Operative treatment of the chronic post-traumatic boutonnière deformity by the technique of pieper.

We report eleven cases of chronic, non-fixed, post-traumatic boutonnière deformity treated by the technique of Pieper: One lateral slip was mobilised and distally desinserted. At the PIP, the slip was pulled through the central slip and sutured in correct tension to the released opposite lateral slip. 73 % regained full extension at the proximal interphalangeal joint. Despite a mild extension deficit of 15 degrees at the distal interphalangeal joint in 64 %, ten of eleven patients were content with the post-operative outcome. We conclude that the technique of Pieper is a good and valuable operative procedure to correct chronic non-fixated button-hole deformity.

[Digital nerve block anaesthesia: historical development and two cases of finger-tip necrosis, a rare complication]. / Fingerblock-Anästhesie - Uber die geschichtliche Entwicklung und zwei Fälle einer Fingernekrose als seltene Komplikation.

Two cases of finger-tip necrosis following digital blocks are presented. These are rare complications of this technique. Pathogenesis and treatment options are discussed and the literature reviewed. Circulatory problems can be avoided by using adrenalin free anaesthetics, infiltrating at the metacarpal level with small volumes, and using upper-arm tourniquets instead of rubber bands at the phalangeal level.

Experience in upper eyelid reconstruction with the Cutler-Beard technique.

Reconstruction of full-thickness upper eyelid defects has to supply a movable lid with perfect corneal protection, good aesthetic quality, and acceptable sequelae at the donor site. The Cutler-Beard procedure, a full-thickness cutaneoconjunctival inferior eyelid advancement flap, is a reliable method for reconstruction of total or partial upper eyelid defects. Especially in older individuals, the skin of the donor site is loose and provides sufficient tissue to stretch. Color and texture of the donor matches the recipient site perfectly. Destabilization or ectropion of the donor site, the lower lid, and retraction or entropion of the recipient site, the upper lid, are the main complications. Therefore, a modification of the classic technique should be considered by implantation of an enforcing inlay in the reconstructed lid (eye bank sclera, fascia lata, ear cartilage), especially in reconstruction of extended defects of the upper lid.

[Distal pedicled sural island flap-plasty for defect coverage of the distal lower extremity]. / Die distal gestielte Suralis-Insellappenplastik zur Defektdeckung an der distalen unteren Extremität.

Soft tissue defects on the distal lower extremity often need extended reconstructive procedures, especially if tendinous, articular, or bony structures are exposed. The use of local flaps in the perimalleolar, pretibial and calcaneal area is limited, often free tissue transfer is required. The distally based sural island flap is a pedicled soft-tissue flap on the vascular axis of the sural nerve. It can be raised as a fasciocutaneous or a lipofascial flap. We report our experience of 16 cases, nine of these cases in the lipofascial technique. The aim of soft tissue coverage was reached in 15 cases. In one patient a partial necrosis of the flap occurred requiring a reoperation with free flap coverage. The main advantages of the technique are the extended arc of rotation in the problematic area of the ankle and the lower extremity, the easy and fast preparation and the stable flap perfusion. The lipofascial as well as the fasciocutaneous flap have some risk of loss or donor-site morbidity that can be avoided by adhering strictly to certain operative principles.

[Mallet-thumb--presentation and discussion of 3 cases of a rare lesion]. / Der Mallet-Daumen--Vorstellung und Diskussion von drei Fällen einer seltenen Läsion.

Three cases of closed extensor tendon ruptures without osseous involvement in Verdan's zone 1 of the thumb (Mallet thumb) are presented and the various treatment options discussed based on the pertinent literature. As a consequence of the special anatomy of the thumb's extensor tendons which differs from that in the fingers, we recommend surgical treatment of this rare lesion by transosseous refixation of the ruptured tendon. Thus, early postoperative motion can be initiated resulting in rapid recovery of complete function.

[Experiences with internal thoracic vessels in breast reconstruction with the free TRAM flap]. / Erfahrungen mit den Thoracica interna-Gefässen bei der Brustrekonstruktion mit dem freien TRAM-Lappen.

In breast reconstruction with free TRAM flaps, the thoracodorsal vessels are most commonly used as recipient vessels. In case of an irradiated and scarred axillary region, the internal thoracic vessels may be an alternative. In the pertinent literature it has been pointed out that the veins may be fragile and thin and, thus, not suitable for microvascular anastomosis. In a series of 31 breast reconstructions with free TRAM flaps, the internal thoracic vessels were dissected and evaluated in 24 cases in order to assess the value of this vascular system as a recipient site for free flap transplantation. In four cases, the veins were too small for anastomosis, and in one case the artery was severed during dissection. End-to-end anastomoses were performed in 19 cases (79%). The following complications were recorded: One marginal necrosis; one venous thrombosis, which was detected and salvaged by revision; one recurrent arterial thrombosis, resulting in flap loss; one pleural lesion healed uneventfully.

[Soft tissue reconstruction of the finger with free, posterior ramus of the anterior interosseous artery-based septo-cutaneous flap. Anatomy--technique--case examples]. / Weichteilrekonstruktion der Finger mit freien, auf dem Ramus posterior der Arteria interossea anterior basierenden septokutanen Lappen. Anatomie--Technik--Fallbeispiele.

In cases of larger soft-tissue defects of the fingers which cannot be covered with local or regional flaps, pedicled or even free flaps can be used. Pedicled flaps and most free flaps are too bulky and need several trimmings before a cosmetically and functionally satisfactory result is achieved. Free flaps used for soft-tissue reconstruction in digits should be thin and should have a low donor-site morbidity. The free flaps based on the anterior interosseous artery, especially the one based on the dorsal branch, are ideal for soft-tissue reconstruction of single digits. They are very thin and can be harvested in the same operative field. Donor-site morbidity is usually low. The clinical usefullness of this flap is shown in the reconstruction of three consecutive cases of severely damaged fingers.

Simultaneous fractures of the waist and tuberosity of the scaphoid.

We present a case of a double fracture of the scaphoid. A non-displaced transverse fracture of the waist was associated with a displaced fracture of the tuberosity in the same scaphoid. To our knowledge this combination in an acutely fractured scaphoid has been described in only six previous cases.

[Radial island flap for the reconstruction of the 1st commissure]. / Der Radialis-Insellappen zur Rekonstruktion der 1. Kommissur.

The fasciocutaneous radial forearm island flap was used in six cases for reconstruction of the first web space after tumor resection, severe burns, a complex hand injury and a congenital adduction contracture of the thumb. Reconstruction of a deep and wide first web was possible in all cases. All flaps except the last one operated fifteen months ago have recovered protective sensation although nerve reconstruction was performed only twice. The donor defect could be closed directly in three cases. Corrective surgery for an unsightly scarred donor area was considered in one case. The radial forearm island flap is therefore a reliable and low-risk procedure for coverage of first web defects.

[Clinical research in hand surgery: the problem and value of retrospective studies]. / Klinische Forschung in der Handchirurgie: Problematik und Wert retrospektiver Studien.

Retrospective studies are still very important in clinical decision making although they present severe methodological deficiencies compared to controlled trials. Imprecise and incomplete data gathering, lack of homogeneity in the group studied, and lack of randomisation are the main drawbacks. Indications for retrospective studies and criteria for their execution are presented.

[The motion stable intraosseous wire suture--a prospective study]. / Die übungsstabile intraossäre Drahtnaht--eine prospektive Studie.

In a prospective study the results of 86 cases of transverse metacarpal and phalangeal fractures, corrective osteotomies and bone grafts treated by intraosseous wiring were reviewed six months postoperatively. The follow-up rate was 98%. Data included the time off work, the functional results in terms of total active range of motion of finger joints, intraoperative and postoperative complications, and additional stabilizing procedures.

[What results can be expected following the biceps replacement operation? An analysis of retrospective data]. / Welches Ergebnis können wir nach einer Bizeps-Ersatzoperation erwarten? Eine Analyse retrospektiver Daten.

The authors reviewed the literature and analysed the results of Steindler's technique, the transfer of pectoralis major muscle and its modifications, and the transfer of latissimus dorsi muscle. They determined the average extension lag, flexion, mobility, and strength in the publications they reviewed. Their own results were included in the statistics. The analysis of the results of the various techniques showed, 1. There is not always good correlation between the theoretical advantages and disadvantages of a surgical method and the clinical results of a particular operation in the restoration of elbow flexion. 2. The technical difficulty of a particular surgical method and the postoperative results must be taken into consideration when selecting the right operation. 3. There is a need for controlled studies of the different methods.

[Long-term results following resection arthroplasty and prosthesis implantation in idiopathic saddle joint arthrosis]. / Langzeitergebnisse nach Resektionsarthroplastiken und Prothesenimplantationen bei der idiopathischen Sattelgelenkarthrose.

Thirty-six patients with arthrosis of the carpometacarpal joint of the thumb were treated, 19 patients by resecting the trapezium and interposing a tendon, 17 patients by replacing the resected trapezium with silastic prosthesis (Swanson). The follow-up time was in average 22 respectively 44 months; both groups were comparable. The patients treated by resection of the trapezium and tendon interposition were more satisfied and had less pain than those treated by implantation of a Swanson prosthesis. There was no difference in mobility and strength of pinch between the two groups. After resection of the trapezium and tendon interposition the authors found a proximal translocation averaging 7 mm (6 to 14), however these patients had a good functional result and no pain. Five patients had a luxation of the Swanson prosthesis, and four required a second operation.

Reconstruction of heel and sole defects by free flaps.

One latissimus dorsi musculocutaneous flap and five radial forearm flaps were used in reconstruction of weight-bearing parts of the heel and sole, the follow-up period being 7 to 38 months. Additional injuries such as forefoot amputations or amputations of the other leg were present in four patients. There was no flap loss. The latissimus dorsi flap proved to be too bulky and showed recurrent ulcerations, several reoperations were necessary, and definite healing has not occurred. The five forearm flaps gave good results, with a walking range from 2 hours to unimpeded walking. Complications included fissuring at the edges of one large flap and a local infection which was successfully treated. Cutaneous sensation returned in all but one flap, where it was reduced preoperatively due to a meningomyelocele. The results indicate that the fasciocutaneous radial forearm flap should be taken into consideration for reconstruction of weight-bearing areas of the heel and sole. Shortcomings of this flap include an unsightly donor defect and possible hair growth on the flap.

[Transposition of pedicled pisiform bone in the treatment of stage III lunate malacia]. / Die Transposition des gestielten Os pisiforme zur Behandlung der Lunatum-Malazie Stadium III.

In six patients who were suffering from Stage III Kienböck's disease, as defined by Decoulx, the lunate was completely removed and replaced by the pisiforme on its vascular pedicle. There was an average follow-up of twenty months. The authors report a reduction in the level of pain and a 40 degrees average increase in mobility.