Dynamic Manugraphy as a Promising Tool to Assess the Outcome of Limited Aponeurectomy in Patients With Dupuytren's Contracture.

Background: Dupuytren's contractures interfere with physiological gripping. While limited aponeurectomy is an accepted treatment modality to restore finger mobility, methods to objectify functional outcome beyond determination of the range of motion are scarce. Methods: Patients with Dupuytren's contracture being scheduled for unilateral limited aponeurectomy were invited to participate. Clinical data were gathered prospectively by chart review and interview. The DASH-score and flexion contracture for fingers were registered prior to surgery, 3 and 6 months afterwards. At the same time, dynamic manugraphy for simultaneous recording of the grip pattern and forces generated by the affected hand and anatomic areas (i.e., thumb, index finger, middle finger, ring finger, little finger and palm) were performed. All findings obtained during the follow-up period were compared to the situation at baseline. Comparison between paired samples was done using Wilcoxon rank test. All p-values are two-sided and p < 0.05 was considered to be significant. Results: Out of 23 consecutively enrolled patients, 19 (15 men, 4 women) completed follow-up examinations. Manugraphy confirmed the impairment of physiological gripping with concomitant pathological load distribution at base line. Limited aponeurectomy significantly reduced flexion contractures. However, the DASH-score remained at an excellent level in one patient, indicated improvement in 11 and worsening in seven patients. Six patients had lower grip force at t6 compared to the preoperative condition, although the preoperative flexion contracture (≥110°) was considerably improved in all of them. In four of those, the DASH-score improved while it turned worse in two of them. The force of surgically treated fingers remained unchanged in three patients while it was improved and worsened in half of the remaining patients, respectively. Manugraphy revealed physiological gripping by enlargement of contact area and higher force transmission by the fingertips in 10 of 12 patients with constant or even improved DASH-score and in three of seven patients with a worsened DASH-score. Conclusions: Assessing the reduction of flexion contracture and grip force alone is not sufficient to comprehensively reflect the functional outcome of aponeurectomy for Dupuytren's disease. Visualizing physiological grip pattern provides an additional tool to objectify the success of surgical treatment.

The circular arc shaped nail for fixing the tibiotalocalcaneal arthrodesis. After clinical results.

BACKGROUND: Tibiotalocalcaneal arthrodesis is commonly considered a salvage option for a variety of hindfoot disorders involving the ankle and subtalar joint mostly with concomitant deformity. Retrograde interlocking nailing represents one of the biomechanically most stable fixation modes after reduction of hindfoot geometry. The considerable complications, non-union and revision rates at a moderate outcome reported even with modern retrograde nails underscore the idea that the development of an optimized retrograde nail may be warranted. METHODS: A novel circular shaped nail was designed with a perfect fit to the reamed canal and the implant geometry which respects physiologic hindfoot anatomy and alignment. The present clinical series reports the experience and the clinical and radiographic outcomes after application of the implant in the first 30 consecutive patients. Assessments included validated versions of the AOFAS Ankle/Hindfoot Score and the Foot Function Index. RESULTS: Anatomical alignment was achieved and maintained in 29/30 cases with a single case of later loss of reduction due to a technical error which led to surgical reintervention two months after the index procedure. The overall union rate reached 93%. Two non-unions (one ankle, one subtalar joint) were observed without necessitating further surgery. Three superficial surgical site infections were registered which made a local flap coverage necessary in two patients due to local skin break-down. No deep infection occurred. There were 2 implant removals, one was not related to hindfoot nailing. At the time of follow-up, the AOFAS Ankle/Hindfoot Score was 57 (median) from a maximum of 86 points. The self-assessment via the Foot Function Index improved from preoperative 155 points to 62.5 postoperatively (median values, p<0.001, Wilcoxon test). CONCLUSION: On the basis of our results, which saw a high rate of successful fusion and patient satisfaction and where the hindfoot reduction was maintained until definite healing in the vast majority of cases, the novel circular arc nail represents a viable and safe option for tibiotalocalcaneal arthrodesis with a low complication rate.

Proliferation, migration and differentiation potential of human mesenchymal progenitor cells derived from osteoarthritic subchondral cancellous bone.

Background: For regenerative therapies in the orthopedic field, one prerequisite for therapeutic success in the treatment of cartilage defects is the potential of body's own cells to migrate, proliferate and differentiate into functional cells. While this has been demonstrated for mesenchymal stem and progenitor cells (MPC) from healthy tissue sources, the potential of cells from degenerative conditions is unclear. In this study the regenerative potential of MPC derived from subchondral cancellous bone with diagnosed osteoarthritis is evaluated in vitro. Methods: OaMPC isolated from bone chips of three individual patients with Kellgren grade 3 osteoarthritis were characterized by analysis of cell surface antigen pattern. Cell proliferation was evaluated by doubling time and population doubling rate. Cell migration was assessed using a multi-well migration assay. Multi-lineage potential was evaluated by histological staining of adipogenic, osteogenic and chondrogenic markers. In addition, chondrogenic differentiation was verified by qPCR. Results: OaMPC showed a stable proliferation and a typical surface antigen pattern known from mesenchymal stem cells. Cell migration of oaMPC can be induced by human blood serum. OaMPC were capable of adipogenic, osteogenic and chondrogenic differentiation comparable to MPC derived from healthy conditions. Conclusion: OaMPC derived from knee joints affected by osteoarthritic conditions showed regeneration potential regarding migration, proliferation and chondrogenic differentiation. This suggests that oaMPC are able to contribute to cartilage repair tissue formation.

Parameters influencing hand grip strength measured with the manugraphy system.

BACKGROUND: This study aimed to determine whether sex, hand length and the individual training status affect hand strength and whether these measurements differ if they are recorded using the Jamar dynamometer or a new cylindrical measuring system. METHODS: For this purpose, 152 healthy adults were examined using a new manugraphy measuring system (novel, Munich, Germany) comprising two measuring cylinders of different sizes and a Jamar electronic dynamometer with two grip positions corresponding approximately to the sizes of the cylinders. A descriptive analysis was performed as well as a correlation analysis using the Pearson correlation coefficient. To prepare predictive models, multiple linear regression analyses were carried out to determine factors that influence the force and p ≤ 0.05 was considered statistically significant. RESULTS: A significant difference in the maximum and mean strength was observed that is dependent on sex, with men stronger than women, in line with expectations, and hand length, with small hands able to exert less force than large hands. No consistent increase in strength could be attributed to repetitive manual loads applied either at work or in leisure activities. CONCLUSIONS: Both measurement techniques yielded similar results, suggesting that manugraphy is well suited for clinical research purposes because it not only takes measurements that are just as reproducible and valid as the conventional measurement technique but in doing so measures not just the total strength of a hand but also enables more precise comparisons of isolated hand regions applying dynamic measurements.

[Treatment strategy and planning for pilon fractures]. / Versorgungsstrategie und Planung bei Pilonfrakturen.

BACKGROUND: Pilon fractures are mainly severe and prognostically serious injuries with a high rate of relevant soft tissue involvement. The adequate decision making and choice of treatment in the early phase of trauma are of paramount importance for the final outcome. This essentially encompasses the management of the soft tissue damage, the surgical planning and the differentiated selection of procedures. GOALS/MATERIAL AND METHODS: Most concepts of staged treatment nowadays offer a wide range of options which are integrated into expert-based algorithms. The aim of the present analysis was to display the strategy variations for the treatment of pilon fractures taking into account the advantages and disadvantages of the corresponding treatment concepts. RESULTS: A staged procedure including primary closed reduction employing ligamentotaxis and fixation of the joints of the hindfoot via tibiocalcaneal metatarsal fixation offers a safe basis for consecutive imaging and the selection of specific approaches for definitive reconstruction. A simultaneous reconstruction and fixation of the fibula during the primary intervention are generally not recommended in order to avoid any limitations for subsequent reconstructive procedures. A time frame for definitive reconstruction covers a period of up to 3 weeks after trauma and allows a detailed planning considering the individual dynamics of the soft tissue situation and any logistic requirements. For the choice of the definitive treatment concept a wide range of procedures and implants are available. There are also valid concepts for primary treatment of defined fracture constellations while primary arthrodesis represents a solution in cases of major destruction of the joint surface. DISCUSSION AND CONCLUSION: Knowledge of the multiple procedural variations for pilon fracture treatment creates the basis to optimize the treatment modalities and to take into account individual parameters of the fracture.

A Case of Implant Failure in Partial Wrist Fusion Applying Magnesium-Based Headless Bone Screws.

This article presents a case of implant failure resulting in mechanical instability of a scaphotrapezotrapezoideal arthrodesis using magnesium-based headless bone screws. During revision surgery osteolysis surrounding the screws was observed as well as degraded screw threads already in existence at 6 weeks after implantation. The supposed osseous integration attributed to magnesium-based screws could not be reproduced in this particular case. Thus, it can be reasoned that the use of magnesium-based screws for partial wrist arthrodesis cannot be encouraged, at least not in dual use.

Four-Strand Core Suture Improves Flexor Tendon Repair Compared to Two-Strand Technique in a Rabbit Model.

Introduction. This study was designed to investigate the influence of the amount of suture material on the formation of peritendinous adhesions of intrasynovial flexor tendon repairs. Materials and Methods. In 14 rabbits, the flexor tendons of the third and the fourth digit of the right hind leg were cut and repaired using a 2- or 4-strand core suture technique. The repaired tendons were harvested after three and eight weeks. The range of motion of the affected toes was measured and the tendons were processed histologically. The distance between the transected tendon ends, the changes in the peritendinous space, and cellular and extracellular inflammatory reaction were quantified by different staining. Results. A 4-strand core suture resulted in significantly less gap formation. The 2-strand core suture showed a tendency to less adhesion formation. Doubling of the intratendinous suture material was accompanied by an initial increase in leukocyte infiltration and showed a greater amount of formation of myofibroblasts. From the third to the eighth week after flexor tendon repair, both the cellular and the extracellular inflammation decreased significantly. Conclusion. A 4-strand core suture repair leads to a significantly better tendon healing process with less diastasis between the sutured tendon ends despite initially pronounced inflammatory response.

Subtalar joint instability.

PURPOSE: Subtalar joint instability may frequently be overlooked and erroneously be integrated under the diagnosis of ankle joint instability. It was the scope of this review to characterize the present state-of-art with regard to the adequate diagnosis and treatment. METHODS: While the clinical picture is mostly inconclusive for subtalar joint instability, a high degree of suspicion for this diagnosis is needed to employ weight-bearing x-rays, standardized stress radiography, CT scanning and MRI to further elucidate the etiopathology RESULTS: Geometrical reasons as hindfoot deformities, isolated or combined injuries or instabilities in conjunction with the ankle ligament complex do exist which should be differentiated in detail and classified to indicate the adequate treatment. Treatment of acute lesions is simple and effective. A certain percentage of the patients with chronic subtalar instability is incorrectly labeled with the diagnosis of a sinus tarsi syndrome. CONCLUSION: Subtalar joint arthroscopy for reconfirmation of the correct diagnosis conjoined with restoration of physiological hindfoot alignment and a preferably anatomical ligamentous reconstruction provide the basis for a good functional recovery.

Vascularized Hypothenar Fat Pad Flap in Revision Surgery for Carpal Tunnel Syndrome.

OBJECTIVE: To evaluate the results of the hypothenar fat pad flap in revision surgery for carpal tunnel syndrome (CTS). PATIENTS AND METHODS: We retrospectively analyzed 18 consecutive patients (14 women, 4 men) who had recurrent CTS. The average age was 61 years. All patients had undergone the index carpal tunnel release 5 to 22 months ago. From November 2009 to November 2013, they were treated by decompression of the median nerve and a vascularized hypothenar fat pad flap. The intraoperative findings were assessed as well as the level of pain, recovery of sensory and motor dysfunction, Hoffmann-Tinel sign, nerve conduction studies, grip and pinch strength, and Disability of Hand and Shoulder Questionnaire (DASH) score. All patients were reevaluated at an average of 22 months after revision surgery. RESULTS: After revision surgery, 15 patients reported symptomatic improvement. No patient reported worsening of symptoms. A median DASH score of 18 was reached. Grip strength recovered to 90% of the contralateral side. Overall, 15 patients were satisfied with the result of the operation; 3 did not cope with pain and dysfunction. Recurrence was not found in any case. CONCLUSION: The hypothenar fat pad flap can be used successfully as an adjunct to microsurgical neurolysis for the treatment of recurrent CTS secondary to perineural scarring, although a functional deficit remains in some patients.

[Manifestation of Dupuytren nodules following fracture of the distal radius]. / Dupuytrenknotenbildung nach Operation einer distalen Radiusfraktur.

PURPOSE: The aim of this study is to evaluate the incidence of post-traumatic development of Dupuytren nodules in distal radius fractures treated operatively. PATIENTS AND METHODS: In 2 prospective randomised studies for operative treatment of distal radius fractures, the formation of Dupuytren nodules was registered. One of the exclusion criteria was a pre-existing Dupuytren's disease at the date of trauma. In addition to the notification of the development of Dupuytren nodules, signs of a complex regional pain syndrome were registered as well as the wrist function, level of pain and grip strength. The Castaing and the Gartland and Werley scores were assessed. The clinical outcomes of patients with and without Dupuytren nodules were compared. 239 of 275 (87%) of the patients could be examined 1 year after the operation, consisting of 32 men and 207 women with a median age of 64.2 years. The patients with Dupuytren nodules were re-evaluated after 16-60 months (median 41.8) for progression of the disease. RESULTS: 21 patients (8.7%) developed changes of the palmar aponeurosis. In 20 patients nodules were stated, one patient showed a cord at the fourth ray of the injured hand. 19 out of 21 patients were female (90.5%). At re-evaluation after 41.8 months (16-60) progression could not be noted nor could similar changes be seen on the contralateral side. Patients with Dupuytren nodules were not handicapped in their hand function. 3 patients (14.3%) revealed a positive family history for Dupuytren's disease. Abuse of alcohol or diabetes was not present in any of the patients with Dupuytren nodules, 7 (33%) were smokers. CONCLUSION: The occurrence of Dupyutren nodules can be triggered by a trauma or operation. It may be speculated that these nodules are an entity of their own as no progression of the contracture could be seen during the follow-up period.