Berthold Bickert

MIDCARPAL ARTHRODESIS WITH COMPLETE SCAPHOID EXCISION AND INTERPOSITION BONE GRAFT IN THE TREATMENT OF ADVANCED CARPAL COLLAPSE (SNAC/SLAC WRIST): OPERATIVE TECHNIQUE AND OUTCOME ASSESSMENT

Thirty-six patients with stage II or III SNAC and SLAC wrists were treated by midcarpal arthrodesis and complete scaphoid excision. When assessed at a mean follow-up of 25 months, pain was significantly reduced both under resting and stress conditions. The active range of motion was 54% of the contralateral wrist and grip strength was 65% of the non-operated hand. The mean DASH score was 28 points, the Mayo wrist score was 63 points, and the Krimmer wrist score was 68. Correlation of the wrist scores with the DASH values demonstrated a significant correlation. Our data demonstrate that midcarpal fusion with complete excision of the scaphoid is a reliable procedure for treating advanced carpal collapse.

Scapholunate Ligament Repair Using the Mitek™ Bone Anchor Technique and Preliminary Results

A retrospective study was done to assess the outcome after repair of completely ruptured scapholunate interosseous ligaments using the Mitek™ Mini G2 bone anchor. From 1994 to 1996. 12 patients underwent scapholunate ligament repair using the bone anchor. A follow-up assessment was done at a mean of 19 months postoperatively and revealed excellent or good results in eight patients, satisfactory in two, and poor in two patients, one of whom had developed lunate necrosis. One patient with an excellent functional result demonstrated recurrent dissociation of the scapholunate gap radiographically. The technique described proved to be simpler than conventional procedures in our hands, and yields similar functional results.

Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienböck's disease.

Sixty patients underwent total wrist arthrodesis for post-traumatic arthrosis, or Kienböcks disease. All of them could be included in the study with complete data. The average follow-up time was 37 months. Forty-nine patients were males, 11 were females; the average age was 48 years. Outcomes were assessed by several methods. Grip strength was measured using the DEXTER-Computer-System and was reduced by 50% compared to the contralateral side. Pain was evaluated pre- and postoperatively with a visual analogue scale from 0 to 100 and was reduced to 55% of the preoperative values. Patients activities of daily living (ADLs) and general postoperative quality of life were estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. For functional evaluation additionally the Mayo and Krimmer wrist scores were used. The overall DASH score was 51.4, the wrist scores reached 46.4 and 50.5, respectively. Both scores correlated significantly with the DASH. It can be concluded from our data that pain relief was sufficient in the most patients, although complete pain relief was rare. Although 80% of the patients complained about reduction of postoperative quality of life with impaired personal hygiene and functional deficits, the majority (80%) would undergo the procedure again. Seventy percent of the patients returned to their original occupation. Compared to other measures commonly used to assess outcomes after wrist arthrodesis, the DASH questionnaire proved to be a very useful tool for the evaluation of subjective outcomes in upper extremity disorders as well.

Fibulo-scapho-lunate arthrodesis as a motion-preserving procedure after tumour resection of the distal radius.

Free microvascular fibula transfer is an established method for reconstruction of the distal radius following tumour resection. If the radial articular surface is resected, fixation of the fibula to the carpus is either performed as a complete wrist fusion, or the fibular head is transferred together with the shaft to replace the radial joint surface, thus allowing some wrist mobility but providing only limited wrist stability. Fibulo-scapho-lunate fusion represents an alternative. This reconstruction in two patients provided excellent wrist stability and a functional range of midcarpal motion.

The 1,2-Intercompartmental Supraretinacular Artery Vascularized Bone Graft for Scaphoid Nonunion: Management and Clinical Outcome

PURPOSE To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN). METHODS A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included. RESULTS Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference. CONCLUSIONS Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Clinical tests and magnetic resonance imaging have limited diagnostic value for triangular fibrocartilaginous complex lesions

IntroductionThe diagnostic value of clinical tests and magnetic resonance (MR) imaging for the investigation of triangular fibrocartilaginous complex (TFCC) lesions is not clear due to a lack of clinical data. Materials and methodsWe retrospectively analyzed 908 patients who underwent clinical tests and arthroscopy for suspected TFCC lesions at our institution. Further, MR imaging findings concerning the TFCC were gathered. We correlated clinical tests and MR imaging findings with those obtained during arthroscopy, and we calculated sensitivity, specificity, as well as positive and negative predictive values.ResultsIn the whole cohort, the positive predictive values of all clinical tests were low, ranging from 0.53 to 0.55. The ulna grinding test had the highest sensitivity, but lowest specificity. Sensitivity and specificity of the ulnar fovea sign and magnetic resonance imaging were similar, ranging from 0.73 to 0.76, and from 0.41 to 0.44, respectively. To some degree, the diagnostic value seemed to depend on the Palmer class of TFCC lesion.ConclusionsAccording to this study, clinical tests and MR imaging findings are of very limited diagnostic value for the diagnosis of TFCC lesions.

Degeneration process of symptomatic central tears in the triangular fibrocartilage.

Very little is known about the degeneration or healing process in traumatic triangular fibrocartilage complex (TFCC) lesions. Forty-two patients with symptomatic central traumatic tears in the TFCC (Palmer 1 A) were included in this study. The cartilage was debrided arthroscopically and used for histologic examination. Histologic sections were stained with hematoxylin and eosin (HE) and furthermore, with collagen I and II antibodies. The histologic findings were compared with degenerative findings in 12 patients with degenerative TFCC (Palmer 2 C) lesions. In patients with recent trauma (<18 months), we mostly found no degenerative changes or only moderate changes, located in the inner part of the tissue. In patients with trauma having occurred more than 18 months ago, the typical degeneration phenomena were mostly extensive and pervasive throughout the entire specimen and similar to our control group (Palmer 2 C). The immunohistochemistry examination showed that in patients having suffered trauma within the last 18 months, the staining for collagen I and II was more intensive than in patients with trauma having occurred more than 18 months ago. The collagen I and II staining in the control group (Palmer 2 C) was weaker, too. Degeneration phenomena can be found in patients with trauma having occurred more than 18 months ago. The degree of degeneration correlated with the length of time passed since the occurrence of trauma.

Versorgung proximaler Kahnbeinpseudarthrosen und -frakturen mit der Mini-Herbert-Schraube über einen dorsalen Zugang

ZusammenfassungEs wurden 32 Patienten im Alter von 16–49 Jahren über einen dorsalen Handgelenkzugang mit der Mini-Herbert-Schraube versorgt. Die Indikation zur Operation waren 5 Frakturen (Typ B3 nach Herbert), 2 verzögerte Frakturheilungen (Typ C nach Herbert) und 25 Pseudarthrosen (Typ D1 bis D3 nach Filan u. Herbert). Bei 6 Patienten wurde keine Spongiosa transplantiert, in 19 Fällen Radiusspongiosa, in 4 Fällen ein Beckenkammblock und in 3 Fällen ein vaskularisierter Radiusspan eingesetzt. Die durchschnittliche Ruhigstellungsdauer betrug 9 Wochen. 26 Patienten konnten nach einem durchschnittlichen Zeitraum von 14,5 Monaten klinisch nachuntersucht werden. Radiologisch wurde das Ergebnis von 30 Patienten (94%) erfasst.26 Skaphoide (100% der Frakturen, 84% der Pseudarthrosen) zeigten radiologisch eine knöcherne Konsolidierung. Dabei fielen in jeweils 3 Fällen Lockerungszeichen bzw. ein Vorschub der Schraube in das Radiokarpalgelenk auf. Eine “Humpback”-Deformität wurde in 4 Fällen beobachtet. Bei 4 Patienten persistierte die Pseudarthrose, wobei es in einem Fall zu einer straffen Pseudarthrose kam. 6 Patienten zeigten eine beginnende periskaphoidale Arthrose.Die Kraftmessung (JAMAR II) ergab für den Kraftgriff 91%, für den Dreifingergriff 94% und für den Seitgriff 95% der Gegenseite. Der durchschnittliche Schmerzwert auf der visuellen Analogskala lag in Ruhe bei einem, bei Bewegung bei 11 und unter Belastung bei 33 Punkten. Das Bewegungsausmaß betrug für die Extension/Flexion 79% und die Radial-/Ulnardeviation 83% der Gegenseite. Der durchschnittliche DASH-Wert ergab 15 Punkte.Die Ergebnisse zeigen, dass sich die Mini-Herbert-Schraube in der Versorgung sowohl von Frakturen als auch Pseudarthrosen des proximalen Skaphoid-Drittels als Standardverfahren etabliert hat.Abstract32 patients, aged 16 to 49 years, were treated by osteosynthesis using the Herbert mini screw. The indications were five fractures (type B3, Herbert classification), two delayed unions (type C) and 25 nonunions (type D1 to D3, Filan and Herbert classification). Six patients received no bone grafts, 19 received cancellous bone graft from the radius. An interpositional iliac crest bone graft was used in four, and a vascularized bone graft from the distal radius in three cases respectively. The average postoperative immobilisation in a forearm splint was nine weeks. 26 patients could be recruited for clinical follow-up at an average of 14,5 months. The radiological results were assessed in 30 cases (94%).Bony consolidation was achieved in 26 cases (100% of the fractures, 84% of the nonunions). In three cases a loosening of the screw, and in three further cases a dislocation into the radiocarpal joint were observed. A humpback deformity was present in four cases. Three patients showed a persisting nonunion, one patient a fibrous union. Early degenerative changes of the radiocarpal joint were observed in six cases.The clinical follow up examination showed an average grip strength of 91% (JAMAR II), 94% for the three finger, and 95% for the pinch grip compared to the contralateral side. The mean postoperative pain score on the visual analog scale was one for resting conditions, eleven for motion and 33 under stress. The range of motion was 79% of the opposite side for extension/flexion and 83% for radial/ulnar deviation. The average DASH-score reached 15 points.The Herbert mini screw has proven to be a reliable implant for reconstruction of proximal pole fractures and nonunions of the scaphoid.

Scaphoid nonunions in skeletally immature adolescents

Scaphoid nonunions in children requiring operative treatment are rare. The aim of this study was to analyze our own patient population of the last 13 years to assess the postoperative outcome of these operations. Seven patients, under aged 14 years, were treated for scaphoid nonunions. Patients were clinically and radiologically examined and subjective outcomes were measured, such as the visual analogue pain scale (VAPS), Disability of the Arm, Shoulder and Hand (DASH) score, and Krimmer score. All patients showed an excellent outcome, as determined by the DASH score, Krimmer score, and VAPS. No differences between grip strength and range of motion between the operated and non-operated hand were observed. Therefore, we propose that scaphoid nonunions in skeletally immature adolescents can be treated satisfactorily with excision of the nonunion and bone grafting.

Current Strategies for Sarcoma Reconstruction at the Forearm and Hand

Multistructural reconstructive procedures are often required to achieve a sufficient reconstruction of the forearm and/or hand after radical tumor resection. Clear margin (R0) resection is the main therapeutic goal for the treatment of sarcomas. Plastic reconstructive procedures with the possibility of microvascular transplantations play a key role in coverage of complex defects. In our department, 20 patients with soft tissue sarcomas of the hand/forearm were treated between 1995 and 2005. Eleven patients were male, nine female. The average follow-up time was 42 months. The most common tumor type was the myxoid fibrous histiocytoma in 10 cases. Six patients received a free microvascular transplantation to cover the defect after radical resection, local flaps, or primary closure was performed in five cases. Preservation was not possible in nine cases. Ten patients received radiation and four obtained chemotherapy postoperatively (two patients received neoadjuvant chemotherapy). Extremity function, the DASH questionnaire, and patient satisfaction were our examination parameters. Our results show the necessity of plastic-surgical reconstruction of the forearm and hand as an integrative component of modern sarcoma therapy. It can be concluded that plastic-surgical reconstruction of the extremity plays a key role within the multimodal concept of therapy for patients with sarcoma at the forearm and hand.