[Treatment errors in hand surgery. Comparison criteria for education in hand surgery and additional training in hand surgery based on error statistics of Chamber of Medicine, North Rhine-Westphalia]. / Behandlungsfehler in der Handchirurgie. Ein Vergleich zwischen handchirurgischen Ausbildungskriterien chirurgischer Fachgebiete und der Zusatz-Weiterbildung anhand der Behandlungsfehlerstatistik der Ärztekammer Nordrhein.

Hand surgery is an interdisciplinary specialty in which the contents of further training in the individual fields differ widely. We have first investigated general quality criteria and then the further training programmes of the specialties general surgery, orthopaedic and trauma surgery as well as plastic and aesthetic surgery. On the basis of the treatment error statistics of the Chamber of Medicine of North Rhine-Westphalia from the years 2004-2008, the treatment error quotas for a period of 5 years were evaluated according to specialty and the presence of additional training in hand surgery. This revealed that treatment errors in hand surgery with 41.7% were markedly more frequent than the general average value of 31.1%. On individual evaluations, the error quota for qualified surgeons without additional training was 44% whereas that for surgeons with additional training was 26%. Most frequently treatment errors were reported for distal radius fractures, followed by soft-tissue and cut injuries, carpal tunnel syndrome and finger fractures. The largest difference in the error quotas for the groups with and without further training in hand surgery was found for soft-tissue injuries including tendon injuries, 13.3% as compared with 53.7%.

[Modified volar plate arthroplasty for posttraumatic and idiopathic osteoarthritis of the metacarpophalangeal and proximal interphalangeal joints]. / Die Resektionsarthroplastik mit Interposition der palmaren Faserplatte zur Behandlung posttraumatischer oder idiopathischer Arthrosen der Fingergrund- und Mittelgelenke.

This article presents the results of modified resectional arthroplasty with interposition of the proximally based palmar plate and economic partial resection of the proximal joint surface without cutting the collateral ligaments. Indications were posttraumatic, idiopathic, and tumorous arthrosis of the metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints.In MP joints, the range of motion improved in eight patients from 40 degrees to a median of 70 degrees with an extension deficit of 10 degrees and a pinch strength of 4.5 kg. All patients (n=8) were free of complaints at a DASH level of 8. In PIP joints, the range of motion improved from 40 degrees to 60 degrees after 35 months in 12 patients with dynamic postoperative treatment. All patients except one were pain-free at a DASH level of 27. Postoperative dynamic splinting was superior to static care.

[Long-term follow-up of fracture dislocations and comminuted fractures of the PIP joint treated with Suzuki's pin and rubber traction system]. / Spätergebnisse der frühfunktionellen Behandlung von intraartikulären Mittelgliedbasisfrakturen mit dem Bewegungsfixateur nach Suzuki.

Fracture dislocations and comminuted fractures of the PIP joint are considered as severe injuries with uncertain outcome. Short-term results of several traction devices in the treatment of PIP joint fractures have been published. But the further course concerning the injured joint surface has not been described yet. From 1995 to 2001 we treated 26 patients who suffered comminuted intraarticular fractures and fracture dislocations with the digital dynamic external fixator from Suzuki. The time of follow-up was 8 years (median) with a range of 5 - 11 years. Due to this rather long period only 13 patients were available for follow-up. The flexion of PIP joint gained a median value of 95 degrees (range: 35 - 100 degrees ), extension loss was 0 degrees (median; range: 0 - 35 degrees ). Range of motion of the PIP joint was 85 degrees (median; range: 0 - 100 degrees ). The evaluation of the X-rays shows an initial anatomic reduction with complete joint congruency in only 20 % of the cases, but over time there was a remodelling of the joint surface in 89 % without obvious signs of degeneration of the joint. We suppose that the surprisingly good long-term results are linked to this extraordinary remodelling. No patient complained about pain using the affected finger without load and only 2 patients experienced mild pain on heavy use. Compared to the 2-years results of another patient group that we published in 2001 the long-term results tend to be slightly better. We conclude that dynamic traction and early motion of intraarticular PIP joint fractures are the treatment of choice, as virtually pain-free and good motion is achieved also in the long-term due to the remarkable remodelling capacity of the joint surface.

[Clinical results of terminolateral neurorrhaphy in digital nerves]. / Klinische Ergebnisse von End-zu-Seit-Nervennähten.

In end-to-side-neurorrhaphy the collateral sprouting of axons has been proven in many animal studies. It has not yet been determined if a satisfactory sensory recovery occurs. Unfortunately, there is still a lack of well documented clinical studies. We have used end-to-side nerve sutures in five patients. Four of them showed gaps in digital nerves, the fifth patient had a partial transsection of the superficial branch of the radial nerve. At the time of follow-up examination, surgery had been performed an average of 21 months previously (11 - 39 months). We examined sensibility, temperature perception, patient satisfaction and the presence of pain and neuroma. Two of the patients with injured digital nerves reached an almost normal two-point discrimination of 6 mm, the other two patients only achieved a value > 10 mm. With monofilaments one patient was able to recognise the 3.61 filament, which constitutes a standard value. The other three recognised the 4.31 filament, which is only one degree less. All measurements concerning the superficial branch of the radial nerve turned out to be less satisfactory, however, one must consider that the sensation qualitiy in this area is less to begin with. No neuromas occurred, except in the case of the radial nerve. None of the patients showed full recovery of temperature perception. Two were able to recognise a warm and three a cold probe head. Our results confirm the findings made in other studies which also found a clinical correlate to collateral axonal sprouting. Unfortunately results are still inconsistent.

[Long-term results after lunate replacement by the vascularised os pisiform for treatment of Kienböck's disease III b]. / Langzeitergebnisse nach Transposition des gestielten Os pisiforme zur Behandlung der Mondbeinnekrose Stadium III b.

Saffar's procedure is used only rarely today. In order to assess the value of this operation in the treatment of advanced Kienböck's disease, after a mean follow-up period of 19 years we could review 7 of 12 patients who had had their lunate replaced by the vascularised pisiform. At the time of follow-up all patients were fully employed without restrictions, and no patient had had to change his job. The mean DASH score was 5.9. The average pain level by VAS was 0.9 and four patients were totally free of pain. Grip strength of the affected arm was reduced to 77% of the opposite side, the active range of motion (extension/flection) was 97 degrees, which was 72% of that of the not affected side. All patients reported high satisfaction with the results of the operation. Although the clinical results were very good, we found substantial radiographical alterations: In 5 patients we found an advanced intercarpal osteoarthritis. Four patients presented a spontaneous synostosis between the pisiform and the triquetrum. The average CHR (carpal height ratio) was 0.43. The presented long-term results after lunate replacement by the vascularised pisiform indicate a high patient satisfaction and very good functional results in spite of significant radiological changes.

[Flexion contractures of the PIP joints: pathogenesis, classification and results following arthrolysis]. / Beugekontrakturen der Mittelgelenke: Pathogenese, Klassifikation und Ergebnisse nach Arthrolysen.

The most frequent cause of flexion contracture is immobilization, which may occur with or without trauma. Posttraumatic flexion contracture mainly develops from direct injury, intraarticular fluid and the physiological muscle balance. Nontraumatic post-immobilisation stiffness is due to biochemical and biomechanic changes as well as processes, which are determined by the metabolic activities of tissue and the lack of stress. Because of the variable and the changing anatomical substrates, and owing to different prognostic factors, it is necessary to subdivide the group of flexion contractures with regard to their prognostic factors. Thus, we recommend to differentiate between simple periarticular contractures, complex periarticular contractures with tenodesis and/or contractures caused by scars, as well as a corresponding classification of corresponding treatment procedures. The results in the literature will then be categorized accordingly within a metaanalysis. With regard to the reduction of flexion contractures and the range of motion, the group of simple periarticular arthrolysis shows better results than the group of complex periarticular arthrolysis. The mediolateral approach is preferred in the first group.

[Ulnar wrist pain]. / Der ulnare Handgelenkschmerz.

The distal radioulnar joint (DRUJ), the ulnocarpal joint and the ulnar carpus form an functional anatomical complex, as the head of the ulna is an articulated part of DRUJ as well as having a stabilising action and acting as an abutment due to its direct attachment to the triangular fibrocartilage complex. Pain in this area poses a diagnostic problem due to the close proximity of these structures. In addition to describing the standard clinical examination, the major pathologies of these ulnar hand components, their symptomatology and the basis of their therapy are discussed.

Fingers, hands or patients? The concept of independent observations.

In hand surgery trials, it is often possible to take several measurements from the same patient, because many disorders here affect bilateral or multiple structures, such as the hand itself, the finger joints or the tendons. Most conventional statistical analyses that take place on the level of hands, digit rays or joints rather than patients violate the assumption that observations should be independent. Furthermore, ignoring the multiplicity of data inflates sample size and thus may lead to spurious significance. This article describes three options to deal with such problems. First, the analysis can simply be restricted to only one measurement per patient. Second, a self-controlled design may be advantageous for conditions that usually have a bilateral pattern. Third, complex statistical modelling (involving generalized estimating equations) can be used to analyse all available measurements with adjustment for data dependency.

[The dynamic treatment of intraarticular fractures of the base of the middle phalanx with the Suzuki dynamic fixator]. / Die dynamische Behandlung von intraartikulären Mittelgliedbasisfrakturen mit dem Bewegungsfixateur nach Suzuki*

Between 1994 and 1998, we have treated eleven patients with intraarticular fractures of the base of the middle phalanx including impaction, dislocation, and pilon types of injuries. All patients were evaluated after a median follow-up period of 25.8 (8 to 57) months. Treatment was carried out according to Suzuki's technique with a dynamic PIP-joint distraction fixator consisting of Kirschner wires and rubber bands. In five cases, there was additional osteosynthesis (Kirschner wires, resorbable hemicerclage) or cancellous bone-grafting for reconstruction of the joint surface. Early mobilisation commenced with active exercises for the PIP joint on the day of surgery. The dynamic extension fixator was applied for an average duration of 28 (15 to 42) days. By the time of follow-up examinations, we found a range of motion on an average of 64 (0 to 105) degrees including a lack of extension of 11 (0 to 60) degrees and a median flexion capacity of 75 (30 to105) degrees. All fractures healed uneventfully with restored joint stability. Eight patients were completely painfree, three complained of mild occupational pain.

[Does Epping resection arthroplasty lead to loss of hand strength? A prospective study]. / Führt die Resektionsarthroplastik nach Epping zur Kraftminderung der Hand? Eine prospektive Studie.

FCR-sling resectional arthroplasty does not definitely prevent a proximalisation of the first metacarpal bone. Since power transmission of the thenar muscles requires a particular length of the thumb, does proximalisation lead to a reduction of grip strength of the hand? In a prospective study, hand-, key- and pinch-grip strength was compared to preoperative data. Pain intensity and thumb mobility were also examined. In comparison to preoperative data, the pain-free pinch grip improved 60% after three months and 100% after 12 months (p < 0.01). The maximum pinch grip improved 11% after three and 34% after 12 months (p < 0.01). The pain-free key grip improved 22% after three months and 50% after 12 months (p < 0.01). The maximum key grip showed a fair reduction after three months, but after 12 months the key pinch strength came up to preoperative level. The hand grip strength showed a statistically significant improvement of 9% after three months and 34% after 12 months (p < 0.01). After one year, 80% of the patients were completely painfree. There was no clinically relevant disturbance of thumb movement following surgery. Owing to proximalisation of the first metacarpal, a scapho-metacarpal distance of 5.3 (2-9) mm was measured. Despite proximalisation of the first metacarpal, a significant improvement of the grip strength was observed, which was rooted in simultaneous pain reduction.

[The nutritive vascular canals. The magnetic resonance differential diagnosis of carpal cystic lesions?]. / Nutritialgefässkanäle. Magnetresonanztomographische Differentialdiagnose karpaler zystischer Läsionen?

PURPOSE: To find and describe potential MRI criteria of nutrient vessel canals of carpal bones. METHODS AND MATERIAL: 16 wrists of 13 patients with pain and radiographic depiction of cystic changes within the lunate were examined. The MRI protocol included coronal and sagittal T1- and T2-weighted SE sequences (4 mm slices, 120 FOV, 256 x 256 matrix) as well as coronal STIR images. Final diagnosis was confirmed by surgery (n = 5) and follow up. 10 cadaveric ossa lunata were studied to describe size, number, location and shape of nutrient vessel canals. RESULTS: Ganglion cysts (n = 6) showed characteristic signs. In ulnar impaction syndrome (n = 1) small cystic lesions in the lunate were surrounded by a sclerotic rim and located near the proximal ulnar surface. In Kienböck's disease (n = 3) cystic components were irregular and surrounded by bone marrow edema. Nutrient vessel canals (n = 7) imaged as 1 to 3 small cystic lesions within the palmar or dorsal subchondral region. CONCLUSION: MRI can aid in differential diagnosis of cystic carpal lesions. Nutrient vessel canals may not be mistaken for pathologic cystic lesions. Carpal ganglion cysts show distinct diagnostic pattern.

[Osteosynthesis with resorbable hemi-cerclage in metacarpal fractures]. / Osteosynthesen mit resorbierbaren Hemizerklagen bei Metakarpalfrakturen.

The use and results of biodegradable hemicerclages for metacarpal fracture fixation were reviewed retrospectively. A total of 92 metacarpal fractures in 78 patients were treated with polyglycolic or polydioxanon sutures. Study parameters included time for bony union, duration of immobilisation, total active range of motion, and complications. The hemicerclage achieved rigid fracture fixation and permitted early mobilisation exercises without jeopardizing bony union. Immobilization of metacarpals was performed for a median of 3.4 (1.5 to 6) weeks. There were no complications of wound healing. Adequate bony union was achieved after a median of 4.5 weeks (3.5 to 7 weeks). In one case, premature loading of the fracture led to displacement and delayed union. At the end of treatment (6.1 [4 to 7.5] weeks), total active range of motion was 98 (85 to 100)%. Ideal indications are oblique or torsion fractures of the metacarpals. In these cases, immobilisation up to wound healing is sufficient.

Results of proximal interphalangeal joint release for flexion contractures: midlateral versus palmar incision.

Forty-two patients (45 fingers) were retrospectively reviewed after operative release of flexion contractures of the proximal interphalangeal (PIP) joint. The release was accomplished through a palmar incision in 19 fingers, usually followed by skin coverage using a lateral transposition flap. A midlateral incision was used in 26 fingers. The 2 groups were comparably matched with respect to degree of contracture and demographic characteristics. Active range of motion (ROM) was measured before and after surgery. In the palmar incision group, preoperative median PIP joint ROM was 60 degrees to 90 degrees (extension/flexion) and 30 degrees to 90 degrees at the 3-year follow-up examination. In the midlateral incision group, preoperative median PIP joint ROM was 50 degrees to 90 degrees (extension/flexion) and 0 degrees to 90 degrees at the 1.5-year follow-up examination. The improvement in ROM was significantly better in the midlateral incision group than in the palmar incision group.

[Value of clinical diagnosis in carpal tunnel syndrome]. / Die Wertigkeit der klinischen Diagnostik beim Karpaltunnelsyndrom.

The aim of this study was to examine sensitivity and specificity of Durkan test in 54 patients with carpal tunnel syndrome confirmed by electrophysiological testing, as compared to a control group of 54 patients without clinical signs of the syndrome. Sensitivity and specificity of Durkan test alone, as well as in combination with Phalen test and Hoffmann-Tinel test, were determined. The sensitivity of Durkan test was 0.87, its specificity was 0.96. The sensitivity of Phalen test was 0.85 with a specificity of 0.96. It was discovered that the combination of Phalen with Durkan test achieved a sensitivity of 0.94 and a specificity of 0.96, thus equalling the respective values for electrophysiological testing (nerve conduction velocity, electromyography) which so far is regarded as the golden standard diagnostic test for carpal tunnel syndrome. If Hoffmann-Tinel test is included as a further clinical parameter, then both sensitivity and specificity reach 0.96. This study, therefore, raises the question of whether costly electrophysiological testing is in fact necessary before surgery for carpal tunnel syndrome, when the clinical tests have already proven positive.

Fixation of metacarpal fractures using absorbable hemi-cerclage sutures.

We retrospectively reviewed the use of biodegradable hemi-cerclage sutures in the treatment of 79 metacarpal fractures in 66 patients. The polyglycolic acid hemi-cerclages achieved sufficient fracture fixation to permit early motion exercises, but fractures were also immobilized for a mean of 3.7 (range, 1.5-6) weeks postoperatively, during which time physiotherapy was given. Adequate bony stability was achieved after a mean of 4.5 (range, 3.5-7) weeks and fracture redisplacement occurred in only one case.

[Motor replacement operations in chronic ulnar nerve paralysis]. / Motorische Ersatzoperationen bei veralteten N.-ulnaris-Paresen.

Irreparable damage to the motor function of the ulnar nerve results primarily in paralysis of the intrinsic muscles and reduces the functional capacity of the hand by about one-half. Tendon transfers are therefore indicated when the following grasp functions are impaired; (1) claw hand with dyskinetic finger movements; (2) impaired thumb adduction with limited key pinch power; (3) instability of the index MP joint; (4) adduction weakness of the little finger. The various procedures and transposition techniques are discussed and the author's preferred methods of tendon transfer are presented.

[Possibilities and limits of intramedullary Kirschner wire osteosynthesis in treatment of metacarpal fractures]. / Die Möglichkeiten und Grenzen der intramedullären Kirschner-Drahtosteosynthese zur Behandlung der Metakarpalfrakturen.

An alternative method for treating metacarpal fractures using intramedullary Kirschner-wire pinning is presented. This procedure does not immobilize the metacarpophalangeal joint, thus allowing early motion exercises of the affected hand which is of particular advantage in fractures of the metacarpal neck. Since May 1993, we have treated 33 patients with 37 fractures; the fifth metacarpal was involved in each case. An awl is used to prepare an opening in the cortex for insertion of two or three pre-bent K-wires which are then advanced distally from the base of the metacarpal bone. The hand is immobilized on a plaster splint for one week. Work load is increased after three weeks. With the exception of three cases, our patients achieved free movement of the fingers with anatomical alignment of the fracture site at the time of wire removal. Three cases were re-operated upon due to K-wire migration or fracture displacement. Ideal indications for this procedure are distal transverse and short oblique fractures.

Contralateral transplantation of a finger for restoration of thumb function.

Transplantation of a finger from the contralateral hand for thumb reconstruction is seldom done because of possible psychological problems for the patient. We present two cases in which a previously damaged index finger of the contralateral hand was transplanted. In both patients the metacarpophalangeal joint of the index finger replaced that of the thumb. A powerful pinch to the fingers was achieved and the appearance of both the donor and the recipient hands was considerably improved.

[Pseudarthrosis of the capitate bone. Report of 2 cases]. / Die Pseudarthrose des Os capitatum. Bericht über zwei Fälle.

Well protected by its central position and richly vascularized, the capitate bone is rarely involved in posttraumatic pseudarthrosis. Drawing on two cases, the present study will describe anatomy, aetiology, pathogenesis, diagnosis, and therapy of pseudarthroses of the capitate. Restoration of the physiological capitate height was achieved in both cases with a corticocancellous bone graft from the iliac crest which led on to bony union within three months.