[Homodigital neurovascular island flap according to Venkataswami]. / Defektdeckung mit dem anterograden homodigitalen Insellappen nach Venkataswami.

OBJECTIVE: Reliable wound coverage of the fingertip and palmar aspect of the middle finger with a sensate flap in order to restore early function. INDICATIONS: Palmar, oblique pulp defects or amputations at the distal finger phalange with uncovered bone, tendons, and/or neurovascular structures. CONTRAINDICATIONS: Peripheral perfusion deficiency, size of defect exceeding flap capacity, obliteration of the flap artery, i.e. contralateral finger artery. SURGICAL TECHNIQUE: Harvesting of adipocutane, midlateral triangle based on proper digital vessel flap; distal flap transposition and primary closure of the harvesting defect, flap dimension 4-5 mm larger than defect. POSTOPERATIVE MANAGEMENT: Finger splint for 2 weeks, followed by exercises with flap conditioning. RESULTS: Very reliable defect coverage with 9% minor and temporary complications, all of which healed without consequences.

Anterior intermeniscal ligament: frequency in MRI studies and spatial relationship to the entry point for intramedullary tibial nailing related to the risk of iatrogenic violation.

BACKGROUND: Anterior knee pain is the most common complication after intramedullary tibial nailing. Often, the cause is multifactorial and individually different. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible origin of postsurgical anterior knee pain. Both the importance and function of the AIL remain somewhat ambivalent, and even the figures quoted in the literature for its existence in the population vary drastically. Our aim was to verify the estimated frequency of the AIL in the literature by retrospectively analysing the data of MRI studies conducted at our hospital. In addition, we attempted to assess the potential risk of AIL violation during intramedullary tibial nailing, based on the spatial arrangement. METHODS: Two independent examiners analysed the images generated in 351 MRI studies conducted at our hospital between June 2013 and May 2014. All cases who did not reveal any previous knee-joint injury or osteoarthritis of the knee were allocated to group I. All other cases were included in group II. To estimate the potential risk of AIL injury during the nailing procedure, the distance between the AIL and the theoretical entry point for intramedullary nailing was measured. RESULTS: We identified the AIL on the images of nearly all patients (96.5%) in group I. In group II, the presence of the AIL was confirmed in only 51.4% of cases (p < 0.001). The average distance between the AIL and theoretical entry point for intramedullary tibial nailing was 10.1 mm (range 3.48-18.88 mm). CONCLUSIONS: Because we were able to confirm the presence of the AIL in nearly all patients without a history of knee joint injuries or osteoarthrosis, we presume that the AIL may play a role in knee joint function. Violation of the AIL during intramedullary nailing appears likely due to the close position of the AIL in relation to the entry point for the inserted nail. As a result and due to its rich sensory innervation, a connection between AIL violation during tibial nailing and postoperative onset of anterior knee pain seems likely. To eliminate one risk factor of anterior knee pain development and in view of the unresolved issues of AIL function, violation of the ligament during any operative procedure should be avoided.

[Open reduction and screw/plate osteosynthesis of metacarpal fractures]. / Offene Reposition und Schrauben­/Plattenosteosynthese von Mittelhandfrakturen.

OBJECTIVE: Anatomic reduction and stabile fixation for immediate mobilisation and restoration of unrestricted function. INDICATIONS: Instabile metacarpal fractures with or without malrotation, dislocated metacarpal fractures with malrotation or finger extension deficit, longitudinally shortened metacarpal fractures with finger extension deficit. CONTRAINDICATIONS: Persistent infections (empyema, osteomyelitis, phlegmon) SURGICAL TECHNIQUE: Longitudinal intermetacarpal incision along the fracture zone, debridement of the fracture zone with retainment of periost, anatomic reduction and retention of spiral fractures with at least two lag screws or retention of comminuted or transverse fractures with locking plate osteosynthesis while retaining periost. POSTOPERATIVE MANAGEMENT: Buddy splinting of the corresponding finger to enable immediate mobilisation without weight bearing for 6 weeks. RESULTS: Locking plate osteosynthesis and compression screw osteosynthesis after anatomic reduction of metacarpal fractures proved to be very reliable with a low complication rate and a good functional outcome (modified Mayo Wrist Score [MMWS]: mean 88 (20-100); Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire: mean 41(24-86)).

[Radiation exposure caused by the OrthoScan mini C-arm in hand surgery: a one-year case series]. / Röntgenstrahlenexposition in der Handchirurgie durch den OrthoScan Mini-C-Arm: eine 1-Jahres Fallserie.

BACKGROUND: Mobile X-ray imaging systems are standard in the operating theatre. Mini-C-arms are the prevailing technology in hand surgery. Unfortunately, the exposure to Mini-C-arm radiation is often underestimated. METHODS: For one year, the intraoperative radiation dose delivered by an OrthoScan High Definition Mini-C-arm with a flat panel detector was measured using headband and finger ring dosimeters in all hand and wrist surgeries performed by three experienced hand surgeons. RESULTS: Two hundred and thirteen patients underwent surgical treatment involving the use of an OrthoScan High Definition Mini-C-arm. The total radiation dose administered by all three hand surgeons over 12 months was 9033.39 mGy with a total irradiation time of 376:38 min. A radiation exposure of 2.0 mSv was detected on both finger ring dosimeters of one surgeon during one month. For all other dosimeters, the monthly radiation exposure was below the detection limit of < 0.3 mSv. CONCLUSION: The radiation exposure reached during about 100 surgeries/surgeon/year involving the use of an OrthoScan Mini-C-arm does not exceed the annual occupational exposure limits of 50 mSv for the hand and 20 mSv for the lens of the eye. Only at an X-ray exposure of 800-1000 mGy/month can radiation exposure be detected with a finger ring dosimeter (measuring range 0.3 mSv-10 Sv) in a hand surgeon. Due to the potential health risk posed by stochastic radiation effects, all possible safeguards including behavioural measures should be observed.

Importance of Mechanoreceptors and Other Neural Structures Within the Anterior Intermeniscal Ligament in the Etiology of Anterior Knee Pain After Tibial Nailing.

BACKGROUND: Anterior knee pain is the most common complication after intramedullary tibial nailing. The cause is often multifactorial and varies among individuals. Violation of the anterior intermeniscal ligament (AIL) during intramedullary tibial nailing might be a possible source of postsurgical anterior knee pain. Although there is a certain ambiguity regarding the importance and function of the AIL, neural structures in the AIL tissue might play a significant role with respect to functional purposes and pain perception. METHODS: We subjected 6 AIL specimens to histologic examination to identify the neural structures that are a mandatory requirement as a source of anterior knee pain. Specifically, we performed three-dimensional immunohistochemical investigation of subtyping, orientation, and detailed characterization of neural structures within the AIL tissue. RESULTS: Histologic and three-dimensional immunohistochemical examinations confirmed the presence of neural structures in all 6 AIL specimens. We identified myelinated and unmyelinated nerve fibers, as well as all types of mechanoreceptors. CONCLUSIONS: Free nerve endings are a mandatory requirement for pain perception as a result of AIL violation during tibial nailing. Our verification of all different types of mechanoreceptors in the AIL tissue makes a role of the ligament in knee joint function and proprioception highly probable. Further investigations are necessary to clarify possible correlations between neural supply and function of the AIL. Violation of the ligament during operative procedures should be avoided, although the significance of the AIL is still debated.

Pronator quadratus repair with a part of the brachioradialis muscle insertion in volar plate fixation of distal radius fractures: a prospective randomised trial.

INTRODUCTION: Stable pronator quadratus repair following volar plate fixation of distal radius fractures with complete plate coverage is difficult. MATERIALS AND METHODS: This study compares a modified pronator quadratus repair technique involving the brachioradialis muscle insertion (test group) with a conventional radial incision through the muscle without pronator quadratus repair (standard group). This prospective randomised study included 16 patients in the test group and 12 in the standard group; all were available for clinical, radiographic and ultrasound examination at a mean follow-up of 15 months. RESULTS: Pronator quadratus repair was feasible in all test group patients, and complete coverage of the distal plate was achieved in 11. No differences in functional outcome were observed between the groups. CONCLUSION: Pronator quadratus repair with a part of the brachioradialis muscle insertion is a reliable technique for coverage of a volar plate by slight distal transposition. In the repair of distal radius fractures, this may better protect the finger flexor tendons against irritation and/or rupture. That likelihood should now be studied.

Correction to: Insertion of the Ascension PyroCarbon PIP total joint in 152 human cadaver fingers: analysis of implant positions and malpositions.

In the experimental study the distal component of the Ascension PyroCarbon proximal interphalangeal total joint prosthesis was implanted 180° rotated. Figures 2-5 show the implant malpositions. The methods, results, and conclusion of the study were not affected by this.

Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures.

BACKGROUND: During intramedullary nailing of tibial fractures, the insertion angle of the nail is of great importance. When the nail impacts the posterior cortex due to a large insertion angle with a dorsal target course, higher insertion forces are needed, and the danger of iatrogenic fractures increases. Accordingly, the insertion direction should be as parallel as possible to the longitudinal axis of the tibia. We aimed to confirm the hypothesis that intramedullary nailing of tibial fractures can be performed with smaller insertion angles via a suprapatellar approach rather than infrapatellar approach. METHODS: In 19 human bodies of donors with intact tibiae, we performed intramedullary nailing by both a suprapatellar and an infrapatellar approach. The correct entry point was determined by fluoroscopy. Subsequently, the medullary canal was reamed up to a diameter of 10 mm, and a 9 mm polytetrafluorethylen tube was inserted instead of a tibia nail. The angle between the proximal aspect of the tube and the longitudinal axis of the tibia was measured using a computer-assisted surgery system. RESULTS: The angle between the proximal aspect of the inserted tube, simulating the tibial nail, and the longitudinal tibial axis was significantly larger when using the infrapatellar approach. CONCLUSIONS: We achieved an insertion angle significantly more parallel to the longitudinal axis when using a suprapatellar approach for intramedullary nailing of tibial fractures. Thereby, both the risk of iatrogenic fracture of the posterior cortex and apex anterior angulation of the short proximal fragment can be reduced during intramedullary nailing of tibial fractures.

Treatment of digital pyogenic flexor tenosynovitis: single open debridement, irrigation, and primary wound closure followed by antibiotic therapy.

INTRODUCTION: Digital pyogenic flexor tenosynovitis requires fast, aggressive treatment. Although this infection occurs frequently, treatment consensus is lacking. MATERIALS AND METHODS: Between 2011 and 2015, 22 patients with acute pyogenic flexor tenosynovitis were treated with a single open debridement followed by irrigation; the incision was closed and a 10-day antibiotic course was administered. The average incision-to-suture time was 25 min, and the average hospital stay was 4 days. Recovery was uncomplicated for 20 patients, while two were reoperated, one due to germ resistance and the other due to necrotizing fasciitis. At an average of 30 month postoperatively, 21 of the 22 patients were available for follow-up. The affected finger was inspected, and sensibility, range of motion, and grip force were compared with the opposite side, and the DASH score was determined. Each patient documented pain in the affected finger at rest and during activity, and rated overall satisfaction with the treatment on a visual analogue scale. RESULTS: Almost all patients were free of pain at follow-up and very satisfied. Compared to the contralateral side, each of the affected fingers had the same range of motion and sensibility. Grip force was similar on both sides. The average DASH score was 35 points. CONCLUSION: A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic treatment resolved uncomplicated pyogenic flexor tenosynovitis. After 2 and a half years, the treatment yielded high patient satisfaction with neither functional nor subjective impairment of the affected finger.

Supplementary arthrolysis of the proximal interphalangeal finger joint in Dupuytren's contracture: primary operation versus revision.

INTRODUCTION: In operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint (PIP) flexion contracture remains after fasciectomy which can be corrected by a supplementary arthrolysis, but few data comparing primary and revision surgery are available. MATERIALS AND METHODS: Fifteen patients who had a fasciectomy and supplementary PIP arthrolysis at the affected finger for the first time were compared to 13 patients who had a revision fasciectomy with a supplementary PIP arthrolysis. Upon follow-up at 22 months, flexion contracture was measured and data were compared to the preoperative values. Patient satisfaction with the outcome of the operation was determined and patients completed the Disabilities of the Arm, Shoulder and Hand outcome measure questionnaire. RESULTS: Fingers of patients with Dupuytren's disease that had a partial fasciectomy and supplementary arthrolysis of the PIP for the first time had a median residual PIP flexion contracture of 30° compared 39° of fingers that had a partial fasciectomy and supplementary arthrolysis of the PIP as a revision. The patients of both groups were equally satisfied with the outcome of the operation, while their DASH scores were nearly identical. CONCLUSION: After a mean follow-up of 2 years, the outcome of recurrent PIP contracture is comparable in patients with Dupuytren's disease that were treated by partial fasciectomy and supplementary arthrolysis for the first time and as a revision.

Insertion of the Ascension PyroCarbon PIP total joint in 152 human cadaver fingers: analysis of implant positions and malpositions.

INTRODUCTION: The Ascension PyroCarbon proximal interphalangeal (PIP) total joint is used in osteoarthritis of the PIP finger joint. No systematic study of the positioning of this prosthesis and its relation to proximal and middle phalanx morphology has yet been reported. MATERIALS AND METHODS: Positioning of the proximal and distal components of the Ascension PyroCarbon PIP total joint was radiographically analysed in 152 human cadaver fingers. RESULTS: Ideal implant position in the axis of the phalanx and with contact of the implant head with bone in both the frontal and sagittal planes was seen in only 33 % of the phalanges. Implant malposition was observed in the remaining 67 % of phalanges. CONCLUSION: The current design of the Ascension PyroCarbon PIP total joint can lead to malpositioning that we attribute to its incomplete accommodation of the morphology of the proximal and middle phalanx, the surgical challenges the design poses, or both acting together.

[Amputation of the hand due to necrotising fasciitis: a case report]. / Amputation der Hand bei nekrotisierender Fasziitis: Ein Fallbericht.

We report the case of an 81-year-old woman who fell at home on her left hand and suffered a laceration of her forehead. Within days a fulminant necrotizing fasciitis of the hand from group A ß-haemolytic streptococcus developed. Lacking an apparent local germ entry point at the hand, the infection was initially misinterpreted as compartment syndrome. The patient's life was saved by amputation of the hand.

Arthroscopically assisted reduction and internal fixation of a femoral anterior cruciate ligament osteochondral avulsion fracture in a 14-year-old girl via transphyseal inside-out technique.

Femoral avulsion fracture of the anterior cruciate ligament (ACL) in children and adolescents is rare, and its arthroscopic treatment is even more so. A femoral avulsion fracture of the ACL of a 14-year-old girl was arthroscopically reduced and fixed by a Kirschner wire (K-wire) via an inside-out technique. A 1.4-mm K-wire was drilled inside-out into the osseous defect of the lateral femoral condyle under arthroscopic visualization. The avulsed fragment was reduced and then drilled retrograde by the wire. After bending the intra-articular visible end of the K-wire by a knot pusher, the fragment was gently fixed by pulling the wire from outside. At 24 months, both knee stability and range of motion were the same in the operated and the healthy opposite leg. Magnetic resonance imaging evaluation and conventional radiographs showed an intact ACL without detectable disturbance in the growth plate. Only seven cases of a proximal avulsion of the ACL in children and adolescents have been published. Six were treated by open reduction and internal fixation, one by arthroscopic reduction without fixation.

Jamming of fingers: an experimental study to determine force and deflection in participants and human cadaver specimens for development of a new bionic test device for validation of power-operated motor vehicle side door windows.

The deformability of human fingers is central to addressing the real-life hazard of finger jamming between the window and seal entry of a power-operated motor vehicle side door window. The index and little fingers of the left hand of 109 participants and of 20 cadaver specimens were placed in a measurement setup. Participants progressively jammed their fingers at five different dorsal-palmar jam positions up to the maximum tolerable pain threshold, whereas the cadaver specimens were jammed up to the maximum possible deflection. Force-deflection curves were calculated corresponding to increasing deflection of the compressed tissue layers of the fingers. The average maximum force applied by the participants was 42 N to the index finger and 35 N to the little finger. In the cadaver fingers, the average of the maximum force applied was 1886 N for the index finger and 1833 N for the little finger. In 200 jam positions, 25 fractures were observed on radiographs; fractures occurred at an average force of 1485 N. These data assisted the development of a prototype of a bionic test device for more realistic validation of power-operated motor vehicle windows.

Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole.

PURPOSE: To evaluate the differences between radioscapholunate (RSL) arthrodesis alone versus RSL arthrodesis with additional distal scaphoidectomy. METHODS: We retrospectively evaluated 61 patients who were treated with RSL arthrodesis for painful posttraumatic osteoarthritis. Thirty patients had an RSL arthrodesis with additional resection of the distal scaphoid pole (group A), and 31 had RSL arthrodesis alone (group B). Six patients in group A and 8 in group B had the RSL arthrodesis converted to a complete wrist arthrodesis during follow-up. Those patients were excluded from the survey. Of the remaining 47 patients, 35 (20 from group A, 15 from group B) returned for a clinical and radiological examination at an average of 28 (range, 10-47) months after the index surgery. The results were rated by the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. The patients' outcomes after RSL arthrodesis with or without distal scaphoidectomy were compared for pain, wrist motion, grip strength, nonunion rate, osteoarthritis of the adjacent joints, the Disabilities of the Arm, Shoulder, and Hand score and the modified Mayo Wrist Score. RESULTS: Three patients with RSL arthrodesis alone showed a radioscaphoid nonunion. All arthrodeses in group A healed. In the clinical evaluation, there was no significant difference between groups A and B in the Disabilities of the Arm, Shoulder, and Hand score, the modified Mayo Wrist Score, grip strength, pain, or wrist motion. Assuming that wrist motion might be better in patients with a nonunion, the average wrist motion was recalculated after eliminating 3 patients with a radioscaphoid nonunion from group B. Radial deviation was then found to be significantly better in group A. CONCLUSIONS: Additional distal scaphoidectomy with RSL arthrodesis seems to improve postoperative radial deviation of the wrist. The radioscaphoid nonunion rate is high with RSL arthrodesis alone. Distal scaphoidectomy appeared to increase the successful fusion rate of RSL arthrodeses. No significant effect on wrist extension, flexion, ulnar deviation, pain level, restriction in activities of daily living, or grip strength was noted.

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienböck's disease: first results of an ongoing observational study.

INTRODUCTION: Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienböck's disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienböck's disease. MATERIALS AND METHODS: Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients. RESULTS: In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39 % of the opposite hand. Grip strength improved from 52.9 to 62.1 %. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0 % of the opposite hand. Grip strength improved from 38.6 to 69.0 %, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0. CONCLUSION: One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.

Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up.

BACKGROUND: The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device. METHODS: Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. RESULTS: All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points. CONCLUSION: The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Treatment of acute Achilles tendon rupture: fibrin glue versus fibrin glue augmented with the plantaris longus tendon.

UNLABELLED: In the surgical repair of Achilles tendon ruptures, suturing is standard, although fibrin glue also has been used for repair since the 1980s. Augmentation with the plantaris longus tendon is also a popular technique; however, no study has yet compared the outcome of augmented versus only glued repair of ruptured Achilles tendons. This study compares the long-term results of surgical repair of Achilles tendon rupture with fibrin glue versus fibrin glue augmented with the plantaris longus tendon. Forty patients who had undergone Achilles tendon repair with fibrin glue took part in a follow-up examination after an average of 11.5 years. The fibrin group consisted of 16 patients and the fibrin glue augmented with plantaris longus tendon group consisted of 15 patients. The modified Thermann score (adapted from Weber) and results of an isokinetic force measurement were the same in both groups, whereas complications in the 2 groups also did not differ. We conclude that augmentation with the plantaris longus tendon is not necessary when operatively treating acute ruptured Achilles tendons with fibrin glue. LEVEL OF CLINICAL EVIDENCE: 2.

[Plaster of Paris in hand surgery]. / Gipsverbände in der Handchirurgie.

Immobilization is as essential to conservative treatment of the hand as it is perioperatively in surgical treatment. Low cost and outstanding moldability distinguish plaster of Paris. This paper surveys frequently used applications of plaster of Paris in hand surgery.

Long-term results after operatively treated Achilles tendon rupture: fibrin glue versus suture.

UNLABELLED: The use of fibrin glue for repairing Achilles tendon ruptures was introduced in the 1980s. Although fibrin glue has been in regular use since that time, suturing remains the standard for surgical repair. Studies have indicated that, in the short term, fibrin glue is as effective as suturing. To date, there have been no long-term studies comparing the outcomes of these 2 techniques. This study compares the long-term results of surgical repair of Achilles tendon rupture with sutures versus fibrin glue. Forty-two patients who had undergone Achilles tendon repair with either suture or fibrin glue took part in a follow-up examination after an average of 12.1 years. The fibrin group consisted of 31 patients and the suture group consisted of 11 patients. Patients treated with fibrin glue reached a higher modified Thermann score (adapted from Weber), achieved equal results in an isokinetic force measurement, and showed fewer complications. The authors concluded that the use of fibrin glue for the repair of ruptured Achilles tendon is a suitable alternative to traditional sutures. LEVEL OF CLINICAL EVIDENCE: 2.