neuropathy of the superficial branch of the radial nerve and concomitant scaphotrapezial arthritis. A total of 19 procedures were performed resulting in two good, five fair and five poor results. A treatment algorithm is presented.

Gadolinium-enhanced preoperative MRI scans as a prognostic parameter in scaphoid nonunion.

The purpose of this prospective study was to correlate preoperative gadolinium-enhanced MRI scans with intraoperative bleeding of the proximal fragment and postoperative union in a series of consecutive patients with established scaphoid nonunions. In 60 patients (6 females, 54 males) with a mean age of 29 years, scaphoid perfusion was judged preoperatively as normal, impaired or absent using a gadolinium-enhanced MRI scan. Scaphoid reconstruction was performed using a nonvascularized bone graft and screw fixation. Perfusion of the proximal fragment was assessed intraoperatively in 49 of 60 patients; compromised or absent vascularity was predicted with a specificity of 90% by contrast-enhanced MRI. However, there was no significant correlation between preoperative MRI assessment of vascularity and subsequent union of the scaphoid.

[New concepts in local burn wound therapy]. / Neue Konzepte in der Oberflächentherapie bei Verbrennungswunden.

Local burn wound care represents an integral part in the treatment of burn victims. A primary treatment goal is to prevent superficial infections, which can lead to life-threatening bacteraemia and sepsis. Secondary goals include improvement of functional and aesthetic outcome of the regenerating skin or scar tissue. Within the last few years numerous innovations have been evolved and some have already been incorporated into the clinical routine. In line with this, the first mid-term studies can be found in the literature. For instance, a hydrosurgical system can now be used for debridement and novel skin substitutes like Suprathel and Matriderm are commercially available. This review article summarises the most recent innovations in local burn wound care and puts them into a scientific perspective.

[Early active motion after transfer of the extensor indicis tendon--a randomised prospective trial]. / Die frühaktive Nachbehandlung nach Extensor indicis-Sehnentransposition--eine prospektiv randomisierte Studie.

BACKGROUND: We conducted a prospective randomised trial to compare the postoperative results and complications following two postoperative treatment protocols (dynamic motion vs. early active motion) after transfer of the extensor indicis tendon. PATIENTS AND METHODS: 21 patients (10 female, 11 male) were randomly assigned to two treatment protocols after transfer of the extensor indicis tendon. In one group of patients ("dynamic"), the reconstructed tendon was extended passively with a rubber band system, in the other study group ("active"), early active extension of the thumb was initiated. Active range of motion in the interphalangeal (IP) and metacarpophalangeal joints (MP) as well as grip and pinch strength were evaluated after the third, fourth, sixth and eighth postoperative week. All complications during the first postoperative year were noted. Statistical analysis was performed with chi-square and Mann-Whitney U-tests. RESULTS: After the eighth postoperative week, in the IP joint an average range of motion of 69 degrees (45-110 degrees) was found in the dynamic study group and 58 degrees (40-75 degrees ) in the active study group. After three weeks, patients treated with the dynamic treatment protocol demonstrated significantly (p=0.03) greater ranges of motion, during the further treatment course no significant differences between the two groups were detected. After eight weeks, the average grip and pinch strength was 66 %/73 % of the contralateral side in the dynamic study group and 63 %/71 % in the active study group. CONCLUSION: With respect to the small groups of patients, both treatment protocols demonstrate comparable clinical results after 8 weeks. Early active motion does not result in a higher rate of complications but fails to speed up rehabilitation.

[Functional and aesthetic refinements of free flap coverage at the dorsum of the hand and distal forearm]. / Funktionelle und ästhetische Gesichtspunkte bei der Defektdeckung der Streckseite an Hand und distalem Unterarm mit freien Lappenplastiken.

INTRODUCTION: Free coverage of exposed functional structures of the hand and distal forearm can be achieved using a variety of free flaps. However, there is a lack of data in the literature which tissue components are best used for defect coverage of this specific area regarding aspects such as tendon gliding and tissue elasticity. The purpose of this retrospective study was to compare and to evaluate the functional and aesthetical results using free cutaneous, fascial and muscle flaps. PATIENTS AND METHODS: Between 1994 and 2002, a total of 56 patients underwent free flap coverage at the dorsal side of the hand and forearm at our institution. Of these patients, 20 with 21 free flaps met the study criteria and were available for follow-up examination. Depending on the tissue component used patients were allocated into three different groups. In group 1 eight patients received a fascial flap, in group 2 eight a cutaneous flap and in group 3 five a muscle flap. The mean follow-up was 50 months (range: 4-103 months). At follow-up examination the patients answered the Client Satisfaction Questionnaire (CSQ 8) and the DASH questionnaire. RESULTS: Regarding range of motion of the wrist and fingers, fascial flaps clearly showed the best results. Concerning grip strength and pinch grip, fascial and cutaneous flaps demonstrated the same results. Patients with cutaneous flaps showed the best DASH score. Regarding the overall aesthetical outcome, fascial and cutaneous flaps were far better than muscle flaps. Donor site morbidity was lowest for fascial flaps followed by muscle flaps and was highest for cutaneous flaps. CONCLUSION: Cutaneous and fascial flaps had the best functional and aesthetical results. Fascial flaps achieved the best aesthetical outcome of the donor site. We recommend free fascial flaps and cutaneous flaps as the first choice due to their advantages in the specific area of the dorsal site of the hand and distal forearm which requires pliable and thin tissue coverage.