Florian Neubrech

Four-corner fusion: comparison of patient satisfaction and functional outcome of conventional K-wire technique vs. a new locking plate

BackgroundFour-corner fusion is a standard procedure for advanced carpal collapse. Several operative techniques and numerous implants for osseous fixation have been described. Recently, a specially designed locking plate (Aptus©, Medartis, Basel, Switzerland) was introduced. The purpose of this study was to compare functional results after osseous fixation using K-wires (standard of care, SOC) with four-corner fusion and locking plate fixation.Methods21 patients who underwent four-corner fusion in our institution between 2008 and 2013 were included in a retrospective analysis. In 11 patients, osseous fixation was performed using locking plates whereas ten patients underwent bone fixation with conventional K-wires. Outcome parameters were functional outcome, osseous consolidation, patient satisfaction (DASH- and Krimmer Score), pain and perioperative morbidity and the time until patients returned to daily work. Patients were divided in two groups and paired t-tests were performed for statistical analysis.ResultsNo implant related complications were observed. Osseous consolidation was achieved in all cases. Differences between groups were not significant regarding active range of motion (AROM), pain and function. Overall patient satisfaction was acceptable in all cases; differences in the DASH questionnaire and the Krimmer questionnaire were not significant. One patient of the plate group required conversion to total wrist arthrodesis without implant-related complications.ConclusionBoth techniques for four-corner fusion have similar healing rates. Using the more expensive locking implant avoids a second operation for K-wire removal, but no statistical differences were detected in functional outcome as well as in patient satisfaction when compared to SOC.

Nervetubes zur Versorgung von traumatischen sensiblen Nervenläsionen der Hand – Übersicht sowie retrospektive Planungsstudie für eine randomisiert-kontrollierte multizentrische Studie

BACKGROUND Nerve tubes are used for bridging of short nerve gaps and for coating of primary end-to-end nerve sutures. This article provides an overview of available implants and their application. Also it presents a retrospective planning study aiming to determine the static 2-point discrimination after primary peripheral nerve repair with and without the use of a nerve tube. The results have been used to determine the sample size of a prospective randomised trial. PATIENTS AND METHODS 54 peripheral nerve injuries of 41 patients were treated by primary end-to-end nerve sutures with or without the additional use of a nerve tube (n=28 and n=26, respectively). 38 digital nerves and 16 median and ulnar nerves were affected. Nerve tubes were used for the repair of 15 digital nerves and 13 median and ulnar nerves. Clinical follow-up was performed 46 months after surgery (patients without nerve tubes) and 18 months after surgery (patients with nerve tubes), respectively. Static 2-point discrimination (2PD) was measured by double-tip compasses (weight: 18 g) and patients were examined for clinical signs of neuroma. Further examinations included grip strength as a percentage value compared with the uninjured hand and, in case of finger injuries, the range of motion in the proximal and distal interphalangeal joints, Strickland score, DASH score and implant-associated complications. RESULTS In patients with primary end-to-end sutures for finger injuries, there were no statistically significant differences between treatment with and without nerve tubes regarding 2PD, grip strength, DASH- or Strickland score. However, 2PD values of patients with nerve tubes had an increased spread. Average 2PD in digital nerves was 4.5 mm (3-15; SD: 3.9) without nerve tubes and 5.5 mm (3-15; SD: 5) with nerve tubes. Average 2PD after lesions of the median and ulnar nerves was 10 mm (3-15; SD: 5.9 and 5.4, respectively) in both groups. CONCLUSION The additional use of a nerve tube showed no superiority in this planning study. The expected average 2PD is 5 mm after digital nerve injuries and 10 mm after lesions of the median or ulnar nerves.

Prävalenz und Koprävalenz des Komplexen Regionalen Schmerzsyndromes (CRPS) und des Karpaltunnelsyndromes (KTS) in der Handrehabilitation

BACKGROUND In the current literature, there are reports of associations between complex regional pain syndromes (CRPS) and carpal tunnel syndromes (CTS). The aim of this study was to determine the prevalence of both disease patterns in hand rehabilitation patients and to investigate whether there is a correlation between CTS and CRPS. Furthermore, differences in the healing process of patients with and without additional CTS, and the effectiveness of the rehabilitative therapy for both diseases, were investigated. PATIENTS AND METHODS The computerised medical records of 791 patients in the years 2009-2015 who had been in hand rehabilitation were retrospectively analysed. At the beginning and end of rehabilitation, measurements were made of pain by visual analogue scales (VAS, 0-10), grip strength and finger mobility (mean distance from finger pulp to palmar D2-D5). The clinical course was statistically analysed. CRPS diagnosis was confirmed clinically by a pain therapist, CTS diagnosis was confirmed by neurological and neurophysiological examination. Surgical therapy was performed despite CRPS diagnosis. RESULTS The prevalence of CRPS was 161/1000 and of CTS 62/1000; the co-prevalence of the 2 diagnoses was 24/1000 (p<0.0001). In the CRPS group, after a mean of 8 (1-21) weeks of rehabilitative therapy, mean pain was reduced from 5 (1-10) to 3 (0-9), grip strength improved from 10 (0-39)kg to 18.5 (2.5-45.5)kg and finger mobility increased from 2.9 (0-7.6)cm to 1.8 (0-7.8)cm. In the CRPS+CTS group, after a mean of 6.8 (3-23) weeks of rehabilitative therapy, mean pain was reduced from 5 (0-8) to 2.6 (0-5), grip strength improved from 9.7 (2.4-25.5)kg to 17.4 (0.9-47.4)kg and finger mobility increased from 2.7 (0-5.3)cm to 1.7 (0-5.3)cm. Improvement over the period of rehabilitation was significant in both groups, though the period of therapy was significantly shorter in the CRPS+CTS group. CONCLUSION CRPS and CTS are often associated. Rehabilitative therapy was effective for CRPS- and CRPS+CTS patients.

Domestic bioethanol-fireplaces–a new source of severe burn accidents

BACKGROUND Bioethanol-fueled fireplaces are popular interior home decoration accessories. Although their safety is promoted frequently, actual presentations of severe burn injuries in our burn intensive care unit (ICU) have focused the authors on safety problems with these devices. In this article we want to explore the mechanisms for these accidents and state our experiences with this increasingly relevant risk for severe burn injuries. MATERIALS AND METHODS The computerized medical records of all burn intensive care patients in our burn unit between 2000 and 2014 were studied. Since 2010, 12 patients with bioethanol associated burn injuries were identified. Their data was compared to the values of all patients, except the ones injured by bioethanol fireplaces that presented themselves to our burn ICU between the years 2010 and 2014. RESULTS At time of admission the bioethanol patients had a mean ABSI-score of 4.8 (+/- 2.2 standard deviation (SD)). A mean of 17 percent (+/- 9.1 SD) body surface area was burned. Involvement of face and hands was very common. An operative treatment was needed in 8 cases. A median of 20 days of hospitalization (range 3-121) and a median of 4.5 days on the ICU (range 1-64) were necessary. No patient died. In most cases the injuries happened while refilling or while starting the fire, even though safety instructions were followed. In the control group, consisting of 748 patients, the mean ABSI-score was 5.6 (+/- 2.7 SD). A mean of 16.5 percent (+/- 10.1 SD) body surface area was burned. Treatment required a median of 3 days on the burn ICU (range 1-120). Regarding these parameters, the burden of disease was comparable in both groups. CONCLUSION Bioethanol-fueled fireplaces for interior home decoration are a potential source for severe burn accidents even by intended use.

Influences of Macrohemodynamic Conditions on Systemic Microhemodynamic Changes in Burns.

PurposeThe clinical course after major burns is characterized by microcirculatory changes and consecutive capillary leakage. However, current clinical monitoring does not properly assess microcirculation, whereas macrohemodynamic changes are continuously evaluated. Here, we assess if macrohemodynamic and microhemodynamic parameters after burn trauma are correlated in a rat model. MethodsBurn plasma harvested from donor rats 4 hours after thermal injury (30% total body surface area, 100 °C water, 12 seconds) was administered intravenously to healthy animals during 2 hours of intravital microscopy (burn group [BG]). Shamburn plasma (same procedure but water at 37°C) was transferred for negative controls (shamburn group [SBG]). Intravital microscopy was performed at 0, 60, and 120 minutes to assess capillary leakage measuring fluorescein isothiocyanate-albumin extravasation. Macrocirculation was assessed using mean arterial pressure and heart rate, whereas microcirculation was evaluated using red blood cell velocity, venular diameter, venular wall shear rate and plasma extravasation at 0, 60, and 120 minutes in postcapillary venules. ResultsThirty mesenteric venules (16 animals) in SBG and 31 mesenteric venules (15 animals) in BG were observed during intravital microscopy. Mean arterial pressure and heart rate remained within acceptable margins and showed no significant differences, neither within nor between groups. Significant correlations between macrohemodynamic and microhemodynamic conditions were neither observed for BG nor SBG, except from a significant correlation of MAP and plasma extravasation at T60. However, at T120 mesenteric venules in the BG clearly showed microvascular burn edema, whereas venules in SBG did not. ConclusionsStabilization of macrohemodynamic conditions may not necessarily have positive effects on microcirculatory derangements—a fact that has not been shown for burns yet, that is—however, well described for sepsis. Further studies are required to show whether distinct monitoring of microcirculation may offer new approaches for burn trauma treatment.