J. van Schoonhoven

The Role of Current Techniques and Concepts in Peripheral Nerve Repair

Patients with peripheral nerve injuries, especially severe injury, often face poor nerve regeneration and incomplete functional recovery, even after surgical nerve repair. This review summarizes treatment options of peripheral nerve injuries with current techniques and concepts and reviews developments in research and clinical application of these therapies.

Intra- und Interobserver-Reliabilität digital fotodokumentierter Befunde von Handgelenksspiegelungen

PURPOSE The aim of this study was to evaluate the intra- and interobserver reliability of findings in wrist arthroscopies documented by digital photography. PATIENTS AND METHODS 102 consecutive wrist arthroscopies were documented by at least 6 photographs: (1) radioscaphoidal joint with radiopalmar ligaments, (2) scapholunate ligament from radiocarpal, (3) TFCC, (4) lunotriquetral joint with ulnar recessus, (5) scapholunate, and (6) lunotriquetral joint from midcarpal. More photographs were taken of additional pathologies. Arthroscopic findings were documented in an arthroscopy form (synovitis: no/yes, articular effusion: no/yes, cartilage lesion: no/yes). Lesions of the scapholunate ligament were classified according to Geissler, scapholunate and lunotriquetral ligament lesions were graded as partial or complete, TFCC lesions were categorised according to Palmer and trampoline effects noted. Three months later the 6 standard photos and then all photos were re-evaluated by the scoping surgeon and two experienced hand surgeons. Cohens kappa was used as a measure of agreement between findings three months postoperatively and those in the operation report. Further statistical analyses were done, e. g., to compare intra- and interobserver reliability. RESULTS In general intraobserver reliability (mean kappa 0.44) was better than interobserver reliability (0.28, 0.30). Assessing all available photos (0.47) did not improve reliability compared to assessing only the six standard photos (0.44). On grading scapholunate ligament lesions as partial or complete the interobserver reliability was fair (0.37, 0.30). Using Geisslers classification the interobserver reliability was κ=0.34 and 0.23. There was substantial intra- (0.61) and interobserver reliability (0.63, 0.60) for cartilage lesions. While intraobserver reliability for TFCC lesions was substantial (0.61), interobserver reliability was only moderate (0.31, 0.48). CONCLUSION Even with wrist arthroscopy, the best diagnostic modality for scapholunate ligament, TFCC and carpal cartilage lesions, hand surgeons do not agree in diagnosis and pathology. Therefore, the documentation of arthroscopic findings has to be improved. Digital video documentation of wrist arthroscopy may illustrate wrist pathologies more adequately. However, this still has to be proven by further studies.

Korrektureingriffe nach distaler Radiusfraktur

After a fracture of the distal radius, especially with malunion, many patients complain of a decreased range of forearm rotation and pain on the ulnar side of the wrist. The purpose of this article is to describe the therapeutic options available in such cases. Decision making as to whether there is an indication for corrective surgery or not is based on the patients symptoms and the clinical findings, whereas the decision as to which surgery to perform must take into account the radiological findings. If possible, reconstruction of the anatomy using a distal radius osteotomy should be carried out.ZusammenfassungNach einer distalen Radiusfraktur klagen immer wieder Patienten, insbesondere bei Ausheilung des Bruchs in Fehlstellung, über Beschwerden. Im Vordergrund stehen dabei neben einer Einschränkung der Unterarmdrehung Schmerzen auf der Ellenseite des Handgelenks. Ziel der Arbeit ist es, die verschiedenen Behandlungsmöglichkeiten dazustellen. Während bei der Entscheidung, ob eine operative Intervention sinnvoll ist, die geklagten Beschwerden und klinischen Befunde ausschlaggebend sind, ist bei der Auswahl des Operationsverfahrens mehr der radiologische Befund von Bedeutung. Wenn immer möglich sollte eine Rekonstruktion möglichst anatomischer Verhältnisse durch eine Radiuskorrekturosteotomie angestrebt werden.AbstractAfter a fracture of the distal radius, especially with malunion, many patients complain of a decreased range of forearm rotation and pain on the ulnar side of the wrist. The purpose of this article is to describe the therapeutic options available in such cases. Decision making as to whether there is an indication for corrective surgery or not is based on the patient’s symptoms and the clinical findings, whereas the decision as to which surgery to perform must take into account the radiological findings. If possible, reconstruction of the anatomy using a distal radius osteotomy should be carried out.

Indikation und Ergebnisse der Ulnaverkürzungsosteotomie bei ulnokarpalem Handgelenksschmerz

ZusammenfassungEine häufige Ursache des chronischen ulnokarpalen Handgelenkschmerzes ist das Ulna-impaction-Syndrom. Die Ulnaverkürzungsosteotomie stellt eine wirkungsvolle Therapie dieser Problematik dar sowohl bei anlagebedingten, als auch bei posttraumatischen Plusvarianten der Ulna. Bei Plusvarianten nach distaler Radiusfraktur ist auf eine ausreichende Stellung der Radiuskonsole zu achten. Der Verkürzungsosteotomie bei anlagebedingtem Impaction-Syndrom sollte der Versuch einer arthroskopischen Druckentlastung des ulnokarpalen Komplexes vorgeschaltet werden. Bei der Osteotomie muß der exakten Längenkorrektur besondere Beachtung geschenkt werden, da eine zu ausgedehnte Verkürzung die Gefahr von Problemen im distalen Radioulnargelenk birgt. Um eine stabile Osteosynthese zu gewährleisten empfehlen wir eine Schrägosteotomie und die Verwendung einer 7-Loch-Platte.AbstractThe ulnar impaction syndrome is proven to be a common source of ulnar sided wrist pain. Ulna-shortening osteotomy represents a successful therapy for this kind of problem, both congenital or posttraumatic positive ulnar variance. Positive variance resulting from a distal radius fracture needs correct dorsal and radial angulation of the radius. In case of congenital positive variance arthroscopic debridement for decompression of the TFCC should be performed first. The adequate correction of the length is the major problem. Disorders of the distal radioulnar joint may result due to overcorrection. Oblique osteotomy using 7-hole-plates is our preferred treatment.

Comparison of the results between reconstruction of the extensor pollicis longus tendon using a free interposition tendon graft and extensor indicis transposition

QUESTION Is there a difference in the results of free tendon grafting or transfer of the extensor indicis tendon for the reconstruction of the extensor pollicis longus tendon? PATIENTS AND METHODS Two groups of patients, who underwent surgery between 1992 and 1998, were compared. From 58 patients with tendon grafts 48 were re-examined. For reconstruction, a graft harvested from the palmaris longus tendon was applied that was woven into the proximal and distal stump of the extensor pollicis tendon according to the technique of Pulvertaft. From 56 patients with transfer of the extensor indicis tendon, 40 were re-examined. The extensor indicis transfer was performed by the standard technique. Extension and flexion of the metacarpophalangeal and interphalangeal joints of the thumb, retroposition, abduction and opposition were examined. In addition, the span of the hand, grip strength and pinch strength were measured. A summarising assessment was performed according to the Geldmacher score, the subjective impairment was assessed by the DASH score. RESULTS Both groups were comparable according to demographic data and aetiology of the rupture. The range of motion was nearly identical after both surgical techniques. Range of motion of the joints of the thumb, abduction and opposition reached normal values but both methods restored only 60 % of the normal retroposition. According to the Geldmacher score, both methods showed good and excellent results. The DASH score resulted in low values with 10 and, respectively, 14 points. After extensor indicis transfer all patients demonstrated isolated extension of the index. CONCLUSIONS Both methods establish equally good results. Free tendon grafting is technically more demanding but preserves a more powerful isolated extension of the index finger and should, therefore, be preferred in patients with special demands on this function (e.g., musicians). The transfer of the extensor indicis tendon is technically less demanding, requires retraining and may impair the isolated function of the index finger.

The importance of the distal radioulnar joint for reconstructive procedures in the malunited distal radius fracture

SummaryClinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignement of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.ZusammenfassungBei der in Fehlstellung verheilten distalen Radiusfraktur steht zumeist die ulnokarpale Symptomatik im Vordergrund. Knöcherne Ursachen sind eine intraartikuläre Inkongruenz, eine Verkippung der Incisura ulnaris am distalen Radiusfragment oder die Ulna-plus-Situation am Handgelenk. Eine persistierende Luxation des distalen Radioulnargelenks (DRUG) führt zum kompletten Verlust der Unterarmdrehbewegung. Der ligamentäre oder knöcherne Abriß des ulnokarpalen Bandkomplexes (TFCC) bedingt eine Instabilität des DRUG. Jede dieser Komponenten prädisponiert unkorrigiert zur Arthrose des DRUG, deren Therapie nicht mehr rekonstruktiver Natur ist und immer zu einem Funktionsverlust führt. An rekonstruktiven Therapieverfahren stehen die Radiuskorrekturosteotomie, die Ulnaverkürzungsosteotomie, die Reposition einer Luxation und die Refixierung des TFCC zur Verfügung. Die genaue Analyse der im Einzelfall zugrundeliegenden, pathologischen Fehlstellungskombination und der ulnokarpalen Begleitverletzungen muß für die Auswahl des Therapieverfahrens ausschlaggebend sein.

Störungen des distalen Radioulnargelenkes nach distaler Radiusfraktur

After a fracture of the distal radius, whether healed in an anatomic position or malunited, many patients complain about problems on the ulnar side of the wrist with pain and decreased range of forearm rotation. In addition many patients are unhappy with the unpleasant appearance of the wrist joint. The complaints are related to tears of the triangular fibrocartilaginous complex, instability, and/or incongruity of the distal radioulnar joint and degenerative changes. Malunion of the distal radius must be taken into account when discussing treatment options. The purpose of this paper is to describe a treatment algorithm with respect to the clinical symptoms, the pathology as well as the presence or absence of a deformity of the distal radius.ZusammenfassungUnabhängig davon, ob die Fraktur in anatomischer Stellung oder in Fehlstellung verheilt ist, klagen Patienten nach einer distalen Radiusfraktur immer wieder über Beschwerden auf der Ellenseite des Handgelenkes. Neben Schmerzen werden in erster Linie Einschränkungen der Unterarmumwendbewegung und das oft gestörte Aussehen des Handgelenkes beklagt. Ursachen der Beschwerden sind Verletzungen des ulnokarpalen Komplexes, eine Instabilität und/oder Inkongruenz des distalen Radioulnargelenkes und eine sich daraus entwickelnde Arthrose des Gelenkes. Bei der Behandlung ist einer vorhandenen Fehlstellung des distalen Radius Rechnung zu tragen. Ziel der Arbeit ist es, einen Behandlungsalgorithmus unter Berücksichtigung der Beschwerdesymptomatik einerseits, der Ursachen andererseits als auch der Stellung des distalen Radius darzustellen. AbstractAfter a fracture of the distal radius, whether healed in an anatomic position or malunited, many patients complain about problems on the ulnar side of the wrist with pain and decreased range of forearm rotation. In addition many patients are unhappy with the unpleasant appearance of the wrist joint. The complaints are related to tears of the triangular fibrocartilaginous complex, instability, and/or incongruity of the distal radioulnar joint and degenerative changes. Malunion of the distal radius must be taken into account when discussing treatment options. The purpose of this paper is to describe a treatment algorithm with respect to the clinical symptoms, the pathology as well as the presence or absence of a deformity of the distal radius.

Die Arthroskopie des distalen Radioulnargelenks

OBJECTIVE Insertion of a small joint arthroscope into the proximal and distal parts of the distal radioulnar joint (DRUJ) allows visualization of the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar-sided surface of the triangular fibrocartilage complex (TFCC). INDICATIONS Evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X-rays and MRI, suspected cartilage lesions without osteochondral changes (signs of osteoarthritis), undefined swelling of the DRUJ in suspected synovitis, removal of loose bodies and arthroscopical synovialectomy, suspected lesions of the deep part of the TFCC, respectively foveal avulsions, wear or superficial tears of the proximal TFCC and arthroscopic-assisted ulnar shortening. CONTRAINDICATIONS Significant changes of the local topographical anatomy, extensive scar formation, ulna plus variance, local infection or open wounds, affected sensibility in the area of the dorsal branch of the ulnar nerve, fractures of the sigmoid notch or the ulnar head, capsular tears causing effusion of irrigation fluid. SURGICAL TECHNIQUE In vertical extension of the wrist, two portals are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. Partial visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ, and the proximal surface of the TFCC. POSTOPERATIVE MANAGEMENT Following isolated diagnostic arthroscopies immobilization of the wrist in a semicircular ulnar-sided cast for 1 week. No extensive load to the wrist for 4 weeks. RESULTS Still rarely performed procedure for diagnosis and therapy of ulnar-sided wrist pain. Technically demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases this procedure offers valuable additional information about the distal radioulnar joint.

Rettungsoperationen und deren Differenzialindikation am distalen Radioulnargelenk

ZusammenfassungDie häufigste Ursache für die Entstehung der Arthrose des distalen Radioulnargelenkes (DRUG) ist die in Fehlstellung verheilte distale Radiusfraktur. Eine vollständige Wiederherstellung der Funktion des DRUG kann weder durch Ulnakopfresektion, Hemiresektions-Interpositions-Arthroplastik, Kapandji-Sauvé-Operation noch durch endoprothetischen Ersatz des Ulnakopfes erreicht werden. Die Bewertung der einzelnen Methoden muss sich an der Komplikationsrate orientieren. Die wesentliche Komplikation der resezierenden Verfahren besteht in der biomechanischen Destabilisierung des distalen Unterarmgefüges mit sekundärer, schmerzhafter Instabilität des distalen Ulnaendes, und zwar für die Ulnakopfresektion erheblich häufiger als für die anderen Therapieverfahren. Wir sehen daher keine Indikation mehr für die vollständige Entfernung des Ulnakopfes. Nach Ergebnissen und Häufigkeit der sekundären Instabilität für die Hemiresektions-Interpositionsarthroplasik und die Kapandji-Sauvé-Operation sind diese Methoden gleichwertig. Bei vorbestehender Instabilität des DRUG oder erheblicher Achsenfehlstellung favorisieren wir die Hemiresektions-Interpositions-Arthroplastik. Studien ergaben, dass durch den endoprothetischen Ersatz des Ulnakopfes eine sekundäre Instabilität behoben, oder, bei primärer Verwendung, vermieden werden kann. Die Hauptindikation ist die Revision bei schmerzhafter, sekundärer Instabilität des distalen Ulnaendes. Bis zum Vorliegen von Langzeitergebnissen begrenzen wir den primären endoprothetischen Ersatz des Ulnakopfes auf spezielle Indikationen.AbstractThe most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.

The Value of Wrist Arthroscopy in Kienböck's Disease

PURPOSE/BACKGROUND The integrity of the articular surfaces is of major importance for the prognosis and treatment of lunate necrosis (Kienböcks disease). Though arthroscopy is the most reliable method in the diagnosis of intraarticular pathology it is rarely applied in this condition. The purpose of this study was to evaluate the value of arthroscopy in Kienböcks disease. PATIENTS/MATERIAL AND METHODS 20 prospectively evaluated patients underwent arthroscopy for Kienböcks disease. Initial diagnosis was performed by enhanced magnet resonance images, standard radiographies and computed tomography. Preoperative staging was performed according to the MRI-adapted classification of Lichtman and Ross . The arthroscopical measures followed standard procedures. Cartilage lesions were rated by an own modified classification. The wrists were further staged according to an arthroscopical classification system for Kienböcks disease (Bain and Begg ). The posterior and anterior interosseus nerves were resected in all patients and, if necessary, an arthroscopical debridement of the lunate performed. RESULTS No clinical or statistical correlation was found between the Lichtman-stages and the distribution and severity of the cartilage lesions. In selected cases severe cartilage lesions (3 degrees and 4 degrees ) were already found in Lichtman-stage IIIA and IIIB, while less severe lesions than expected were observed in Lichtman-stage IV. There was no correlation between the Lichtman-stages and the classification according to Bain and Begg. In selected cases without cartilage lesions carpal collapse (Lichtman stage IIIB) was found. The individual response was unequivocal: Four patients reported minimal, five patients remarkable improvement but all did not demand further procedures. Four patients reported complete relieve. Seven patients demanded further operations (3 proximal row carpectomies, 4 STT fusions). In three of these seven cases the arthroscopical evaluation guided the further operative therapy to appropriate procedures. CONCLUSIONS In Kienböcks disease arthroscopy more precisely detected alterations of the articular surfaces than radiological diagnostics. Radiological staging over- but also underestimated the cartilage damage. Arthroscopic results strongly influenced the further surgical treatment. Therefore in Kienböcks disease arthroscopy is of high value and recommended.