K. Wilhelm

The scapholunate interosseous ligament in MR arthrography of the wrist: correlation with non-enhanced MRI and wrist arthroscopy

Abstract Objective. To compare three-compartment MR wrist arthrography with non-enhanced MRI in correlation with wrist arthroscopy, and to evaluate the potential of MR arthrography for consistently visualizing all parts of the scapholunate interosseous ligament of the wrist (SLIL) and exactly diagnosing the site and extent of SLIL defects. Design and Patients. In 41 patients with wrist pain (34 patients with wrist pain for more than 6 months) plain radiographs, stress views, non-enhanced MRI and three-compartment MR arthrography were done within 2 h of each other, using three-dimensional volume acquisition (0.6–1.0 mm effective slice thickness) with a gradient-recalled echo sequence and a 1.5-T magnet. The MR arthrography findings were compared with the findings from non-enhanced MRI and correlated with the arthroscopic findings in all patients. Results. The dorsal, central and palmar segments of the SLIL could be delineated exactly by MR arthrography in 95% of the patients; with non-enhanced MRI only 28% of SLIL segments were seen consistently. Demonstration of SLIL defects was possible with high diagnostic confidence in 42% of SLIL segments by non-enhanced MRI and in 94% by MR arthrography. With wrist arthroscopy as the standard of reference, sensitivity and specificity values for SLIL perforations were 52%/34% for non-enhanced MRI and 90%/87% for MR arthrography. Conclusions. MR arthrography, using three-dimensional volume acquisition with thin slices (0.6–1.0 mm), combines the advantages of three-compartment arthrography and non-enhanced MRI. It shows the precise location and magnitude of ligamentous defects of all parts of the SLIL, correlates well with wrist arthroscopy and has potential implications for diagnosis and treatment planning.

The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy.

We assessed the value of three‐compartment magnetic resonance (MR) wrist arthrography in comparison with non‐enhanced magnetic resonance imaging (MRI) for the evaluation of 13 individual wrist ligaments in 35 patients with refractory wrist pain. In 20 of these patients MR findings were correlated with the findings from multiportal wrist arthroscopy. For MR imaging (1.5‐T magnet) a three‐dimensional volume acquisition with a gradient‐recalled echo sequence and 0.6–1.0 mm effective slice thickness was used. The delineation of individual wrist ligaments was rated as “good” in 10% of non‐enhanced MR and 90% of MR arthrography images. Ligament evaluation was possible with high diagnostic confidence in 11% by non‐enhanced MR imaging and 90% by MR arthrography. With wrist arthroscopy as the standard of reference, average sensitivities/specificities/accuracies for the diagnosis of full‐thickness ligamentous defects were 0.81/0.75/0.77 for non‐enhanced MR imaging and 0.97/0.96/0.96 for MR arthrography. Our findings suggest that MR arthrography is more accurate than standard MRI in delineating and evaluating the ligaments of the wrist.J. Magn. Reson. Imaging 1999;9:468–474.

Altered patterns of subchondral bone mineralization in Kienböck's disease.

The pattern of subchondral bone density, which is supposed to reflect the long-term distribution of stress, was investigated in both wrist joints of nine healthy young subjects and seven patients suffering from Kienböck’s disease by means of CT osteoabsorptiometry. Two density maxima were found on the distal articular surface of the radius in the healthy subjects, corresponding to the position of the scaphoid and the lunate. Our relative quantitative results showed three different physiological types of stress indicated by the predominantly monocentric density maxima either on the scaphoid or the lunate surface of the radius and the symmetrical distribution of the mineralization. In Kienböck’s disease no type of mineralization predominated. In the progressive stages the lunate density maximum was absent. The overall mineralization was generally less than in controls. Changes in the pattern of mineralization were also found on the contralateral side.

Stress Analysis of the Radiocarpal Joint from a Determination of the Subchondral Mineralisation Pattern

It is well known that there is a regularity of distribution of the subchondral bone density in the larger joints. This has been shown by Knief1 and Konermann,5 using x-ray densitometry. Some years ago, Pauwels12 convincingly demonstrated that the distribution of the subchondral bone density reflects the localisation of the long-term stresses acting upon the articular surface of a joint. For a very long time no diagnostic method has been available by which the long-term stress to which joints are subjected can be accurately assessed in vivo. The conventional AP x-rays are summation pictures which can give no precise information about the actual area of distribution.

Die homoioplastische Nerventransplantation mit lyophilisiertem Nerv

SummaryThe bridging of nervous defects became promissing, after succeeding in a great extent to neutralize homologous nerve grafts through extraction of enzymes and antigenes.From the 33 homologous nerve graftings performed within the last 10 months, with graft lengths between 3 and 27 cm, only the 17 grafts that were performed more than 5 months ago can be evaluated. 6 cases showed a good reinnervation, that is, the return of motory and sensory nervous activity. Adequate results were achieved in 8 cases, while 3 cases showed no perceptible activity.ZusammenfassungDie Überbrückung von Nervendefekten wurde erfolgversprechend, als es gelang, die homologen Nerventransplantate durch Desenzymatisierung und Desantigenisierung weitgehend zu neutralisieren. Von den bisher durchgeführten 33 homologen Nerventransplantationen innerhalb von 10 Monaten mit Transplantatlängen zwischen 3 und 27 cm können 17 Transplantate, deren Operationszeit länger als 5 Monate zurückliegt, beurteilt werden. In 6 Fällen findet sich eine gute Reinnervation, d. h. Rückkehr der motorischen und sensiblen Nervenleistung. In 8 Fällen kam es zu einer ausreichenden und in 3 Fällen zu keiner meßbaren Nervenleistung.

Eine neue Versuchsanordnung zur Belastbarkeitsprüfung von Achillessehnen

SummaryAn apparatus has been constructed which made it possible to tear Achilles tendons such as the rupture was located between the strain device of the tendon and calcaneus and thus in the reach of the free length of the tendon. Setting a propitious cut was not necessary with this method. With this construction the maximal solidity before rupture was examinated in two parallel experiments with a) dynamic (impulsive) and b) static (slowly imposed) charge. With dynamic charge there were obtained essentially higher data (max. 930 kp) than could be with static charge (max. 680 kp).ZusammenfassungEs wurde eine Apparatur entwickelt, die es ermöglicht, Achillessehnen so zu reißen, daß die Rißstelle zwischen den Einspannungsvorrichtungen für Sehnenspiegel und Calcaneus und somit im Bereich der freien Sehnenlänge liegt. Das Setzen einer Sollrißstelle ist bei dieser Versuchsanordnung nicht erforderlich. Mit dieser Apparatur wurde in zwei parallelen Versuchsreihen die maximale Rißfestigkeit bei a) dynamischen (impulsartigen) und b) statischen (langsam erfolgenden) Belastungen geprüft. Bei dynamischer Belastung ergaben sich wesentlich höhere Werte (maximal 930 kp) als bei statischer (maximal 680 kp).

Der subkutane distale bizepssehnenabriß

Compared to the proximal rupture of the Biceps tendon the distal rupture is extremely rare. The numerous published methods of repair show that a reliable method has not yet been found. Considering functional principles we developed a method which combines a safe fixation of the tendon and a good function. An autologous tendon is brought through a burrhole placed obliquely through the mid position of the tuberosity. The Biceps tendon is now placed between the ends of the autologous tendon and fixed with resorbable u-sutures (Sandwich-technic). Thereby the tension on the tendon is adapted as necessary. The achieved results is demonstrated on two cases.SummaryCompared to the proximal rupture of the Biceps tendon the distal rupture is extremely rare. The numerous published methods of repair show that a reliable method has not get been found.Considering functional principles we developed a method which combines a safe fixation of the tendon and a good function. An autologous tendon is brought through a burrhole placed obliquely through the mid position of the tuberosity. The Biceps tendon is now placed between the ends of the autologous tendon and fixed with resorbable u-sutures (Sandwich-technic). Thereby the tension on the tendon is adapted as necessary.The achieved result is demonstrated on two cases.ZusammenfassungGemessen an den proximalen Bizepssehnenrissen stellen die distalen Bizepssehnen-rupturen eine ausgesprochene Rarität dar. Die vielen in der Literatur angegebenen Verfahren zeigen deutlich, daß ein sicheres Verfahren bisher nicht gefunden wurde.Anhand funktioneller Überlegungen haben wir ein Verfahren entwickelt, das nach unserer Auffassung den anatomischen Erfordernissen nachkommt und gleichzeitig eine stabile Fixierung der Sehne garantiert. Das Verfahren besteht darin, daß durch einen schrägen Bohrkanal im Zentrum der Tuberositas radii eine autologe Sehne eingezogen wird. Zwischen die beiden gleichlangen Sehnenzügel wird darn die distale Bizepssehne eingefügt im Sinne einer sogenannten „Sandwich-Technik” und mit resorbierbaren U-Nähten fixiert. Bei dieser Technik kann die nötige Spannung den Erfordernissen angepaßt werden.Die erzielten Ergebnisse in zwei Fallen werden geschildert.

Local muscle flaps of the second and third interosseus space for the treatment of osteomyelitis in the central metacarpal region

Both experimental and clinical studies showed that muscle flap transposition is a reliable tool in treating chronic infections of the bone. The major advantage of local muscle flaps is the treatment with well perfused autogenous tissue without using any implants. The primary closure of the operation site and the cure of infection within four weeks allow a short immobilisation time. Nevertheless, the loss of muscle function with a possible functional and aesthetic defect in the donor site has to be accepted. The first dorsal interosseus muscle and the abductor digiti minimi muscle have been used successfully for the treatment of metacarpal osteomyelitis. Osteomyelitis in the central metacarpal bones cannot be treated with these techniques, because of their limited range. We present the muscles of the second and third interosseus space for local pedicled muscle flap transfer. The arterial network in this interosseus spaces and the vascularisation of the dorsal and palmar interosseus muscles allow to harvest muscle flaps with either proximal or distal pedicle. The loss of interosseus muscles in the second and third interosseus space is tolerable from a functional and esthetic point of view. Operative techniques are shown for the elevation of dorsal and palmar interosseus muscle flaps. Two cases of osteomyelitis in the central metacarpal bones, which were treated successfully with the new local interosseus muscle flaps, are reported.

Sehneninterpositionsplastik bei teilnekrotisierten Naviculare-Pseudarthrosen

We have seen in 4 cases of 46 operated scaphoid pseudarthrosis aseptic bone necrosis of a fragment. According to the tendon interposition plastic of Froimson for the substitute arthrose of the saddlepoint of the thumb. We exstirpated the bionecrotic fragment of the scaphoid, splitted the tendon of the flexor carpi radialis muscle, removed a part of the tendon from the belly of the muscle, rolled it in and fixed it in the excavated cavity of the bone. After an observation time of 6 months to 1.5 years all 4 patients have not developed complications.SummaryWe have seen in 4 cases of 46 operated scaphoid pseudarthrosis aseptic bone necrosis of a fragment. According to the tendon interposition plastic of Froimson for the substitute arthrose of the saddlepoint of the thumb. We exstirpated the bionecrotic fragment of the scaphoid, splitted the tendon of the flexor carpi radialis muscle, removed a part of the tendon from the belly of the muscle, rolled it in and fixed it in the excavated cavity of the bone.After an observation time of 6 months to 1.5 years all 4 patients have not developped complications.ZusammenfassungBei 46 operierten Naviculare-Pseudarthrosen lag in 4 Fällen eine aseptische Knochennekrose eines der Fragmente vor. In Anlehnung an die Sehneninterpositionsplastik nach Froimson zum Ersatz des Trapezoid bei Daumensattelgelenksarthrosen wurde nach Exstirpation des bionekrotischen Navicularefragmentes die Sehne des M. flexor carpi radialis längsgespalten, am Muskelbauch abgetrennt, eingerollt und in die Knochenhöhle fixiert.Nach einer Beobachtungszeit von 6 Monaten bis 1,5 Jahren waren alle 4 Patienten beschwerdefrei.

Das Sulcus ulnaris-Syndrom

SummaryAcute and chronical lesions of the ulnar nerve rank with the most frequent nerve lesions. The most important pathogenetic factors of the compression syndrome of the ulnar nerve at the elbow are explained. From 1969 to 1973 25 patients (28 cases) with Sulcus ulnaris syndrome had been operated at the Surgical University Hospital in Munich. They were evaluated according to age, profession, symptomatology, findings during the operation, and functional results. All patients had ben operated by the same method. The high quotes of satisfactory results and the low operative risk justify — by certain diagnosis — the surgical decompression and antiposition of the ulnar nerve. In our opinion, this method should be preferred conservative treatment.ZusammenfassungAkute und chronische Schädigungen des Nervus ulnaris zählen zu den häufigsten Nervenläsionen. Die wichtigsten pathogenetischen Faktoren des Nervus ulnaris-Kompressionssyndroms am Ellenbogen werden erläutert. In den Jahren 1969 bis 1973 wurden an der Chirurgischen Universitätsklinik in München 25 Patienten (28 Fälle) an einem Sulcus ulnaris-Syndrom operiert. Dieses Krankengut wird nach Alter, Beruf, Symptomatik, intraoperativen Befunden und funktionellen Endergebnissen aufgeschlüsselt. Alle Patienten wurden nach der gleichen Methode operiert. Die guten Erfolgsquoten und das geringe Operationsrisiko rechtfertigen bei gesicherter Diagnose die operative Dekompression des Nervus ulnaris mit Ventralverlagerung. Diese Methode ist nach unserer Meinung konservativen Behandlungsmethoden vorzuziehen.