[Osteophyte-induced impingement reduces range of motion in humpback deformity of incorrectly healed scaphoid reconstruction]. / Osteophytenbedingtes Impingement verringert die Beweglichkeit bei in "Humpback"-Deformität fehlverheilter Skaphoidrekonstruktion.

BACKGROUND: The gold standard in the treatment of scaphoid pseudarthrosis is reduction, interposition of an iliac crest graft and stabilization with a headless bone (Herbert) screw, aiming to reduce the frequently observed humpback deformity. This study correlated the extent of humpback deformity after scaphoid reconstruction to clinical and radiological postoperative parameters. MATERIAL AND METHODS: Between 2008 and 2010 a total of 56 patients with scaphoid pseudarthrosis were surgically treated. Of the patients 34 could be included in this retrospective study. The average follow-up period was 7.3 months. The humpback deformity was evaluated by computed tomography (CT) scan performed along the long axis of the scaphoid. The disability of the arm, shoulder and hand (DASH) score, grip strength (Jamar), range of motion (RoM), Mayo wrist score (MWS) and other parameters were used to determine the clinical outcome. The patients were divided into two groups: 1) no or only slight humpback deformity (<25°), 2) severe humpback deformity (>45°). RESULTS: The RoM and DASH scores were slightly better for the first group. The second group had a significantly increased incidence of osteophyte formation (p < 0.05) and decreased RoM (-16°). CONCLUSION: It is postulated that the main disadvantage of an nonreduced humpback deformity is the increased occurrence of osteophyte formation in the dorsal aspect of the scaphoid. This can cause an impingement during extension and leads to a significant restriction of movement of the wrist. LEVEL OF EVIDENCE: III.

[Diagnostic accuracy of conventional X-ray imaging for assessment of trapeziometacarpal joint osteoarthritis]. / Genauigkeit der konventionellen Röntgendiagnostik bei der Beurteilung der Daumensattelgelenkarthrose.

BACKGROUND: Osteoarthritis of the trapeziometacarpal joint is a common and painful affliction that can be diagnosed using conventional X­ray imaging as well as arthroscopy and if necessary treated; however, the X­ray classification often does not sufficiently demonstrate the cartilage damage found in arthroscopy. OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy of conventional X­ray imaging compared to arthroscopy for osteoarthritis of the trapeziometacarpal joint. MATERIAL AND METHODS: The preoperative conventional X­ray images of 23 patients were presented to 10 experienced hand surgeons who were blinded to the arthroscopy results. Their ratings were compared to the results found with arthroscopy. RESULTS: Of the patients 11 were found to have grade 4 cartilage lesions according to the Outerbridge classification, 8 grade 3 lesions, 4 grade 2 lesions and no grade 1 lesions. Overall, 43% (95% confidence interval, CI 37-49%) of the cartilage lesions were diagnosed correctly using conventional X­rays. For grade 4 lesions 73% (95% CI 65-81%) of the surgeons made the correct diagnosis, in the case of grade 3 lesions 38% (95% CI 27-49%) and in grade 2 lesions 13% (95% CI 3-23%). CONCLUSION: This study presents an arthroscopy classification system that is specific for osteoarthritis of the trapeziometacarpal joint and provides an additional method of assessment if the X­ray grading of osteoarthritis according to Eaton and Littler is too unspecific. Arthroscopy can be used to safely differentiate the treatment-relevant stage and also includes treatment options.

[The "safe" flap - Preoperative perforator-mapping and intraoperative perfusion assessment to reduce flap-associated morbidity - Consensus statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels]. / Der sichere Lappen ­ Präoperatives Gefäß-Mapping und intraoperative Perfusionsmessung zur Reduktion der lappenbedingten Morbidität.

Reconstructive microsurgery using free and pedicled flaps has become a reliable method with a high success rate. Preoperative perforator mapping and intraoperative assessment of perfusion might further reduce flap-associated morbidity.There are various techniques for perforator mapping and perfusion measurement, but no guidelines regarding their use. Therefore, an expert panel at the 40th Annual Meeting of the German-Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels (DAM) discussed and critically reviewed the current literature. The consensus statement represents the expert opinion based on the available literature and provides recommendations regarding the use of preoperative perforator mapping and intraoperative perfusion measurement.

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.

[Overview and Introduction of a Treatment Concept for Postoperative Care and Mobilisation After Free Flap Transplantation in the Lower Extremity]. / Überblick und Vorstellung eines Behandlungskonzeptes zur postoperativen Therapie und Mobilisation nach freier Lappenplastik an der unteren Extremität.

Introduction: Free flap transplants for soft tissue reconstruction in the lower extremity are associated with a higher rate of complications compared with other areas. Mobilisation and the resulting hydrostatic pressure put strain on the flaps. In general, these effects are countered by slowly increasing hydrostatic pressure with the leg being compressed by elastic bandages. These postoperative regimes are also called dangling procedures or "flap training", but are not scientifically validated and therefore there is no consensus or guideline leading to a standard treatment regime. The goal of our study was to present an overview of currently performed regimes. Material and Methods: We conducted an email survey by sending a questionnaire to departments for plastic and reconstructive surgery in Germany, Austria and Switzerland, which perform free flap transplantations in the lower extremity. The questionnaire ascertained the starting point and the frequency of the dangling procedures, the introduction of weight-bearing on the operated extremity and the incidence of complications occurring during mobilisation. Results: We included 32 departments and compared them by the number of free flap transplantations performed per year. We found a wide variation between the postoperative treatment regimes. In most departments, flap training is started between the 3rd and 7th day after surgery and lasts between 5 and 15 min. The intervals with which flap training intensity is increased are inhomogeneous as well. The time until full weight-bearing is exerted on the operated extremity ranges from day 5 to week 3 postoperatively. Complications due to flap training were reported by one third of the participating departments. Conclusion: Elastic compression and patient mobilisation after free flap procedures in the lower extremity are considered to be very important in reducing complications and in protecting the flap from edema and volume overload. This article demonstrates that there is a wide variety in flap training regimes. It aims to help readers evaluate their own regimes and provides guidance for an individualised patient-oriented regime.

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.

Postoperative negative pressure therapy significantly reduces flap complications in distally based peroneus brevis flaps: Experiences from 74 cases.

BACKGROUND: The distally based peroneus brevis muscle flap is a valuable therapeutic option for coverage of tissue defects around the ankle and the distal lower leg. However, the rate of postoperative flap complications requiring revisional surgery is high due to an impaired venous drainage and oedema formation. The purpose of this study was to evaluate if postoperative negative pressure therapy is able to reduce flap complications. METHODS: From April 2010 until March 2014, we treated 74 patients with distally based peroneus brevis muscle flaps for defect coverage at the lower leg. In four cases, an osteomuscular composite flap has been used to treat partly stability-relevant bone defects. In 43 cases, negative pressure therapy (75mmHg, continuous) with a circular dressing was initiated after the flap procedure for 7 days. In 31 cases no negative pressure therapy was initiated. We retrospectively analysed those two groups of patients. The primary endpoint was the incidence of flap complications with a need for revision surgery, which were classified in three grades. RESULTS: The group treated with negative pressure therapy had significantly less flap complications when compared to the control group (p<0.0001). Concerning the single grades of complication, the negative pressure therapy-group had a significantly smaller rate of skin graft necrosis (Grade 1; p=0.014) and partial flap loss (Grade 2; p=0.002) compared to the control group. There were no statistically significant differences concerning complete flap loss (Grade 3) between both groups. CONCLUSION: Postoperative negative pressure therapy for 7 days reduces flap complications in distally based peroneus brevis flaps.

[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.

[Return of sensitivity after digital nerve reconstruction in children: how does age affect outcome?]. / Sensibilitätsrückkehr nach kindlichen Nervenverlet-zungen der Hand - welche Rolle spielt das Patientenalter?

BACKGROUND: The regenerative capacity after nerve reconstruction in children is believed to be superior compared to that in adults. However, the available data on this topic are limited. The aim of this work is to improve the age-dependent assessment of the prognosis after surgical treatment of peripheral nerve injuries of the hand. PATIENTS AND METHODS: 44 of 147 children with complete transections of proper and common digital nerves who were treated from 2000 to 2009 and who were currently 6 years or older, could be included for follow-up (mean time, 7.5 years). In total there were 60 nerve injuries, of which 56 were directly coaptated, 4 needed grafting. Sensitivity of the fingertips was assessed using the 2-point discrimination (2PD) test and the Semmes-Weinstein monofilament test. We also recorded hypersensitivity, sensitivity to cold, and paresthesia. To account for inter-individual differences in normal 2PD, the difference of the 2PD to the uninjured contralateral side was calculated as delta-2PD. The age at the time of the injury, divided into groups of 0-5, 6-10 and 11-15 years was correlated with the clinical outcome (2PD, monofilamenttest). Taking into account the results classified by age presented by Lohmeyer et al. and Mailänder et al., we assessed the correlation between age at injury (0-85 years) and clinical outcome. RESULTS: After 52 of the 56 direct nerve coaptations (93%) normal sensitivity was found with a 2PD<6 mm, 4 times the 2PD was 6 mm. Following nerve grafting a static 2PD of 6-7 mm was measured. Disturbing paresthesia, sensitivity to cold or hypersensitivity were not reported by any patient. The 2PD of the fingers of the opposite uninjured side showed great inter-individual differences. Patient's age and 2PD significantly correlated with significantly poorer results already in the second decade of life. CONCLUSION: In relation to adults, children have an excellent prognosis after nerve reconstruction. The high inter-individual differences in regular sensitivity, depending on age, co-morbi-dities, etc., suggest putting the results of the injured and uninjured sides into relation. Estimation of the Δs2PD may solve this -problem.

Sirolimus-associated infertility: case report and literature review of possible mechanisms.

The mammalian-target-of-rapamycin/mTOR-inhibitor sirolimus as a component of the immunosuppressive strategy after solid organ transplantation is effective at preventing allograft rejection. However, recent reports indicate that sirolimus is associated with altered sex hormone levels and impaired sperm quality parameters. Herein, we report on a case of sirolimus-associated infertility in a young male heart-lung transplant recipient and provide a detailed synopsis of potential mechanisms by which sirolimus may negatively influence spermatogenesis. Testicular immunohistochemistry, the course of sex hormone and sperm quality parameters of our patient support the hypothesis that mTOR might act as an important key regulator in the reproductive system. Fortunately, due to withdrawal of sirolimus as part of the maintenance, immunosuppression improved sperm quality and sex hormone parameters could be observed. Recently, these improvements even resulted in a spontaneous pregnancy of the patient's wife more than 1 year after the drug was withdrawn. In our view, oligospermia as a possible and at least partly reversible side-effect of mTOR inhibitors has to be taken into consideration, particularly, when administrated to young male patients.

Cardiac transplantation in a 14-yr-old patient with mitochondrial encephalomyopathy.

We report a rare case of a successful cardiac transplantation in a patient suffering from cardiomyopathy and complex mitochondrial disease. The patient presented with severe heart failure and malignant ventricular arrhythmias requiring implantation of a defibrillator and advanced medical treatment. The patient was listed for urgent heart transplantation and received a donor heart after 36 days. One yr post-operatively, the patient has completely recovered.

Successful single lung fontan operation in 2 children: case reports.

We report on 2 children, aged 3 and 4 years, with single ventricle physiology who underwent Fontan operation in the presence of a single right lung successfully with good midterm outcome. Therefore, the absence of one lung is not a contraindication for a Fontan palliation in selected patients with optimal hemodynamics.

Late-onset tacrolimus-associated cerebellar atrophia in a heart transplant recipient.

Tacrolimus is a macrolide immunosuppressant frequently used after solid-organ transplantation. Moderate and severe neurologic side effects have been reported in patients receiving tacrolimus. Cerebral neurotoxicity is a rare but fatal calcineurin inhibitor-related complication, especially in kidney and liver transplant recipients. Often a reduction or a change in immunosuppressive regimen is the only means of clinical management. Herein we report a case of a 31-year-old man who developed cerebellar atrophia while under immunosuppressive therapy 9 years after heart transplantation. His neurologic constitution ameliorated after an immunosuppressant switch from tacrolimus to sirolimus.