Karlheinz Kalb

Langzeitergebnisse nach Handgelenkdenervation

BACKGROUND This retrospective study examines long-term follow-up results after complete denervation of the wrist. PATIENTS AND METHODS Between 1994 and 2000 a total of 61 complete wrist denervations of 59 patients (median age at operation 46 years) were performed. In 2009 29 patients with 30 complete wrist denervations took part in a follow-up examination after an average of 10 years. The mobility of the wrist and the grip force were examined. Pain and satisfaction with the operation were determined by means of a visual analogue scale (VAS) (0-100). The patients were asked about pain reduction and how long it lasted. Further the DASH and the Mayo Wrist Score were evaluated. Radiographs of the denervated wrist were performed and the degree of the degenerative osteoarthritis was determined according to Knirk and Jupiter. RESULTS In 7 of the 36 patients examined, a partial or total wrist arthrodesis was performed. These patients were excluded from the study. Pain was improved in 28 of the 30 denervated wrists examined, in 22 the improvement lasted until the follow-up examination, whereas in 6 the pain increased after a median of 90 months. The median pain intensity was 10 at rest and 50 with activity; the satisfaction was 90. The median of the extension/flexion was 81% and the grip force 82% in comparison to the opposite hand. The DASH Score was 25 and the Mayo Wrist Score 73. CONCLUSION Complete denervation of the wrist according to Wilhelm is a treatment option for the chronically painful wrist and can lead to good grip force, mobility, sufficient pain reduction and satisfaction in the long term.

Die Fesselung des Kahnbeins nach Brunelli in der Modifikation nach Garcia-Elias, Lluch und Stanley zur Behandlung der veralteten skapholunären Dissoziation

OBJECTIVE Stabilization of the scaphoid correcting rotary subluxation and replacement of the biomechanically essential dorsal part of the scapholunate ligament for prevention of osteoarthritis. INDICATIONS Scapholunate dissociation without useful remnants of the ligament and reducible malalignment of the scaphoid. CONTRAINDICATIONS Fixed scaphoid malalignment. Osteoarthritis (SLAC [scapholunate advanced collapse] wrist). SURGICAL TECHNIQUE Dorsal approach to the wrist using the flap described by Berger. Correction of rotary subluxation and stabilization of the scaphoid using a distally based strip of flexor carpi radialis tendon, which is created through a separate palmar incision, and fixed to a bone anchor in the lunate through a tunnel from the palmar side of the distal pole of the scaphoid to the origin of the dorsal part of the scapholunate ligament from the scaphoid combined with transfixation of the scaphoid to the capitate and the lunate bone in corrected position using two Kirschner wires (1.6 mm). Additionally, the flexor carpi radialis strip is looped through a split in the dorsal radiotriquetral ligament and fixed to itself. POSTOPERATIVE MANAGEMENT Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires 8 weeks postoperatively, followed by physiotherapy to improve wrist motion. RESULTS 14 out of 17 patients were available for a clinical and radiologic examination after a mean follow-up time of 10.5 months (minimum 6, maximum 15 months). Two of these patients had to undergo another operative procedure in the meantime, one partial and the other total wrist fusion. The remaining twelve patients had a mean DASH Score (Disabilities of the Arm, Shoulder and Hand) of 25 (minimum 0, maximum 59 points) and a mean modified Mayo Wrist Score of 80 points (minimum 60, maximum 97 points). Contrary to the good clinical results, the final radiologic examination demonstrated a tendency toward loss of correction compared to the postoperative X-rays.

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.

Die skapholunäre Bandverletzung

ZusammenfassungVerletzungen des skapholunären Bandes sind die häufigste Ursache für eine karpale Instabilität. Entsprechend gilt: Bleibt eine skapholunäre Bandruptur unerkannt, kann dies für den betroffenen Patienten gravierende Auswirkungen haben. Im vorliegenden Beitrag werden die Anatomie des Bandes sowie die Kinematik der Handwurzel bei intaktem und zerrissenem Band beschrieben. Nach Erläuterung der Diagnostik sowohl der isolierten skapholunären Bandverletzung als auch der Bandverletzung im Rahmen einer distalen Radiusfraktur wird unser aktueller Behandlungsalgorithmus dargestellt, in welchem die verschiedenen Stadien der Verletzung gezielt adressiert werden.AbstractInjuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.Injuries to the scapholunate ligament are the most frequent cause of carpal instability. Therefore, if a scapholunate lesion is not diagnosed, it may result in a severe dysfunction of the wrist. This review describes the anatomy, and the kinematics of the wrist with an intact as well as a disrupted scapholunate ligament. The diagnostic of an isolated ligament lesion and a ligament injury associated with a fracture of the distal radius is presented. Finally, an algorithm for treatment based on the stage of injury is proposed.

Die vollständige Versteifung des Handgelenks mit der AO-Handgelenk-Arthrodesenplatte

ZusammenfassungOperationszielSteigerung der Gebrauchsfähigkeit der Hand vor allem durch Schmerzreduktion und dadurch bedingte verbesserte Kraftentwicklung.IndikationenSchmerzhafte Destruktion des Radiokarpal- und Mediokarpalgelenks mit Kontraindikationen für bewegungserhaltende Eingriffe.Konservative Therapiemöglichkeiten ausgeschöpft und unzureichend.KontraindikationenPatient mit bewegungserhaltender operativer Maßnahme (z.B. Denervierungsoperation nach Wilhelm) oder konservativer Versorgung (Orthese) schmerzfrei und zufrieden.OperationstechnikStreckseitiger Zugang zum Handgelenk. Resektion der pathologisch veränderten Gelenkflächen des Handgelenks, Auffüllung der Defekte mit autogener Spongiosa aus dem Radius (bei größeren Defekten auch aus dem Beckenkamm) und Stabilisierung mit der AO-Handgelenk-Arthrodesenplatte.WeiterbehandlungSofortiger Beginn mit aktiven Bewegungsübungen der Finger. Ruhigstellung in einer Unterarmgipsschiene (Finger frei!) für 2 Wochen. Nach knöcherner Konsolidierung (Röntgenkontrolle 6 Wochen postoperativ) zunehmender Einsatz der operierten Hand, orientiert an der Schmerzgrenze.ErgebnisseVon den ersten Patienten, bei denen die Autoren zwischen 1994 und 1996 eine Versteifung des Handgelenks mit einer AO-Arthrodesenplatte durchführten, konnten 26 (18 Männer, acht Frauen) durchschnittlich 18 Monate (Minimum 6, Maximum 32 Monate) postoperativ nachuntersucht werden. Der modifizierte Mayo-Wrist-Score ergab durchschnittlich 47 Punkte (Minimum 20, Maximum 70 Punkte), der DASH-Score (Disabilities of the Arm, Shoulder and Hand) betrug im Mittel 46 Punkte (Minimum 4, Maximum 81 Punkte). 20 der 26 Patienten waren mit dem Eingriff zufrieden, eine vollständige Schmerzfreiheit wurde jedoch nicht in allen Fällen erreicht.Acht von zehn Patienten (sieben Männer, drei Frauen) mit beidseitiger Handgelenkarthrodese konnten nach einem durchschnittlichen Beobachtungszeitraum von 66 Monaten (Minimum 27, Maximum 74 Monate) nachuntersucht werden. Der DASH-Score betrug im Mittel 55 Punkte (Minimum 38, Maximum 73 Punkte). Im Vergleich zur präoperativen Situation empfanden alle Patienten eine Verbesserung. Sie konnten sich ausnahmslos selbst versorgen, so dass die beidseitige Handgelenkarthrodese als Ultima Ratio durchaus in Erwägung gezogen werden kann.AbstractObjectiveArthrodesis of the wrist in order to improve functional use of the hand by reducing pain and improving grip strength.IndicationsPainful destruction of both the radiocarpal and mediocarpal joint combined with contraindications to motion-preserving procedures.Conservative treatment insufficient.ContraindicationsPatients who are pain-free and satisfied with a motion-preserving procedure (e.g., Wilhelm’s denervation procedure) or conservative management (casting).Surgical TechniqueDorsal approach to the wrist. Removal of destroyed articular surfaces down to cancellous bone, filling the resulting defects with cancellous bone graft taken either from the the radius or the iliac crest. Stable fixation using the AO wrist fusion plate.Postoperative ManagementImmediate active motion exercises of the fingers. Below-elbow cast for 2 weeks. 6 weeks postoperatively, X-ray control to judge bony healing. Normal use of the hand in daily life but avoiding pain-provoking activities.Results26 (18 men, eight women) of the authors’ first patients with arthrodesis of the wrist using the AO fusion plate were reexamined after a mean follow-up time of 18 months (minimum 6, maximum 32 months). The mean modified Mayo Wrist Score was 47 points (minimum 20, maximum 70 points), the DASH Score (Disabilities of the Arm, Shoulder and Hand) averaged 46 points (minimum 4, maximum 81 points). 20 of the 26 patients were satisfied, but not all patients were completely free of pain.Eight out of a total of ten patients (seven men, three women) with a bilateral wrist arthrodesis were reexamined after a mean follow-up time of 66 months (minimum 27, maximum 74 months). The DASH Score was 55 points on average (minimum 38, maximum 73 points). All patients stated that their clinical situation had improved and that they were able to manage their daily activities without help. So it can be concluded that bilateral arthrodesis of the wrist is a valuable option, if all other possibilities are exhausted.

Die Behandlung der veralteten skapholunären Dissoziation mittels eines Knochen-Band-Knochen-Transplantats nach Cuénod

OBJECTIVE Correction of chronic scapholunate dissociation by replacement of the biomechanically most important dorsal part of the scapholunate ligament using a bone-ligament-bone autograft taken from the carpometacarpal joint II and, additionally, a modified dorsal capsulodesis. INDICATIONS Nonfixed chronic scapholunate dissociation without useful remnants of the ligament in which loss of the dorsal part of the scapholunate ligament is the crucial pathophysiological moment. CONTRAINDICATIONS Chronic scapholunate dissociation with fixed deformity. Osteoarthritis. SURGICAL TECHNIQUE Dorsal incision. Approach to the wrist using the capsular flap described by Berger. Reduction of deformity and temporary transfixation of the scaphoid to the capitate as well as to the lunate. Creation of a trough at the ulnar edge of the dorsal aspect of the scaphoid and another trough at the radial edge of the dorsal aspect of the lunate. Fixation of an exactly fitting bone-ligament-bone autograft taken from the trapezoidometacarpal joint II with 1.2-mm screws into the troughs. Fixation of a part of the dorsal intercarpal ligament which is based on the scaphoid to the lunate using a bone anchor. POSTOPERATIVE MANAGEMENT Immobilization using a below-elbow cast including the metacarpophalangeal joint of the thumb for 8 weeks; removal of Kirschner wires 10 weeks postoperatively; after Kirschner wire removal physiotherapy to improve range of motion. RESULTS Twelve out of 16 male patients were available for a clinical and radiologic examination after a mean follow-up time of 6.3 years (minimum 1.6, maximum 7.3 years). Clinical results were excellent. The modified Mayo Wrist Score averaged 87 points (minimum 65, maximum 100 points). Eleven patients had an excellent or good result, none of the patients showed a poor result. The DASH Score (Disability of the Arm, Shoulder and Hand) was 13 points on average (minimum 0, maximum 42 points). All patients would have the same operation again. Radiologically, a stretching of the bone-ligament-bone autograft was found in six cases. A symptomatic SLAC (scapholunate advanced collapse) wrist with the need for a salvage operation could not be observed.

Rekonstruktion nach Kompartmentsyndrom an Unterarm und Hand

Ischemic muscle contracture after a compartment syndrome of the forearm and hand may result in severe loss of function. In addition to the established muscle contracture, a loss of nerve and vessel function can often be found. The clinical appearance depends on the involved muscles respectively compartments. Even though each case requires individual analysis of the clinical situation, the combination of Tsuges classification with Holdens classification provides a more or less systematic approach to treatment that can be adapted to each case according to the severity of the contracture of the joints and muscles, the degree of nerve and vessel damage, the function of the remaining muscles and nerves, and the availability of other functioning muscles for reconstruction.ZusammenfassungKommt es im Rahmen eines Kompartmentsyndroms des Unterarms und der Hand zu einer ischämischen Muskelnekrose resultieren mitunter schwerste funktionelle Defizite. Neben Kontrakturen infolge der Erstarrung der Muskelnekrose bzw. Narbenbildung prägen sensible und motorische Lähmungen das klinische Bild. Abhängig davon welche Muskeln bzw. Muskelgruppen wie schwer betroffen sind, ergeben sich sehr unterschiedliche Erscheinungsformen. Es ist in jedem Fall individuell zu planen, welches der zahlreichen zur Verfügung stehenden Therapieverfahren zur Anwendung kommen soll/kann. Hierbei erlaubt die Kombination der Klassifikationen nach Tsuge und nach Holden einen systematischen Zugang zur Therapie. Die Schwere der Muskel- und Gelenkkontrakturen sowie der Gefäß-Nerven-Schäden ist dabei ebenso zu berücksichtigen wie noch vorhandene Muskel- und Nervenfunktionen und die Verfügbarkeit intakter Muskeln für eine mögliche motorische Ersatzoperation.AbstractIschemic muscle contracture after a compartment syndrome of the forearm and hand may result in severe loss of function. In addition to the established muscle contracture, a loss of nerve and vessel function can often be found. The clinical appearance depends on the involved muscles respectively compartments. Even though each case requires individual analysis of the clinical situation, the combination of Tsuge’s classification with Holden’s classification provides a more or less systematic approach to treatment that can be adapted to each case according to the severity of the contracture of the joints and muscles, the degree of nerve and vessel damage, the function of the remaining muscles and nerves, and the availability of other functioning muscles for reconstruction.

Radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease

We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4–17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0–52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients. Level of evidence: Therapeutic IV

Skaphoidfraktur und -pseudarthrose@@@Scaphoid fracture and nonunion: Eine aktuelle Standortbestimmung der radiologischen Diagnostik@@@Current status of radiological diagnostics

ZusammenfassungSkaphoidfrakturen, die ca. 2/3 aller Verletzungen am Handgelenk ausmachen, entziehen sich häufig dem Nachweis in der radiologischen Erstdiagnostik. Mit der hochaufgelösten CT und der dezidiert durchgeführten MRT stehen mittlerweile Werkzeuge zur Verfügung, die die Detektion der Skaphoidfraktur bereits am Unfalltag ermöglichen und eine Abschätzung der Fragmentstabilität erlauben. Dabei kann die CT therapierelevante Informationen sowohl zum Frakturausmaß als auch zur Therapiekontrolle liefern. Die MRT weist Skaphoidfrakturen am sensitivsten nach, jedoch müssen diese sicher gegenüber einem „bone bruise“ abgegrenzt werden. Bei primär übersehener Fraktur oder nicht erfolgter Konsolidierung kann sich nachfolgend eine Skaphoidpseudarthrose stadienhaft entwickeln. Die CT gibt wichtige Detailinformationen zur knöchernen Morphologie des Kahnbeins, die kontrastmittelverstärkte MRT zur Vitalitätsbeurteilung des proximalen Skaphoidfragments.AbstractScaphoid fractures, which involve approximately two-thirds of all wrist injuries, are often not detected during initial radiographic examination. By using high-resolution CT and dedicated MRI, it is possible to recognize scaphoid fractures soon at the first diagnostic approach and to assess fragment stability. CT imaging provides all the relevant information of the fracture extent and of the fracture healing in the follow-up. MRI is most sensitive in the detection of scaphoid fractures; however, fracture signs must be differentiated from those of a bone bruise. Both the initially overseen scaphoid fracture and the unsuccessful healing can lead to the natural history of scaphoid nonunion. In the injured scaphoid, CT imaging is essential for depicting the osseous morphology, whereas contrast-enhanced MRI is crucial for assessing the viability of the proximal fragment.

Advanced Imaging of Kienböck’s Disease

In the past, Kienbock’s disease (lunatomalacia, osteonecrosis, or aseptic necrosis of the lunate) was diagnosed exclusively by plain radiography. New capabilities of computed tomography (CT) and magnetic resonance imaging (MRI) have improved image quality due to both spatial resolution and contrast resolution with the use of gadolinium in MRI. At the same time, knowledge in pathology (altered biomechanical load of the wrist, disturbed bone metabolism, and reparative mechanisms of the osteonecrotic bone) has increased. Consequently, early diagnosis and classification of Kienbock’s disease are now significantly influenced by the use of CT and MR imaging. High-resolution CT is used for evaluating the osseous microstructure of the lunate, whereas contrast-enhanced MRI is perfectly suited for assessing the viability of the bone marrow. When synoptically considering the pathoanatomic processes and high-resolution imaging, the Kienbock’s disease process can be visualized in all its stages, beginning with its precursors and initial reaction of the lunate, proceeding with osteosclerotic and collapsing changes and finally terminating in perilunate osteoarthritis. CT and MR imaging also allows the clinician to consider the differential diagnosis, the lunate viability and secondary changes following surgery. Advanced imaging methods should focus on early stages with respect to best treatment options. In this chapter, the imaging capabilities of CT and MRI in Kienbock’s disease are summarized and correlated with the underlying pathology.