[The complexity of hand-surgical procedures in the context of cross-sector care concepts: a consensus recommendation of the German Society of Hand Surgery] / Die Komplexität handchirurgischer Therapien im Kontext sektorenübergreifender Versorgungskonzepte: Konsensusempfehlung der Deutschen Gesellschaft für Handchirurgie.

Overboarding politcal influence in Germany concerning medical issues has come to a new peak. The report by the IGES Institute published in 2022 made an important contribution in this regard. Unfortunately, only that part of the recommendations of this report were implemented in a new version of the contract for outpatient surgery according to Section 115b SGB V (AOP contract), that called for an expansion of outpatient surgery. In particular, those aspects that are important from a medical point of view for a patient-specific adjustment of outpatient surgery (e. g. old age, frailty, comorbidities) as well as the important structural requirements for outpatient postoperative care were included in the new AOP contract at best in a rudimentary manner. For this reason, the German Society for Hand Surgery felt compelled to give its members a recommendation as to which medical aspects must be taken into account, especially when performing hand surgery operations, in order to ensure the highest level of safety for the patients entrusted to us while performing outpatient surgery. An expert group of experienced hand surgeons and hand therapists who work in hospitals of all levels of care as well as resident surgeons was formed in order to formulate mutually agreed recommendations for action.

[Osteitis/Osteomyelitis of the Hand and Wrist]. / Osteitis/Osteomyelitis an Hand und Handgelenk.

Osteomyelitis of the hand and wrist is uncommon compared to the infections of the long bones but not rare. There is poor evidence on many answers to questions concerning this disease. This includes careful consideration of the prevalence, pathogenesis, microbiology, diagnostic methods and the conservative, medical and surgical treatment. The emergence of the disease can subdivided in post-traumatic, postoperative, spread from contiguous infections and hematogenous. The individual patient-specific risk must be considered. Early diagnosis and correct management are essential to preserve bony structures and the articular function of the hand. A two-step surgical procedure is usually necessary, but uncertainties about the optimal treatment are still existing. Satisfactory control rates of the infection and successful bone reconstructions can be achieved. But complications, a limited range of motion and amputations of finger parts can still not be avoided in all cases.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial.

BACKGROUND: Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound. METHODS: This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed. DISCUSSION: Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.

The palmar approach for PIP-arthroplasty according to Simmen: results after 8 years follow-up.

BACKGROUND: Alloarthroplasty of the proximal interphalangeal joint is indicated for patients with osteoarthritis, an inflammatory disease of the joint. According to the current literature, implants made of silicone are not inferior to newer implants and the complications are well known. Therefore, focus should be shifted to the operative approach to improve the results. METHODS: Eleven silicone arthroplasties in 7 patients with arthritis and 35 silicone arthroplasties in 23 patients with osteoarthritis were reviewed after 15.6 months and after 105.3 months. All implants were inserted using the palmar approach according to Simmen. We compared the pre- and postoperative arc of motion, pain, and strength, and present postoperative complications and satisfaction. RESULTS: Patients with arthritis showed a gain in range of motion of 36° and patients with osteoarthritis of 39°. No implant failure occurred, and one revision was performed,. Average extension lag over all operated joints of patients was 2.8°. No swan-neck deformity or extensor tendon adhesion was observed. There was no significant difference in the postoperative results between patients with osteoarthritis and arthritis or between first and second follow-up. CONCLUSION: Silicone arthroplasty restores the functionality of proximal interphalangeal joints in patients with osteoarthritis and inflammatory joint disease. Using a palmar approach, the surgeon can reach palmar and dorsal osteophytes. The extensor mechanism stays intact reducing the risk for extensor lag and other complications compared to the dorsal approach. The results do not change significantly between 1 and 8 years postoperatively.

Ulnocarpal impaction syndrome: treatment with a transverse ulnar shortening osteotomy from an ulnodorsal approach.

INTRODUCTION: Ulnocarpal impaction syndrome is a common cause of chronic ulnar-sided wrist pain. The distal ulnar shortening osteotomy addresses the often present positive ulnar variance and therefore relieves the excessive load on the ulnocarpal joint. In the present study, the results of a technique that uses an ulnodorsal approach with a compression device and a transverse osteotomy are presented and compared to other techniques. MATERIALS AND METHODS: This retrospective study includes 92 wrists with an ulnocarpal impaction syndrome, which were treated with an ulnar shortening osteotomy. The mean duration of postoperative follow-up was 50 months. RESULTS: The mean ulnar variance was 2.17 ± 1.56 mm preoperatively and after the ulnar shortening osteotomy -1.36 ± 1.67 mm (p < 0.05). Radiological consolidation of the osteotomy could be shown in 91 wrists 6 months postoperatively. Patients rated the preoperative pain level at a VAS 7.9 ± 1.7 which decreased to a of VAS 2.4 ± 2.5 (p < 0.05). 19 patients complained of mechanical irritation. There was no neurological irritation. CONCLUSION: It could be shown that the distal ulnar shortening osteotomy by a transverse osteotomy using a compression device and an ulnodorsal approach has a low complication rate. It is comparable to the oblique osteotomy in effectiveness and safety.

Comparison of clinical results after pisiformectomy in patients with rheumatic versus posttraumatic osteoarthritis.

Pisotriquetral osteoarthritis is important to consider in the differential diagnosis of chronic ulnar-sided wrist pain. It can develop following traumatic injury to the pisiform or in rheumatic diseases, such as rheumatoid arthritis or psoriatic arthritis. It has been shown that pisiformectomy can relieve symptoms in cases that have not responded to nonoperative treatment, and the excision does not compromise the function or strength of the wrist. Most studies focus on posttraumatic causes of pisotriquetral osteoarthritis. In the current study, rheumatic causes are also considered and the outcomes are compared. This retrospective study included 35 patients who underwent pisiformectomy for pisotriquetral osteoarthritis. All patients underwent a thorough diagnostic evaluation to exclude other etiologies for ulnar-sided wrist pain. Radiological examinations including posteroanterior and lateral views of the wrist and a tangential view of the pisotriquetral joint were analyzed. All patients had excellent or very good results after pisiformectomy, with a significant reduction in pain. No significant difference was found in the outcomes for patients with rheumatic vs posttraumatic osteoarthritis. Patients with rheumatic causes of pisotriquetral osteoarthritis can be successfully treated with pisiformectomy. With respect to idiopathic causes, these patients need a longer postoperative period to gain full pain relief. It is important to consider the possibility of pisotriquetral osteoarthritis after excluding other diagnoses in patients with rheumatic osteoarthritis.

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist.

PURPOSE: The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient's subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed. METHODS: Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed. RESULTS: In 92.6% of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1%. CONCLUSIONS: The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.

Nodular giant cell tumour of the tendon sheath of the hand: analysis of eighty-four cases: diagnostic decisions and outcome.

INTRODUCTION: The giant cell tumour of the tendon sheath (GCTTS) of the hand is a benign tumour of unknown origin. The clinical diagnosis is supported by preoperative imaging. But the ideal imaging methods necessary for the diagnosis, preoperative planning and total tumour resection are still debated. Standard treatment is surgical resection with histological confirmation. METHODS: We followed up 84 patients who were operated upon for a histologically confirmed nodular type GCTTS for an average of 4.7 years (range four to eight). The preoperative symptoms and radiological findings of X-ray, ultrasound and MRI were reviewed and the surgeon asked for their impact on the surgical procedure. RESULTS: The average age at operation was 50.9 years, 65.5% of the patients were female and 61.9% of the lesions were located on the palmar aspect. Most tumours were found on the first three fingers. Two patients had tumours at two separate sites (2.4%). After an average follow up of 31.5 months two recurrences were observed (2.4%). In addition to X-ray and ultrasound, the preoperative findings of the MRI had no influence on the surgical procedure. CONCLUSION: Our data on the nodular GCTTS are in accordance with published data concerning the age distribution, gender distribution, and localisation. No soft-tissue imaging method is superior for the diagnosis of nodular GCTTS or for the preoperative planning. A preoperative MRI may not be necessary as clinical and ultrasound examination are sufficient. To exclude bony erosions, a preoperative X-ray is necessary.

Adaptation of human CD4+ T cells to pathophysiological hypoxia: a transcriptome analysis.

OBJECTIVE: Inflamed tissues are usually characterized by low oxygen levels. We investigated whether pathophysiological hypoxia (pO(2) < 1%) as found in the rheumatoid synovium modulates the transcriptome of human CD4+ T cells. METHODS: We analyzed the extent to which hypoxia influences the transcriptome in the rheumatoid synovium according to a gene cluster reflecting adaptation to low oxygen levels. Hypoxia-inducible factor-1alpha (HIF-1alpha) was detected in the rheumatoid synovium using immunohistochemistry. Isolated human CD4+ T cells were exposed to hypoxia and analyzed using microarray analysis, quantitative polymerase chain reaction, and immunoblot detection. RESULTS: In rheumatoid arthritis (RA) synovial tissue samples, hypoxia modulates the transcription profile. This profile is similar, but not identical, to that found in isolated CD4+ T cells incubated under hypoxic conditions. We show that HIF-1alpha is expressed in synovial tissue samples and in hypoxic CD4+ cells; and that hypoxia directly affects differential gene expression in human T cells with up to 4.8% modulation of the transcriptome. Functional genome analysis revealed substantial effects of hypoxia on immune response, transcriptional regulation, protein modification, cell growth and proliferation, and cell metabolism. CONCLUSION: Severe hypoxia, a feature of joint inflammation, considerably modulates the transcriptome of cells found in the rheumatoid synovium. Human CD4+ T cells adapt to hypoxic conditions mainly by HIF-1-driven effects on the transcriptome reflecting a profound influence on immune functions. Thus, hypoxia must be taken into account when therapeutically targeting inflammation.

Does chemotherapy impair the bone healing and biomechanical stability of vascularized rib and fibula grafts?

The purpose of this study was to observe the impact of chemotherapy on the healing and biomechanical properties of vascularized bone grafts. Ten male beagle dogs were divided into two experimental groups: a chemotherapy group (CH) and control group (C). Group CH received adjuvant and neo-adjuvant chemotherapy. Each animal of both groups underwent the following operative procedures. The 5th and 7th rib were removed and replaced by vascularized pedicle transfers of the adjacent 4th and 8th rib. Additionally, a free fibular flap was elevated and retransferred to the same anatomic position. The rate of bony union on plain x-ray was 100 percent in group C, 30 percent in the vascularized rib, and 80 percent in the fibula grafts of group CH. Microangiography demonstrated no avascular bone segments in group C and in the fibula flaps of group CH. The vascularized ribs of group CH presented with 20 percent avascular bone segments. Biomechanical tests focusing on the durability of the vascularized grafts against bending and torsion forces demonstrated a reduction of the average maximum bending times by 17 percent and 23.9 percent compared to the controls ( P < 0.05). The twisting times were reduced by 13.8 percent (n.s.) and 32.5 percent ( P < 0.05). The data demonstrated a clear worsening in bone healing and stability after simulated adjuvant and neo-adjuvant chemotherapy. Thus, a large animal model was established for the further determination of the effects of chemotherapy on different vascularized bone transfers.

Impact of radiation therapy on healing and stability of vascularized bone grafts in a dog model.

The purpose of the study was to observe the impact of radiation therapy on healing and biomechanical properties of vascularized bone grafts, and thus to establish an appropriate large animal model. Ten male beagles were divided into two experimental groups: radiation (R) and control (C). The left 5th to 7th ribs of the animals of group R were irradiated 3 and 2 weeks preoperatively, using a dose of 8 Gy each time. Each animal of both groups underwent the following operative procedures. The 5th and 7th ribs were removed, and the 5th rib was replaced by a vascularized pedicle transfer of the 4th rib. The 7th rib was reconstructed using a pedicle transplant of the 8th rib. The 5th and 7th ribs were used as nonvascularized bone grafts to replace the donor sites of the 4th and 8th ribs, respectively. Group R received two further irradiation cycles 2 and 3 weeks postoperatively. The vascularized rib grafts of group R demonstrated a higher number of delayed unions in plain x-rays and avascular bone segments in microangiography than the control group. The presence of vital osteocytes in histology was not significantly different between groups. Biomechanical tests focusing on the durability of vascularized ribs against bending and torsion forces demonstrated a reduction of average maximum bending moments by 56.6% after radiation compared to controls (P < 0.05). Twisting moments were reduced by 47.6% (P < 0.05). The data demonstrate a significant worsening in bone healing and stability after pre- and postoperative radiation therapy to the wound bed and bone grafts. Thus, a large animal model is established for further determination of different strategies of radiotherapy in combination with vascularized bone transfers.