Bettina Juon

Assessment of endothelium and inflammatory response at the onset of reperfusion injury in hand surgery

BackgroundActivation of the endothelium, complement activation and generation of cytokines are known events during ischemia-reperfusion (I/R) that mediate tissue injury. Our aim was to elucidate their respective participation at the onset of the reperfusion phase. Tourniquet application in hand surgery causes short-term ischemia, followed by reperfusion and was therefore used as the model in this study.MethodsTen patients were included in the study after obtaining informed consent. A tourniquet was placed on the upper arm and inflated to 250 mmHg for 116 ± 16 min, during which the surgery was performed. Venous blood and tissue samples from the surgical area were taken at baseline as well as 0, 2, and 10 min after reperfusion and analyzed for the following parameters: Endothelial integrity and/or activation were analyzed by measuring heparan sulfate and syndecan-1 in serum, and vWF, heparan sulfate proteoglycan as well as CD31on tissue. Complement activation was determined by C3a and C4d levels in plasma, levels of C1-inhibitor in serum, and IgG, IgM, C3b/c, and C4b/c deposition on tissue. Cytokines and growth factors IL-5, IL-6, IL-7, IL-8, IL-10, IL-17, G-CSF, GM-CSF, MCP-1, TNFα, VEGF, and PDGF bb were measured in the serum. Finally, CK-MM levels were determined in plasma as a measure for muscle necrosis.ResultsMarkers for endothelial activation and/or integrity as well as complement activation showed no significant changes until 10 min reperfusion. Among the measured cytokines, IL-6, IL-7, IL-17, TNFα, GM-CSF, VEGF, and PDGF bb were significantly increased at 10 min reperfusion with respect to baseline. CK-MM showed a rise from baseline at the onset of reperfusion (p < 0.001) and dropped again at 2 min (p < 0.01) reperfusion, suggesting ischemic muscle damage.ConclusionsIn this clinical model of I/R injury no damage to the endothelium, antibody deposition or complement activation were observed during early reperfusion. However, an increase of pro-inflammatory cytokines and growth factors was shown, suggesting a contribution of these molecules in the early stages of I/R injury.

Treatment of open hand injuries: does timing of surgery matter? A single-centre prospective analysis

Abstract The 6-hour paradigm for surgical treatment of open injuries should be re-evaluated in the era of systematic use of antiseptic solutions and systemic antibiotics. The current study investigates prospectively the impact of timing of surgery on the outcome of open hand injuries. The prospective evaluation included adult patients presenting with open hand injuries between 1 September 2009 and 30 June 2010 to the emergency department of the University Hospital of Berne, Switzerland. Multiple trauma, bilateral hand injuries, bite injuries, and infections were excluded. All patients underwent a standardised treatment protocol with antiseptic solution, sterile dressing, antibiotic prophylaxis, and surgical treatment upon admission. Demographic data, injury details, and delay from trauma to therapy were recorded. Microbiology was gained at surgery. Outcome measurements included infections, complications, pain, and function (clinically, DASH, Mayo score). From 116 patients (mean age 43 years) six patients suffered an infection (5.2%). The observed infections were statistically not associated with delay to surgery, treatment protocol, or to injury complexity. Neither complications, pain, nor functional outcome were statistically associated with delay to surgery, wound disinfection, or administration of antibiotics. In conclusion, early or late timing of surgical treatment of open hand injuries did not show any impact on outcome (infections, complications, pain, function) in this prospective single-centre patient evaluation.

The impact of anxiety and depressive symptoms on chronic pain in conservatively and operatively treated hand surgery patients

The aim of this prospective study was to examine to what extent anxiety and depressive symptoms predict the level of pain at 4-month follow-up in hand surgery patients. A total of 132 consecutive patients (mean age: 51.5±17.1 years, 51.9% female) of a tertiary center for hand surgery participated in this study. The patients underwent conservative or operative treatment, depending on the nature of their hand problem. The initial pain assessment included psychometric testing with the hospital anxiety and depression scale. Ninety-nine patients underwent operative treatment and 33 patients were conservatively treated. At 4-month follow-up, the amount of pain was measured with a visual analog scale (0–10). After controlling for age, sex, and pre-surgical pain intensity, depressive symptoms were a significant predictor for increased pain levels at follow-up in conservatively treated patients. In operatively treated patients, anxiety symptoms showed a trend for being a predictor of pain level at follow-up. The findings support the assumption that psychological factors may have an impact on pain outcome in patients presenting to hand surgery clinics.

The Role of Dynamic Ultrasound in the Immediate Conservative Treatment of Volar Plate Injuries of the PIP Joint: A Series of 78 Patients.

Introduction: The management of volar plate avulsion fractures in the context of a stable joint and a bony fragment of less than 30% has traditionally been conservative. This study was performed to assess volar plate healing with high-resolution ultrasound in order to provide early full mobilization. Material and Methods: Between January 2012 and December 2013, 78 patients with volar plate injuries of the proximal interphalangeal (PIP) joints (42 distortions and 36 dislocations) were treated conservatively in our department for volar plate avulsion fracture associated with stable joint and bony fragment inferior to 30% of the intra-articular surface assessed both by radiography and ultrasound. Conservative treatment included extension stop splinting for the first 2 weeks and Coban bandage until 6 weeks postinjury. However, it may be possible to modify the duration of extension stop splinting based on clinical and ultrasound findings (with no additional X-ray) performed every 2 weeks for the first 3 months and then at 4 months postinjury. Only patients with residual contracture at the 4-month assessment had prolonged follow-up in order to ensure adequate dynamic splint therapy. Results: The amount of soft tissue oedema and the mobility of the volar plate were factors used to determine return to full mobilization. Mean extension-stop-splint wear was 16 ± 2 days. During the first 2 follow-up assessments, 4 patients were excluded from the study because of the instability of the PIP joint. One patient required refixation of a large fragment of 30%, 2 patients required superficial flexor tendon (FDS) tenodesis of the unstable volar plate in hyperextension and 1 other patient required arthrodesis of the PIP joint. In 51 patients, the postoperative follow-up was free of complications at 4 months. In 18 patients, flexion contracture of 20° (range 11°-40°) and oedema during follow-up required dynamic extension splints for 3 to 5 months. After this time, 5 patients had a residual contracture of 10° to 15°. Conclusion: Avulsion fractures of the volar plate at the PIP joint are common. In general, they have a good outcome using the conservative treatment with extension block splints. Flexion contracture is a common complication and may be reduced by immediate splints in full extension at night and Coban bandage during the day. High-resolution sonography is a convenient tool to evaluate palmar plate stability, to assess reduction of oedema, and thus to guide safe return to full range of movement.

Tibial Nerve Palsy by a Crossing Posterior Tibial Artery Branch After Lateral Sliding Calcaneal Osteotomy

Lateralizing calcaneal osteotomy (LCO) is a common procedure for correction of hindfoot varus deformity. Neurovascular injury following calcaneal osteotomies is recognized as a potential complication. The incidence of tibial nerve palsy following LCO is still vague in the literature. The complication with potential underlying reasons have been previously reported for Charcot-MarieTooth disease, highlighting that the thickened and thereby susceptible neuropathic nerve may be compressed underneath the flexor retinaculum that likely tightens after LCO. Tibial nerve palsy after LCO was also reported in patients without neuropathy. Thus, the mechanism of tibial nerve compression after lateralizing calcaneal osteotomy remains uncertain. We report a case of a patient with a cavovarus foot resulting from a cerebrovascular stroke that developed tibial nerve palsy after LCO due to compression of a crossing branch of the posterior tibial artery.

Sonografie neoplastischer Veränderungen

Tumore der Haut und Subkutis konnen mittels Ultraschall gut lokalisiert und ihre Grose bestimmt werden. Echomuster und Farb-Doppler-Sonografie geben in vielen Fallen Hinweise auf deren Pathogenese. Die Grenzen der Sonografie sind vor allem bei grosen Tumoren zu respektieren: sind sie groser als der Sondenkopf, ist ihre Vermessung nicht mehr prazise. Zu den haufigen Weichteiltumoren an der Hand zahlen Riesenzelltumore und pigmentierte villonodulare Synovitiden. Sie gehoren neben den Ganglien zu den haufigsten proliferativen Veranderungen der Hand. Sie konnen Sehnen verlagern, zirkular um Phalangen wachsen und zu knochernen Druckerosionen fuhren, was im Ultraschall erkannt werden kann. Sonografisch sind sie gut abgegrenzt, solide und zeigen unterschiedliche Echomuster, je nach Entzundungsaktivitat auch positive Doppler-Signale. Nerven- und Gefastumore konnen mittels Ultraschall dargestellt werden. Die sonografische Tumorlokalisation und -charakterisierung hilft bei der Therapieplanung.

Sonografie des entzündlich, degenerativ und kompressiv veränderten Gewebes

Mit hochauflosenden Schallkopfen konnen beim Morbus Dupuytren die verschiedenen Manifestationen beurteilt sowie operative und konservative Therapien geplant werden. Die Untersuchung von Sehnen und Muskeln ist besonders aufschlussreich, da die Sonografie eine dynamische Bildgebung ist. Zu den der Ultraschalldiagnostik zugangigen nichttraumatisch bedingten Nervenveranderungen zahlen Kompressionsneuropathien und Neuritiden der peripheren Anteile der Nn. medianus, ulnaris und radialis und deren Endaste. Durch die komplette Reflexion der Ultraschallwellen an der Knochenoberflache lassen sich periostale Konturirregularitaten sehr gut objektivieren. Vor allem im Rahmen der Osteomyelitisfruhdiagnostik hat die Sonografie grose Vorteile. Gelenkinfekte, Synovitiden, Ganglien, arthrotische Veranderungen und ihre Ursachen werden ausfuhrlich behandelt und auf Verteilungsmuster einzelner entzundlich-degenerativer Erkrankungen und ihrer diagnostischen Kriterien eingegangen.

Sonografie des traumatisch veränderten Gewebes

Die Sonografiediagnostik traumatischer Hautveranderungen beurteilt Fremdkorper, Epidermoidzysten, Atherome sowie subkutane Entzundungen, aber auch Narben und Hauttransplantate. Dynamische Methoden konnen offene und geschlossene Sehnenverletzungen quantifizieren. Auch posttraumatische Veranderungen sowie deren Kontrolle und Verlauf konnen nachvollzogen werden. Die Diagnostik traumatischer Nervenlasionen ermoglicht die Objektivierung einer geschlossenen Nervenlasion sowie die Differenzierung zwischen Axonotmesis und Neurotmesis. Die Ultraschallreflexion an der Knochenoberflache hat fur die Diagnostik traumatischer Knochenveranderungen Vorteile; es lassen sich Knochenkonturen dynamisch untersuchen und auch kleinste Pathologien abgrenzen. Die dynamische Ultraschalldiagnostik von Gelenkverletzungen mit ligamentarer Beteiligung unterscheidet Insuffizienzen, Komplett- und Teilrupturen als auch gelenkuberbruckender Strukturen zuverlassig und leitet die entsprechende Therapien ein.