Periprosthetic radiolucency in total wrist arthroplasty: a radiographic study.

This retrospective study investigates the incidences of periprosthetic radiolucency and the position of the prosthesis in patients who underwent total wrist arthroplasty. A total of 50 patients with a mean age of 58 years (SD 11) were included. The available dorsopalmar and lateral radiographs were categorized into the following groups: immediately postoperative and 1, 2, 3, 5 and beyond 6 years postoperatively. The findings of this study indicate that periprosthetic radiolucency is a progressive phenomenon that originates at the bone adjacent to the joint line, possibly due to stress shielding. The size of the periprosthetic radiolucency showed no correlation with any clinical parameter, nor can its size be predicted by intraoperative implant positioning. However, a significant correlation was observed between a reduced implant-middle finger carpometacarpal distance and higher postoperative pain levels as well as patient dissatisfaction. Revision surgery after total wrist arthroplasty should not be solely guided by radiological signs of periprosthetic radiolucency. Instead, this study suggests that consideration for revision surgery should be reserved for symptomatic patients experiencing persistent pain and swelling accompanied by radiographic evidence of carpal implant subsidence.Level of evidence: IV.

Effect of Music on the Efficiency of Performing a Microsurgical Arterial Anastomosis: A Prospective Randomized Study.

Introduction Music is commonly played in operating rooms. Because microsurgery demands utmost concentration and precise motor control, we conducted the present study to investigate a potentially beneficial impact of music on performing a microsurgical anastomosis. Materials and Methods We included a novice group (15 inexperienced medical students) and a professional group (15 experienced microsurgeons) in our study. Simple randomization was performed to allocate participants to the music-playing first or music-playing second cohort. Each participant performed two end-to-end anastomoses on a chicken thigh model. Participant demographics, their subjective preference for work environment (music/no music), and time to completion were noted. The performance of the participants was assessed using the Stanford Microsurgery and Resident Training (SMaRT) scale by an independent examiner, and the final anastomoses were evaluated according to the anastomosis lapse index. Results Listening to music had no significant effect on time to completion, SMaRT scale, and anastomosis lapse index scores in both novice and professional cohorts. However, the subjective preference to work while listening to music correlated with high SMaRT scale scores within the professional cohort ( p = 0.044). Conclusion Playing their preferred music in the operating room improves the performance scores of surgeons, but only if they subjectively appreciate working with background music.

Total Wrist Arthroplasty for Posttraumatic Wrist Osteoarthritis: A Cohort Study Comparing Three Indications.

Scapholunate ligament ruptures and scaphoid nonunion with consecutive advanced collapse (SLAC and SNAC wrists) as well as intra-articular distal radius fractures (DRF) are prone to cause posttraumatic wrist osteoarthritis. The aim of this study was to compare the outcomes of these indications for total wrist arthroplasty. We included 13, 11, and 8 patients with an overall mean age of 60 ± 9 years in the SLAC, SNAC, and DRF cohort, respectively. After an average follow-up period of 6 ± 3 years, we found no difference between our groups regarding pain levels and functional scores, although these parameters significantly improved compared to preoperative parameters. Complication and revision rates revealed no significant difference. However, significantly higher extension, arc of range of motion values in the flexion-extension, as well as in radial-ulnar deviation plain were detected in the SLAC compared to the DRF group. Finally, TWA proved to show a beneficial performance in all three investigated indications.

Wrist Hemiarthroplasty for Complex Intraarticular Distal Radius Fracture in a Patient with Manifest Osteoporosis.

Distal radius fracture (DRF) is one of the most common fractures of the elderly. The higher the degree of joint surface destruction, and the more adverse factors are involved, the more challenging proper treatment becomes. In this regard, osteoporosis as underlying systemic disease, chondropathy or degeneration of adjacent wrist bones as well as incompliance significantly impair the success of the chosen primary therapy. Wrist hemiarthroplasty has already been reported as primary or secondary procedure for DRFs. In this case report, we present a patient with a severely comminuted DRF including posttraumatic degeneration of the lunate as well as manifest osteoporosis. Wrist hemiarthroplasty using the ReMotion radius component in combination with proximal row carpectomy was performed as secondary surgery. This procedure proved to be a viable treatment option in terms of achieving low pain levels, high range of motion values and stable osteointegration over a course of 6.5 follow-up years.

Metacarpal reconstruction with a medial femoral condyle flap based on a 3D-printed model: a case report.

Metacarpal bone reconstruction renders a surgical challenge. We describe a case using 3D printing assisted medial femoral condyle flap for extensive metacarpal reconstruction after wide resection of a large giant cell tumor recurrence. Thus, the length and stability of the entire third ray could be restored without any tumor recurrence. (50 w).

TOUCH® Prosthesis for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Case Series.

The dual mobility concept currently represents the newest generation of thumb carpometacarpal prostheses. The aim of this study was to evaluate the short-term outcomes of TOUCH® prosthesis. From September 2019 to July 2020, 40 prosthesis were implanted in 37 patients suffering from symptomatic stage III osteoarthritis. All included patients with a median age of 57.7 (IQR: 13.6) finished the systematic follow-up regimen (4, 8, 16 weeks, 6, and 12 months postoperatively). All parameters significantly improved (p < 0.0001) compared to the preoperative status. At 1 year follow-up, median DASH Scores decreased from 54 (IQR 22) to 12 (IQR 28) and pain levels improved from 8 (IQR 2) to 1 (IQR 2). Moreover, key-pinch strength increased from 3.8 (2.0) to 5.8 (2.5), while palmar abduction, radial abduction, and opposition also significantly improved. 35/37 patients were satisfied with the functional outcomes. We observed 10 complications, of which 6 were tendon-related issues, and 2 were due to an inappropriate choice of neck size. We could detect one dislocation but no evidence of cup loosening, tilting or subsidence in any patient. Despite the occurrence of some complications, we recommend implantation of this prosthesis type due to favorable clinical and radiological performance.

Proximal Row Carpectomy with Total Scapoidectomy vs. Conventional Carpal Resection for ReMotion Total Wrist Arthroplasty.

High complication rates in total wrist arthroplasty (TWA) still lead to controversy in the medical literature, and novel methods for complication reduction are warranted. In the present retrospective cohort study, we compare the outcomes of the proximal row carpectomy (PRC) method including total scaphoidectomy (n = 22) to the manufacturer's conventional carpal resection (CCR) technique, which retains the distal pole of the scaphoid (n = 25), for ReMotion prosthesis implantation in non-rheumatoid patients. Mean follow-up was 65.8 ± 19.8 and 80.0 ± 28.7 months, respectively. Pre- and postoperative clinical assessment included wrist flexion-extension and radial-ulnar deviation; Disability of Arm, Shoulder, and Hand scores; and pain via visual analogue scale. At final follow-up, grip strength and satisfaction were evaluated. All complications, re-operations, and revision surgeries were noted. Clinical complications were significantly lower in the PRC group (p = 0.010). Radial impaction was detected as the most frequent complication in the CCR group (n = 10), while no PRC patients suffered from this complication (p = 0.0008). Clinical assessment, grip strength measurements, and the log rank test evaluating the re-operation as well as revision function showed no significant difference. All functional parameters significantly improved compared to preoperative values in both cohorts. In conclusion, we strongly recommend PRC for ReMotion prosthesis implantation.

[An innovative concept for microsurgical training: a feedback analysis]. / Mikrochirurgisches Training ­ ein innovatives, modulares Ausbildungskonzept: eine Feedbackanalyse.

BACKGROUND: There has been a shift in microsurgical education towards simulation training. Hence a number of training programs are being proposed to educate aspiring microsurgeons. However, it is challenging to master the skill of microsurgery and no program has proposed a fully satisfactory training model to date. Therefore, we present an innovative course concept and assess the participants' feedback. METHODS: Being offered a four-step modular curriculum, participants can tailor their program to their individual needs and reinforce specific aspects of their training. The program is characterised by exercises ranging from basic techniques performed on avital biologic models to specific surgical techniques performed on human anatomic specimens. In our feedback questionnaire we ask participants to evaluate the parameters "course design", "expectations" and "overall satisfaction" based on a Likert scale with 5 items (100 %, 75 %, 50 %, 25 % and 0 %). RESULTS: From 2015 to 2017, 274 students completed and evaluated individual courses. The average values exceeded 90 % for all three parameters. DISCUSSION: In conclusion, we have developed and evaluated an innovative training program with a constantly high satisfaction rate and a rising number of participants, thus contributing to the advancement of microsurgical skills in Central Europe.

Radial and palmar active range of motion measurement: reliability of six methods in healthy adults.

The current study aims to assess the reliability of 6 range-of-motion measurement methods for the thumb carpometacarpal joint: Pollexograph-thumb, Pollexograph-metacarpal, radius-metacarpal goniometry, intermetacarpal goniometry, intermetacarpal distance, and thumb-distal-interphalangeal distance. A senior hand surgeon, an experienced resident, and a less experienced research fellow evaluated the dominant hands of 29 healthy subjects. All 6 methods were performed for radial adduction, radial abduction, and palmar abduction, but only distance methods were measured for palmar adduction. Intrarater and interrater reliability were computed using intraclass correlation coefficient, standard error of measurement, and smallest detectable difference. Pollexograph-thumb method showed the highest active range of movement for radial adduction (12°) and abduction (71°), while all the other angular methods resulted in approximately 20° for radial adduction and 50° for radial abduction. Distance methods showed comparable mean results for radial and palmar range of motion (adduction/abduction): intermetacarpal distance (50 mm/60 mm) and thumb-distal-interphalangeal distance (50 mm/120 mm). Interrater reliability using the results of the intraclass correlation coefficient demonstrates that Pollexograph-thumb and Pollexograph-metacarpal showed excellent reliability for radial adduction and abduction, whereas Pollexograph-thumb method revealed the best reliability for palmar abduction. Moreover, thumb-distal-interphalangeal distance also showed excellent reliability for radial and palmar abduction. Conventional goniometry showed a large variety of reliability results, ranging from poor to excellent. No clinical benefit can be derived from assessing the palmar adduction. We found that the Pollexograph-thumb showed excellent reliability results throughout all measurements. Thumb-distal-interphalangeal-joint distance is especially valuable for assessing radial and palmar abduction.

Total arthroplasty with Ivory® prosthesis versus resection-suspension arthroplasty: a retrospective cohort study on 82 carpometacarpal-I osteoarthritis patients over 4 years.

BACKGROUND: To elucidate the performance of carpometacarpal-I joint prostheses in comparison with the current gold standard treatment, resection-suspension arthroplasty (RA), we conducted a study comparing outcomes of the Ivory prosthesis to those of a cohort of patients receiving RA. METHODS: Initially, we had enrolled 34 prosthesis patients and 48 RA patients, of which 5 and 11 were lost to follow-up. We defined Eaton/Littler stage 3 osteoarthritis, no previous surgery, no concomitant arthrosis, no rheumatic arthritis, no history of trauma and a minimum follow-up period of 2 years as inclusion criteria. We assessed patient demographics, disability of the arm, shoulder, and hand score, pain via visual analogue scale, subjective strength of the thumb, range of motion (radial and palmar abduction and opposition), and patient satisfaction. All occurring complications were recorded. RESULTS: Follow-up included a mean period of 4.5 years (2-7.4) in the prosthesis cohort and 4.1 years (2-6.8) in the RA group. Disability of the arm, shoulder, and hand scores, pain scores, palmar abduction and opposition, and subjective satisfaction showed no significant differences between the two cohorts. Postoperative loss of strength was significantly less in the prosthesis group (p = 0.01). Moreover, we were able to demonstrate better range of motion in terms of radial abduction in the prosthesis group (p = 0.001). The overall complication rate was significantly higher in the prosthesis cohort (41.4% vs. 10.8%) (p = 0.008). Nevertheless, the Ivory prosthesis group showed a survival rate of 93.1%. CONCLUSION: As the high complication rate is compensated by a better functional outcome (enhanced range of motion and strength), we believe that prosthesis implantation can be a reasonable treatment option for carpometacarpal-I osteoarthritis in a particular patient group. Level of Evidence IIIl: Retrospective cohort study.

Elektra prosthesis versus resection-suspension arthroplasty for thumb carpometacarpal osteoarthritis: a long-term cohort study.

The present study compares 34 patients with thumb carpometacarpal osteoarthritis (37 thumbs) treated with the Elektra® prosthesis, with 18 patients (18 thumbs) treated with resection-suspension arthroplasty, with an overall mean follow-up period of 13.3 years. Evaluation with disability of arm and shoulder scores, pain via visual analogue scale and range of motion (radial and palmar abduction, and opposition) indicated no significant difference. However, the cohort with a surviving prosthesis showed significantly better subjective grip strength (p = 0.04). Complications occurred in 23 of the 37 thumbs in the prosthesis group compared with two in the resection-suspension arthroplasty patients. Seventeen prostheses required revision. At revision operations, we observed local signs of metallosis in 15 of 17 cases. The patients receiving resection-suspension arthroplasty were more satisfied with their treatment (p = 0.003). Therefore, we cannot recommend the implantation of Elektra® prosthesis and we speculate that the key problem of aseptic cup loosening is a result of the metal-on-metal bearing. Level of evidence: III.

Autologous Fat Transplantation for Thumb Carpometacarpal Joint Osteoarthritis (Liparthroplasty): A Case Series with Two Years of Follow-UP.

Adipose-derived mesenchymal stem cell (ASC) therapy is currently a focus of regenerative medicine. Lipoaspirate is rich in ASCs and is evolving into a promising, less-invasive tool to treat thumb carpometacarpal osteoarthritis as compared with common surgical techniques, for example, trapeziectomy or prosthesis implantation. The present study aimed to examine the effect of 1 mL intraarticular lipoaspirate injection (liparthroplasty) in 31 thumb carpometacarpal osteoarthritis patients (27 woman and four men) with a median age of 58 (interquartile range (IQR) of 10) years and Eaton-Littler Stage 2 or 3. Median pain levels assessed via visual analogue scale significantly decreased from 7 (IQR 2) to 4 (IQR 6) after six months (p < 0.0001) and 2 (IQR 5) after two years (p < 0.0001). Median pre-interventional Disabilities of the Arm, Shoulder and Hand (DASH) scores of 59 (IQR 26) significantly reduced to a value of 40 (IQR 43) after six months (p = 0.004) and to 35 (IQR 34) after two years (p < 0.0001). Subjective grip strength showed no significant improvement. However, the time until recurrence of symptoms was measured and a cumulative remission rate of 58% was detected after two years. Satisfaction rates were 68% after six months and 51% after two years. In conclusion, liparthroplasty represents a promising option to reduce pain and functional impairment and to postpone surgery for a certain period of time.

Re-motion total wrist arthroplasty: 39 non-rheumatoid cases with a mean follow-up of 7 years.

We evaluated the outcomes of the Re-motion total wrist arthroplasty in 39 non-rheumatoid patients. The mean follow-up was 7 years (range 3-12). Postoperative wrist flexion-extension and radial-ulnar deviation as well as the scores of the Disability of Arm Shoulder and Hand questionnaire and the visual analogue scale pain scores improved significantly. Complications occurred in 13 wrists, five of which required further surgery. The most frequent complication was impingement between the scaphoid and the radial implant (n = 5), which can be avoided by complete or almost complete scaphoid resection. Periprosthetic radiolucency developed around the radial component in three cases and three radial screws loosened. Despite the incidence of high implant survival in 38 of 39 wrists over 7 years (97%), the complication rate is not satisfying. Knowledge of the risk of complications and patient selection are essential when making the decision to choose wrist arthroplasty over arthrodesis. Level of evidence: IV.

Optical magnification should be mandatory for microsurgery: scientific basis and clinical data contributing to quality assurance.

BACKGROUND: Microsurgical techniques are considered standard procedures in reconstructive surgery. Although microsurgery by itself is defined as surgery aided by optical magnification, there are no guidelines for determining in which clinical situations a microscope or loupe should be used. Therefore, we conducted standardized experiments to objectively assess the impact of optical magnification in microsurgery. METHODS: Sixteen participants of microsurgical training courses had to complete 2 sets of experiments. Each set had to be performed with an unaided eye, surgical loupes, and a regular operating microscope. The first set of experiments included coaptation of a chicken femoral nerve, and the second set consisted of anastomosing porcine coronary arteries. Evaluation of the sutured nerves and vessels were performed by 2 experienced microsurgeons using an operating microscope. RESULTS: The 16 participants of the study completed all of the experiments. The nerve coaptation and vascular anastomoses exercises showed a direct relationship of error frequency and lower optical magnification, meaning that the highest number of microsurgical errors occurred with the unaided eye. For nerve coaptation, there was a strong relationship (P<0.05) between the number of mistakes and magnification, and this relationship was very strong (P<0.01) for vascular anastomoses. CONCLUSIONS: We were able to prove that microsurgical success is directly related to optical magnification. The human eye's ability to discriminate potentially important anatomical structures is limited, which might be detrimental for clinical results. Although not legally mandatory, surgeries such as reparative surgery after hand trauma should be conducted with magnifying devices for achieving optimal patient outcomes.

A comparison of pretreatment with a topical combination of nonivamide and nicoboxil and surgical delay in a random pattern skin flap model.

Delay procedures are intended to increase flap safety in otherwise risky flaps. In general they are of surgical nature, making an additional operation necessary. To overcome this drawback, non-surgical alternatives that may be as effective as the surgical procedure are constantly sought. We have previously shown an effective postoperative method to augment flap viability by topical application of a combination of nicoboxil and nonivamide. The goal of this study was to investigate whether this combination is also effective in inducing a delay effect in experimental skin flaps. Thirty male Wistar rats were randomised into three groups (n=10), and a standardised dorsal random pattern (6x2 cm) skin flap was raised on each animal. In rats of group 1, a surgical delay procedure was carried out 1 week prior to full flap harvest by incising the two longitudinal borders of the flap. In group 2 rats, the whole flap area was treated by the topical ointment once a day in order to induce a chemical delay effect for 7 days prior to flap harvest. In group 3 rats, the flap was harvested without any prior intervention and this group served as a control. Skin flap viability was assessed on postoperative day 7, and the extent of the viable skin flap area was compared between the three groups. The surgical delay procedure resulted in a significant increase in the viable area of the skin flaps compared to the chemical delay group and the control group. Additionally, there was a significant increase in skin flap viability between the chemical group and the control group (mean percentage of viable skin flap area in surgical delay group, 80.9+/-15.6; nonivamide/nicoboxil pre-treated group, 71.8+/-4.9; control group, 60.7+/-2.1; p<0.05). Although not as effective as the surgical delay procedure, the topical combination of nicoboxil and nonivamide proved to be of significant value in order to ameliorate ischemic necrosis in experimental skin flaps. Due to its ease and safety in application, this ointment may prove clinically useful in selected situations, especially when combined with an additional postoperative treatment.

Strategies for the reduction of live animal use in microsurgical training and education.

Education and training in microsurgical techniques have historically relied on the use of live animal models. Due to an increase in the numbers of microsurgical operations in recent times, the number of trainees in this highly-specialised surgical field has continued to grow. However, strict legislation, greater public awareness, and an increasing sensitivity toward the ethical aspects of scientific research and medical education, emphatically demand a significant reduction in the numbers of animals used in surgical and academic education. Hence, a growing number of articles are reporting on the use of alternatives to live animals in microsurgical education and training. In this review, we report on the current trends in the development and use of microsurgical training models, and on their potential to reduce the number of live animals used for this purpose. We also share our experiences in this field, resulting from our performance of numerous microsurgical courses each year, over more than ten years. The porcine heart, in microvascular surgery training, and the fresh chicken leg, in microneurosurgical and microvascular surgery training, are excellent models for the teaching of basic techniques to the microsurgical novice. Depending on the selected level of expertise of the trainee, these alternative models are capable of reducing the numbers of live animals used by 80-100%. For an even more enhanced, "closer-to-real-life" scenario, these non-animated vessels can be perfused by a pulsatile pump. Thus, it is currently possible to provide excellent and in-depth training in microsurgical techniques, even when the number of live animals used is reduced to a minimum. With these new and innovative techniques, trainees are able to learn and prepare themselves for the clinical situation, with the sacrifice of considerably fewer laboratory animals than would have occurred previously.

Intraluminal endoscopic evaluation of microvascular anastomosis.

Microsurgery is an established technique in different surgical disciplines. Training in the laboratory remains the mainstay for delivering optimal performance in the operating room. Routine evaluation of microsurgical anastomosis during training usually consists of longitudinal splitting of the performed anastomosis. We present our initial experiences with endoluminal evaluation of microvascular anastomosis by endoscopy. In all experimental settings flexible miniature endoscopes with diameters of 1 and 2mm were used. All experiments were conducted in porcine coronary arteries or artificial vessels such as silastic tubes. The endoscope was introduced into the vessel lumen via an i.v. cannula. Specialised digital software was developed to enhance the displayed image. This so-called round-scan system delivers a two-dimensional picture of the endoluminal surface of a microvascular anastomosis. With the developed scanning software we were able to overcome technical limitations in microvascular endoscopy. Good results were obtained in 1.7 mm artificial vessels and technical errors in microvascular anastomosis were revealed. Endoluminal microvascular endoscopy offers great potential in evaluating skills in microvascular surgery in training settings but theoretically can also be employed in clinical situations. Main limitations encountered include fluids such as blood within vessels and the slow but steady pace by which the endoscope has to be withdrawn from within the vessel lumen.