COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

[Consensus of the Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) on Autologous Fat Grafting]. / Konsensus der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) zur Eigenfett-Transplantation.

On occasion of the Munich Plastic Symposium in Munich the board of the Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) together with a group of experts who were also involved in the preparation of the recently published S2K guideline "Autologous Fat Grafting", prepared a consensus statement from a plastic-surgical point of view so to evaluate current spects and taking into account the current legal framework: 1. Autologous Fat Grafting is a long established treatment in plastic surgery and does not differ from other tissue grafts. 2. Mechanical processing of autologous fat does not provide any substantial change tot he tissue. 3. If other treatment methods to enrich progenitor cells of autolous fat i. e. by an enzymatic process have evidence that autologous adipose tissue or cells were substantially changed, classification as a drug could come in question under current german law (application of AMG/ATMP).

[Correction of the Thumb in Apert Syndrome - Modified Dome Osteotomy and Bilobed Flap]. / Daumenkorrektur bei Apert-Syndrom durch modifizierte Dom-Osteotomie und bilobed flap.

Children with Apert syndrome have extensive malformations of the extremities and the head. The thumb in Apert syndrome is always short with radial deviation and the first web space is narrowed and flattened. These thumbs can be corrected in a simple manner by modified dome osteotomy of the proximal phalanx combined with soft tissue coverage using a bilobed flap with simultaneous widening of the first web space. A preoperative multi-slice computed tomography (MSCT) angiography scan helps in planning the surgical procedures. This article describes the surgical technique and the results in 6 hands of 3 children. The aim is to illustrate the correction of the axis and length of the thumb.

[Concept for a National Implant Registry to Improve Patient Safety]. / Konzept für ein nationales Implantatregister zur Verbesserung der Patientensicherheit.

Since the introduction of silicone implants, several events have led to considerable uncertainty among the patients, public, and users. So far, however, the necessary steps to significantly improving patient safety have not been taken in any of these cases. Requiring stricter approvals for medical devices, improving monitoring by the regulatory authorities and the revision of the Medical Devices Directive are all initial steps in the right direction towards a change in policy, but are insufficient as an early warning system. After the introduction of registers was announced in the coalition agreement, the German Society of Plastic, Aesthetic and Reconstructive Surgeons (DGPRÄC), in close consultation with the Ministry of Health, has developed a concept which is presented here. The need for a uniform and legally binding central register for breast implants is fully supported by the entire medical profession. According to the concept presented by the DGPRÄC, three data qualities would be applicable: Safety data (mandatory), physician information (voluntary) and research data (optional, except if safety related). The public authorities are creating a unified, secure entry portal for all professional associations concerned. This register is based with the professional associations, and from there the mandatory security data will be forwarded to the public authorities. Decoding of the identity of the patient and doctor would only occur in specifically defined emergency situations such as product recalls. Automated tools in the security database provide early detection of problems, so that rapid clarification is possible in consultation with the professional associations, manufacturers and possibly patients. This concept as proposed by the DGPRÄC has thus far been very positively received in all discussions between the various parties concerned.

The Ulnar Nerve After Surgical Transposition: Can Sonography Define the Reason of Persisting Neuropathy?

PURPOSE: Ulnar nerve neuropathy is mainly caused by compression at the level of the cubital tunnel. Two main approaches are currently known for the surgical treatment of this condition: decompression of the nerve in its usual position or transposition to the ulnar flexor side. This study was performed to define the usefulness of ultrasound in patients with persisting symptoms after ulnar nerve transposition. MATERIALS AND METHODS: We present the data of 8 subjects with persisting symptoms after nerve transposition due to compressive neuropathy. The cross-section areas (CSA) and texture changes were recorded. Each ulnar nerve was divided into 6 segments - 3 segments at the proximal pass and 3 segments at the distal pass through the subcutaneous fascia. RESULTS: Texture changes were recorded in 4.6 (76.7 %)  ±â€Š1.2 and outer nerve sheath blurring in mean 4.1 (68.3 %)  ±â€Š1.1 of the segments. Caliber changes were found in the course of the nerve based on the 6 segments: A mean CSA of 7.45  mm²â€Š ±  2.24 was found proximal to the upper fascial passage (PUF), a mean CSA of 11.96  mm²  ±  3.61  at the upper fascial passage (UF), a mean CSA of 11.49  mm²â€Š ±â€Š 8.16 distal to the upper fascial passage (DUF), a mean CSA of 10.84  mm²â€Š ±  4.73 proximal to the lower fascial passage (PLF), a mean CSA of 12.12  mm²â€Š ±â€Š 5  at the lower fascial passage (LF), and a mean CSA of 7.89  mm²  ±  3.42 distal to the lower fascial passage (DLF). All transposed nerves presented relevant kinks at the UF, 6 nerves presented relevant kinks at the LF. CONCLUSION: In cases of secondary ulnar neuropathy after nerve transposition, ultrasound can reliably assess the actual "situation" of the nerve and thus at least ease the decision for secondary surgery.

Supporting the collateral ligament complex in radial polydactyly type Wassel IV.

Despite anatomical metacarpophalangeal joint (MCPJ) reconstruction in radial polydactyly (RP) Wassel IV, the prevention of long-term deformity and instability is still an issue. We report on clinical results following our modified surgical procedure with additional support of the hypoplastic radial collateral ligament complex (RCLC) after musculoligamentous MCPJ reconstruction. Fourteen patients (male: 10, female: 4) with radial resection of isolated RP Wassel IV (1987-2006), average age at surgery 1.7 years (0.6-8.6) were included. Distribution to group A and B depended on the procedure for MCPJ reconstruction. In group A (N = 7), RCLC reinsertion + reinforcement using autologous tendon grafts was performed (follow-up: 4.6 years (1.4-6.9)). Group B (RCLC reinsertion without support) consisted of N = 7 patients; follow-up: 9.6 years (8.2-20.2). The healthy contralateral hand (control A/control B) served as a control. Results were evaluated using our modified Tada-score considering: range of motion (ROM), interphalangeal joint (IPJ) and MCPJ stability on stress examination, palmar abduction and grip strength. Better score results (maximum 10) were seen in A: 7.3 (6-9) compared to B: 6.6 (4-10). Subscore 'stability' A: 1.1 (0-2); B: 0.9 (0-2) and 'alignment' A: 0.86 (0-2); B: 0.57 (0-2) showed greatest influence on the score result. Ulnar angulation at MCPJ level compared to healthy thumbs (control A + B) was greater (p < 0.05), with 11.4° (10-20) in group A and 14.3° (-5 to 30) in group B compared to 0° in control A and 5.7° (0-17) in control B. MCPJ ulnar deviation in A + B: 25° (0-35) compared to healthy thumbs control A + B was higher (p < 0.05). Ulnar deviation was higher in B 45° (30-60) compared to 34° (20-50) in A. In B, instability was evident in four, in A, only in one patient. In B, one patient required two re-operations due to MCPJ instability. Equivalent results were recorded regarding pinch grip and palmar abduction. Anatomical MCPJ reconstruction in combination with autologous support of the hypoplastic RCLC to enhance long-term stability is recommended.

[Radical tumour resection in the upper extremity and heterotopic replantation of the hand. Analyses of functional results in two patients]. / Radikale Tumorresektion im Ellenbogenbereich und heterotope Handreplantation. Analyse der funktionellen Ergebnisse bei zwei Patienten.

We describe here two cases treated 17 years apart from each other. The patients were young males with malignant soft tissue tumours of the forearm and elbow joint. Radical tumour resection involved removal of the elbow joint. Neither of the patients consented to upper arm amputation, but agreed to undergo heterotopic replantation of the amputated distal third of the forearm together with the hand to the stump of the upper arm. The tendons of the forearm were attached to the three muscles of the upper arm, and the distal nerves were coapted with the nerve trunks of the upper arm. However, the reconstructive procedures carried out in these two patients were anatomically different. In the first patient, for technical reasons, only the deep flexor tendons were sutured. Furthermore, development of a postoperative haematoma necessitated revision surgery with split-thickness skin graft to cover the defect of the forearm. Long-term immobilisation together with a conservative approach to mobility had resulted in less than optimal results so that it appeared meaningful to re-operate the patient even 17 years after the primary operation to help him gain improved sensibility as well as motor function. These goals were achieved to a surprising extent by scar release, Z-plasty, removal of split-thickness skin graft, neurolysis, arthrodesis of the IP joint of the thumb, and tendon transposition together with intensive early postoperative sensibility and mobility training. In the second patient, longitudinal division of the muscles of the upper arm into different compartments and interweaving of the long tendons of the forearm into these muscles as well as early intensive mobility training and reintegration of the replanted hand in the body scheme resulted in the rapid gain of extremely good functional results so that the patient is now able to employs his heterotopically replanted hand quite effectively in his activities of daily living as a farmer. We believe that the differences in the surgical techniques employed and intensive postoperative training may explain the varying functional outcomes of these two patients. What is surprising is that it was possible to achieve marked functional improvement even after an interval of 17 years.

[A "simple" method for correction of the Apert's hand]. / Eine "einfache" Methode zur Korrektur der Apert-Hand.

In view of the multiple malformations in patients with Apert syndrome, numerous operations need to be carried out on the skull, midface, jaws, hands and in some cases also feet. We describe here a simplified surgical approach to hand surgery that enables several operative steps to be performed during one session and thus reduces the total number of surgical interventions. After visualising with MSCT angiography the bone and soft-tissue malformations and blood vessels, the operation is planned carefully. Transection and removal of the bony and cartilaginous bridges between the symphalangeal fingers is followed by placement of silastic sheets between the separated fingers for a period of 2 - 3 weeks to help form well-vascularised tissue over the spongy bone, which is then covered by full-thickness skin graft to promote healing. Depending on the severity of the Apert hand, numerous surgical procedures can be performed together at one and the same session. This is a simplified method in which the thumb is also straightened either during the same intervention or at a later date. This approach is explained with the help of three of our cases.

[Chronic compartment syndrome of the flexor muscles in the forearm due to motocross]. / Chronisches Kompartmentsyndrom der Unterarmbeuger beim Motocrossfahren.

A case of a mechanic and motorcyclist is reported who developed unilateral chronic exertional compartment syndrome of the flexor muscles in the forearm. After years of discomfort and medical check-ups, a subcutaneous fasciotomy of the superficial compartments of the flexor muscles in the forearm led to a complete relief of symptoms, which allowed the patient unrestricted activity.