[The phenomenon of covert self-mutilation in the surgical routine]. / Das Phänomen der heimlichen Automutilation im chirurgischen Alltag.

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

[Hand Therapy in the Treatment of Patients with CRPS]. / Die Handtherapie in der Behandlung des CRPS.

In the modern treatment of CRPS a multidisciplinary concept is firmly established (MMPT, multimodal pain therapy). Besides medical therapy and psychotherapy, physio- and occupational therapy count as basic treatment options. Although physio- and occupational therapy (in the following called hand therapy) are the most important basic treatments, the therapy is hardly standardised and there are few scientific investigations concerning their application. Therefore the purpose of this paper is to present the applied hand therapeutic techniques with regard to function/performance, application and effectiveness, and to derive a suitable treatment algorithm. The techniques used in hand therapy are presented and reviewed in regard to their effectiveness by means of a literature search. It turns out that exercise therapy, manual therapy, graded motor imaging, CO2 baths and occupational therapy have a proven benefit for the patients. Although for many of the treatments reliable evidence-based data are lacking a treatment algorithm was established but there is a strong need for further investigations concerning the therapeutic effectiveness in the treatment of CRPS.

[Treatment algorithm for scaphoid nonunion : retrospective case-control study of 208 patients]. / Behandlungsalgorithmus der Kahnbeinpseudarthrose : Eine retrospektive radiologische Fall-Kontroll-Studie von 208 Patienten.

INTRODUCTION: We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. MATERIALS AND METHODS: Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. RESULTS: Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). CONCLUSION: Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.

Four-digit replantation in a mentally retarded person: a case report.

This report describes a case where 4 digits were replanted in a mentally retarded patient with a history of smoking and the inability to follow postoperative arrangements.

[Limited portal carpal tunnel release. An alternative to classic open release?]. / Die minimal-invasive Karpaltunnelspaltung. Eine Alternative zur klassischen offenen Spaltung?

The aim of this study was to determine the significance of limited portal carpal tunnel release compared to the classic open approach. We present a retrospective comparative clinical trial including 161 patients (105 open release and 56 limited portal release). Special interest was directed towards postoperative functionality, disorders and quality of life. Significant advantages could be demonstrated for the limited portal carpal tunnel release: rapid ability to return to work as well as to routine tasks of daily living and high patient satisfaction. In the hands of trained surgeons, limited portal carpal tunnel release represents a rewarding alternative to the classic open release.

[Does additive spongiosaplasty improve outcome after surgical therapy for solitary enchondroma in the hand?]. / Einfluss der Spongiosaplastik auf die Behandlungsergebnisse nach chirurgischer Therapie solitärer Enchondrome der Hand.

INTRODUCTION: The necessity of spongiosaplasty in the treatment of solitary enchondroma in the hand has been a subject of controversial discussions for several years. Over a period of 10 years the authors performed single curettage without spongiosaplasty. The aim of this study was to investigate our results and to compare these findings with those of other studies. PATIENTS AND METHOD: Over the last 10 years we have treated 106 patients with solitary enchondroma of the hand by single curettage without bone grafting. All patients underwent postoperative radiological examination. The mean follow-up was 34 months. The results of the X-ray investigation were examined retrospectively concerning the recurrence rates and the Hasselgren score. RESULTS: Two patients (1.9%) have experienced radiological changes according to Hasselgren score IV. One patient (0.8%) demonstrated radiological III° changes according to score of Hasselgren. Including the patient with the radiological changes according to Hasselgren score III, the overall recurrence rate was 2.8%. DISCUSSION: After comparing our results with those of other studies, we conclude that additional bone-grafting does not improve the recurrence rate of solitary enchondromas of the hand.

[Flexor tendon irritations after locked plate fixation of the distal radius with the 3.5 mm T-plate: identification of risk factors]. / Irritation der Beugesehnen nach palmarer winkelstabiler Plattenosteosynthese des distalen Radius mit der 3,5-mm-T-Platte: Erarbeitung von Risikofaktoren.

AIM: Volar locked plate fixation of distal radius fractures has become an established procedure in the past decade, although reports of flexor tendon injuries due to volar plating have been increasing. The aim of the present study is to identify the risk factors which produce irritations of flexor tendons using the locking palmar 3.5 mm T-plate, with special emphasis placed on the watershed line and the pronator quadratus muscle. METHOD: In this retrospective study, all patients with distal radius fractures who had been treated with a locking volar 3.5 mm T-plate between 2001 and 2005 were evaluated. The X-ray controls were analysed with regard to secondary losses of reduction, bony healing disturbances and the topographic relation to the watershed line. Follow-up included a clinical and subjective assessment using the DASH score. All patients underwent sonography to identify irritations of the tendons under functional conditions (neural and dorsal wrist flexion). RESULTS: A total of 151 patients were treated with the locked volar 3.5 mm T-plate. Of these, 68 patients could be included for follow-up. The mean age was 47.8 years with a mean follow-up period of 3.5 years. Fracture classification according to the AO indicated 13 A, 14 B and 41 C fractures with 37 Colles and 31 Smith fractures. Fracture union was achieved in all patients. A mean palmar tilt of 2.8 degrees (range: 1 to 9 degrees) was observed, with a loss of reduction in three cases of about 5 degrees. There were no implant failures. The mean DASH score was 12. The watershed line was reached by the distal edge of the plate in 48 patients and was exceeded in 20 cases. In 30 patients the pronator quadratus muscle could not be identified. In the remaining 38 cases the mean diameter was reduced to 1.4 mm, while the unaffected contralateral muscle had a mean diameter of 3.8 mm (range: 2.8 to 7 mm). Irritations of flexor tendons occurred only in 4 cases, in those patients where the pronator quadratus muscle could not be identified (2 tendon erosions and 2 tenosynovitises; 5.9%). Relevant functional distal plate prominence was detected in dorsal flexion (power grip) in 3 cases (4.4%), producing tendon deflection. The topographic relation of the plate to the watershed line played a minor role in causing tendon irritations, in contrast to the muscular coverage of the distal plate. Plate coverage by a vital reconstructed pronator quadratus muscle produces a greater distance of the tendon compartment to the plate, whereas a complete muscular coverage of the distal plate edge is difficult to realise, although it is not necessary regarding functional conditions. CONCLUSION: Stabilisation of distal radius fractures with dorsal and volar displacement by the locked palmar 3.5 mm T-plate produces positive results. A careful reconstruction of the pronator quadratus is more important than respecting the watershed line in that it achieves muscular coverage, and thus provides a greater distance of the plate to the tendon compartment. We recommend sonography after bony healing to identify functional plate prominence or tendon irritations under functional conditions (dorsal wrist flexion) and, if necessary, plate removal. Further systematic sonographic examinations should be undertaken including other locked plate systems.

[Is intraoperative luxation of the ulnar nerve a criterion for transposition?]. / Ist die intraoperative Ulnarisluxation ein Kriterium für die Vorverlagerung?

BACKGROUND: The relevance of subcutaneous transposition of the ulnar nerve in the therapy of cubital tunnel syndrome is still under debate. The aim of this study was to compare the results after decompression to additional transposition in cases of intraoperative luxation. METHODS: A total of 54 cases after surgery of cubital tunnel syndrome between 2000 and 2006 were analyzed. Nerve transposition was performed in cases of intraoperatively apparent nerve luxation. RESULTS: Of the patients 12 were treated by decompression alone and 42 by additional subcutaneous transposition. There was no significant difference concerning symptom amelioration, usage properties of the hand, sensation impairment and duration of disability. Force measurements of grip strength and pinch strength revealed no significant differences between either hand in both groups. The 2-point discrimination ability of the 8th to 10th finger nerves was not significantly different between the groups either. CONCLUSION: Nerve transposition revealed no benefits in the treatment of cubital tunnel syndrome when performed in cases of intraoperative nerve luxation.

[Nerve reconstruction and nerve grafting]. / Nervenrekonstruktion und Nervenersatzoperationen.

The surgical treatment of peripheral nerve injuries is still a challenging and highly demanding procedure. Past results have been improved upon by different advances in microsurgical techniques and algorithms. Nevertheless, results are not always satisfying, making secondary procedures necessary. Thus, these secondary procedures such as tendon transfers and arthrodesis of different joints must be taken into account during reconstructive planning. This review gives an overview of peripheral nerve reconstruction (nerve grafting, nerve repair) and the pertinent secondary procedures.

Concepts and developments in peripheral nerve surgery.

Nerve injuries may result in sensory and motor deficits when not treated appropriately. Especially the surgical management of nerve defects still represents a challenge for the surgeon. In these cases the grafting of autologous nerves represents the only reasonable approach. Due to the side effects associated with this method (sacrifice of donor nerves, neuroma formation in the harvesting area, limited availability of donor nerves, etc.), numerous alternatives were proposed in order to avoid the transplantation of autologous tissue. This review provides a general view on the state of the art of how to supply gaping injuries in the peripheral nerve. Furthermore new approaches emphasizing tubulization techniques for the reconstruction of lost nerve tissue are described with a special focus on various materials with their advantages and disadvantages.

[Undergraduate education on chronic wound care at German medical schools--the role of surgical disciplines]. / Stand der medizinischen Lehre im Bereich chronischer Wunden/Wundbehandlung--der Beitrag der chirurgischen Fächer.

INTRODUCTION: In response to the problem of chronic wounds, we decided to investigate the status of chronic wound care in undergraduate medical programs in Germany. MATERIAL AND METHODS: The deans of medical schools in Germany and all relevant instructors of dermatology, surgery, internal medicine and general medicine, pathology and health care of the elderly at 32 universities in Germany were asked to fill out a questionnaire. RESULTS: The mean teaching time is 7 hours [0.75-16.5]. The lessons covered clinical entities such as venous ulcer (21 %), diabetic (18 %) and arterial ulcer (12 %), decubital ulcers (13 %), ulcers with vasculitis (11 %), burns (9 %) and neoplastic ulcers (4 %), or others (12 %). The respective material is taught in approximately two-thirds as a lecture and one-third in seminars and practical sessions. Only in 6 % of the cases a practical examination is performed. DISCUSSION: Undoubtedly 7 hours of teaching on chronic wound care are not sufficient. Stringent coordination of the medical education at each university and practical examinations may improve student education.

[Combined flexor tendon and nerve injury of the hand]. / Kombinierte Beugesehnen- und Nervenverletzungen der Hand.

Any restoration of hand function following tendon and nerve injury has to include the repair or replacement of the hand's ability to perform a great many tasks. It is hard at first to appreciate fully the loss that occurs with flexor tendon injury. Also sensibility can be compromised from tendon injury without direct injury to the nerve, as object recognition in the absence of vision requires finger movement. When peripheral nerve injury is combined with flexor tendon injury, sensibility is directly impaired. There is a loss in the sense of finger or thumb position, pain temperature and touch or pressure recognition, in addition to the tendon injury. However, the outcome after operative treatment of these"minor" injuries of the hand is horrible. Therefore, we try to summarize practical consequences for the repair of combined flexor tendon and nerve injuries which will improve operative outcome. These guidelines are based on current scientific knowledge and our own experience.

[Experience with the s-GAP flap for autologous breast reconstruction]. / Der Stellenwert der s-GAP-Lappenplastik in der Brustrekonstruktion - Ein Erfahrungsbericht.

In breast reconstruction with autologous tissue the DIEP flap has become the gold standard in recent years. The superior gluteal artery perforator (s-GAP) flap is an alternative harvested from the buttock. We present our experience with the s-GAP flap and discuss its role in breast reconstruction. All s-GAP flaps performed for breast reconstruction in the Department of Plastic and Hand Surgery, Behandlungszentrum Vogtareuth from June 2002 until February 2007 were retrospectively analysed. Out of 59 flaps 4 flaps failed, the success rate was 94 %. Partial or fat necrosis occurred in 2 cases. The s-GAP flap served as a safe reconstructive alternative to the DIEP flap. Advantages of the s-GAP flap are reliable perforators, the safe vascular supply and the firm fat structure which facilitates the breast reconstruction. The donor site morbidity is minimal, the gluteal muscles stay intact and the scar is easy to hide in the underwear. Disadvantages are a demanding preparation with a prolonged operating time compared to the DIEP flap. The s-GAP flap is a reliable and safe option for autologeous breast reconstruction. It is the method of choice for staged bilateral breast reconstruction or if the DIEP flap is not available, particularly in the thin patient.

[Recurrence rates of venous leg ulcers and the special importance of its surgical treatment]. / Rezidivraten des venösen ulkus unter chirurgischer therapie.

BACKGROUND: Venous insufficiency may lead to recurrent leg ulcers. The reason for this observation remains still unclear. In this study we tried to underline the influence of surgical treatment on recurrence rate of venous leg ulcers. PATIENTS AND METHODS: In this study 69 patients were treated in a special wound care centre. Before treatment the angiological status was evaluated using phlebography or duplex scan. Afterwards, patients were scored according to the "Venous Clinical Severity Score" of the American Venous Forum. During the observation period compression therapy was performed and wounds were treated with moist dressings. Necroses were removed by radical debridement and large ulcers were covered by mesh graft tissue transfer. When indicated incompetent veins were treated surgically. RESULTS: The follow-up revealed an overall recurrence rate of 21 % after 30 months. Ulcers treated by radical wound debridement or mesh graft tissue transfer demonstrated a significant lower recurrence rate (p = 0.02 and p = 0.03). According to duplex sonography a correlation was evident among severity of venous insufficiency, the "clinical scoring" (p = 0.04), and the recurrence rate (p = 0.023). After surgical intervention by venous stripping, the insufficiency was improved but the recurrence rate was comparable to that of patients treated without venous surgery (p = 0.44). CONCLUSION: Surgical treatment of venous leg ulcers in modern wound care centres can reduce its recurrence rates. Herein this study a correlation among venous insufficiency evidenced by duplex scan and recurrence rate for leg ulcers could be demonstrated.