M. Sauerbier

MIDCARPAL ARTHRODESIS WITH COMPLETE SCAPHOID EXCISION AND INTERPOSITION BONE GRAFT IN THE TREATMENT OF ADVANCED CARPAL COLLAPSE (SNAC/SLAC WRIST): OPERATIVE TECHNIQUE AND OUTCOME ASSESSMENT

Thirty-six patients with stage II or III SNAC and SLAC wrists were treated by midcarpal arthrodesis and complete scaphoid excision. When assessed at a mean follow-up of 25 months, pain was significantly reduced both under resting and stress conditions. The active range of motion was 54% of the contralateral wrist and grip strength was 65% of the non-operated hand. The mean DASH score was 28 points, the Mayo wrist score was 63 points, and the Krimmer wrist score was 68. Correlation of the wrist scores with the DASH values demonstrated a significant correlation. Our data demonstrate that midcarpal fusion with complete excision of the scaphoid is a reliable procedure for treating advanced carpal collapse.

Scapholunate Ligament Repair Using the Mitek™ Bone Anchor Technique and Preliminary Results

A retrospective study was done to assess the outcome after repair of completely ruptured scapholunate interosseous ligaments using the Mitek™ Mini G2 bone anchor. From 1994 to 1996. 12 patients underwent scapholunate ligament repair using the bone anchor. A follow-up assessment was done at a mean of 19 months postoperatively and revealed excellent or good results in eight patients, satisfactory in two, and poor in two patients, one of whom had developed lunate necrosis. One patient with an excellent functional result demonstrated recurrent dissociation of the scapholunate gap radiographically. The technique described proved to be simpler than conventional procedures in our hands, and yields similar functional results.

Subjective and objective outcomes after total wrist arthrodesis in patients with radiocarpal arthrosis or Kienböck's disease.

Sixty patients underwent total wrist arthrodesis for post-traumatic arthrosis, or Kienböcks disease. All of them could be included in the study with complete data. The average follow-up time was 37 months. Forty-nine patients were males, 11 were females; the average age was 48 years. Outcomes were assessed by several methods. Grip strength was measured using the DEXTER-Computer-System and was reduced by 50% compared to the contralateral side. Pain was evaluated pre- and postoperatively with a visual analogue scale from 0 to 100 and was reduced to 55% of the preoperative values. Patients activities of daily living (ADLs) and general postoperative quality of life were estimated with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. For functional evaluation additionally the Mayo and Krimmer wrist scores were used. The overall DASH score was 51.4, the wrist scores reached 46.4 and 50.5, respectively. Both scores correlated significantly with the DASH. It can be concluded from our data that pain relief was sufficient in the most patients, although complete pain relief was rare. Although 80% of the patients complained about reduction of postoperative quality of life with impaired personal hygiene and functional deficits, the majority (80%) would undergo the procedure again. Seventy percent of the patients returned to their original occupation. Compared to other measures commonly used to assess outcomes after wrist arthrodesis, the DASH questionnaire proved to be a very useful tool for the evaluation of subjective outcomes in upper extremity disorders as well.

Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist)

Summary:Outcome evaluation of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist). Purpose:Scaphoid nonunion or scapholunate ligament instability results in carpal collapse and subsequent arthrosis. These conditions, termed SLAC-wrist and SNAC-wrist, are the most common patterns of arthrosis in the wrist. The purpose of this retrospective study was the evaluation of functional outcomes following midcarpal arthrodesis and of patients’ satisfaction with these outcomes. Methods:Forty-nine patients were reexamined at a mean follow-up time of 47 months. Active range of motion (AROM) was verified with a goniometer; grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0–100) for stress and under resting conditions. Patients’ upper-extremity functioning was captured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Radiographic evaluation of bony consolidation was verified by conventional x-ray. Results:Postoperative AROM was 56% and grip strength was 76% compared with the contralateral side. The DASH score was 29 points. Pain relief was 34% at rest and 31% after stress. Forty-five patients demonstrated bony consolidation in x-ray control. Six patients (12%) further required a total arthrodesis of the wrist because of pain or absence of bony consolidation. Conclusion:Our data demonstrate that midcarpal arthrodesis is a reliable procedure for treating SLAC- and SNAC-wrists in stages II and III and, furthermore, one which preserves some range of motion. Total wrist fusion should only be used in exceptional circumstances.

Die Deckung von Weichteildefekten und instabilen Narben über der Achillessehne durch freie mikrochirurgische Lappenplastiken

Zusammenfassung.Einleitung: Zur adäquaten Deckung von Weichteildefekten und chronisch instabilen Narben mit exponierter Achillessehne ist die Übertragung von dünnem, geschmeidigem Gewebe erforderlich. Erstrebenswert ist das möglichst optimale Wiederherstellen der ursprünglichen Kontur und Funktion der distalen Unterschenkelregion. Die Deckung verschiedenartiger Defekte sollte die Größe des Areals berücksichtigen und kann sowohl durch lokale, als durch freie Lappenplastiken erfolgen. Methoden: Von Juli 1993 bis September 1998 wurde bei 14 Patienten (3 Frauen, 11 Männer) im Alter zwischen 15 und 74 Jahren (Durchschnittsalter 47 Jahre) eine Weichteildefektdeckung im Bereich der Achillessehne durch eine freie, mikrochirurgische Lappenplastik durchgeführt. Der durchschnittliche Nachuntersuchungszeitpunkt betrug 33,3 Monate. Die Größe des zu verschließenden Defekts variierte zwischen 8 × 8 – 25 × 28 cm. Ergebnisse: Es wurden 6 Paraskapularlappen (davon 3 mit Scapulafascien-Extension), 4 Radialislappen, sowie 4 M. latissimus dorsi Lappen (davon ein Lappen kombiniert mit Serratusfaszie) zur Defektdeckung verwendet. Die Spendermorbidität im Rückenbereich war für den Großteil der Patienten akzeptabel, im Unterarmbereich befriedigend. Die postoperative Beweglichkeit im oberen Sprunggelenk betrug im Mittel 15-0-40 ° (Extension-Flexion). Alle Patienten waren mit dem Operationsresultat hinsichtlich Funktion und Ästhetik im Vergleich zur Situation vor der Operation zufrieden. Schlußfolgerung: Weichteildeckungen über der exponierten Achillessehne erfordern die Berücksichtigung funktioneller und ästhetischer Gesichtspunkte. Zum Erhalt der Sehnengleitfähigkeit, dem Verstärken der Sehne selbst und zur Konturierung des Unterschenkeldefekts haben sich im Falle größerer Defekte freie Lappenplastiken bewährt. Die Komplikationsrate freier Lappenplastiken ist am distalen Unterschenkel mit der von lokalen Lappenplastiken vergleichbar.Abstract.Introduction: Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessary for coverage of large defects. Methods: From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 11 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up was 33.3 months. The defect size ranged from 8 × 8 to 25 × 28 cm. Results: Six parascapular flaps (three with a vascularized scapular fascial extension), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achilles tendon. Thirteen flaps survived. In one case a parascapular flap had to be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptable for most patients after flap harvesting in the subscapular region and also satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 ° for extension/flexion. All patients were satisfied with the functional and aesthetic result. Conclusion: Soft tissue coverage over the exposed Achilles tendon requires an optimal solution for each patient to achieve an aesthetically pleasing result and acceptable function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The complication rate of microvascular flaps is comparable with that of local flaps.

Restoration of thumb sensibility with the innervated first dorsal metacarpal artery island flap

PURPOSE This study investigated the quality of sensibility from innervated first dorsal metacarpal artery (FDMCA) island flaps in younger and older patients and evaluated the donor site morbidity at the index finger. METHODS Twenty-five patients with an innervated FDMCA island flap to restore sensibility of the thumb were divided into groups according to age (>50 or <50 years). Sensory recovery and cortical reorientation were tested with Semmes-Weinstein monofilaments, a calibrated 2-point discrimination tester, and needle prick testing. Donor site morbidity was evaluated for range of motion, aesthetic appearance, pain, and problems with injuries. RESULTS The mean age of the patients was 48.3 years and the mean follow-up period was 3 years. The 14 patients older than 50 years had a static 2-point discrimination (s2-PD) of 10.9 mm compared with 10.8 mm of the 11 patients younger than 50 years. The average loss of s2-PD of the flap compared with the donor area averaged 2.7 mm in all patients. Complete cortical reorientation occurred in 7 patients older than 50 years and in 5 patients younger than 50 years. Total loss of range of motion of all donor finger joints was 14 degrees (4.4%) compared with the contralateral index finger. Twenty-two patients were satisfied with the result. CONCLUSIONS There were no age-related differences in the surgical results of the innervated FDMCA island flap and the donor site morbidity was negligible.

Funktionelle Ergebnisse nach Handgelenksdenervation

GOAL The goal of this retrospective study was to examine the functional results after complete and partial denervation of the wrist, the time of postoperative pain reduction and the overall satisfaction of the patient related to the extend of denervation and preoperative diagnosis. PATIENTS AND METHODS 43 out of 70 patients with chronic wrist pain who underwent complete or partial wrist denervation from 1993 to 2000 were included in this study. The mean follow-up time was 51 (18-97) months. Prior to denervation a test denervation was performed with the injection of local anesthetics. In order to better differentiate between the overall treatment outcomes we categorized patients in three different groups based on their diagnosis. Group I consisted of 11 patients with radiocarpal arthrosis and carpal instability after SLAC- and SNAC-wrist. In group II 19 patients had radiocarpal arthrosis without carpal instability. Group III consisted of 13 patients without arthrotic changes in the wrist. Apart from the diagnosis we categorized the patients in a group A (29 patients) with complete denervation of the wrist and a group B (14 patients) with only partial denervation of the wrist. Pain reduction was assessed using the visual analog scale. Furthermore we evaluated wrist movement, grip strength, DASH-score, time of disability and the overall patient satisfaction with the procedure. The results were measured by using the Mayo-wrist- and Krimmer-wrist-score. Results of the preoperative test denervation were compared to the postoperative results. Statistical examination was performed between the different groups and comparing pre- to postoperative findings. RESULTS 10 out of 26 patient, whos test denervation results were evaluated, reported good, 10 patients satisfactory and 6 modest pain reduction after test denervation. Only 13 (65%) of the 20 patients with good/satisfactory pain reduction after test denervation benefited from the operation. After the denervation pain was reduced in 30 patients (70%). Ten of these patients (33%) reported an increase of pain after 22 month on average. 20 patients (66%) were pain free at the time of reexamination. 22 patients (76%) in group A and 8 patients (57%) in group B reported postoperative pain reduction. 7 patients (64%) in group I, 12 patients (63%) in group II and 11 patients (85%) in group III reported postoperative pain reduction. Only in group III pain was statistically significantly decreased. Active range of motion for extension/flexion decreased in all groups postoperatively. Grip strength increased in all groups through the operation without statistical significance. The average DASH score of patients in group I was 37.8, in group II 45.5 and in group III 27.1. 6 patients (55%) in group I, 10 patients (53%) in group II and 10 patients (77%) in group III reported to be satisfied with the denervation. CONCLUSION A positive test denervation is not a warranty for postoperative pain reduction after denervation of the wrist. Patients without arthrotic changes of the wrist benefit more from denervation than patients with arthrotic changes. Since the majority of patients with arthrotic changes still profited from a denervation we think of the operation as a valid alternative, since it leaves the possibility open for other, more difficult treatment options such as partial or total wrist fusion.

Treatment of Scaphoid Non-Unions of the Proximal third with Conventional Bone Grafting and Mini-Herbert Screws: an Analysis of Clinical and Radiological Results:

This study assessed the clinical and radiological outcomes after treatment of scaphoid non-union of the proximal third by non-vascularised bone grafts and stabilisation by Mini-Herbert Screws from a dorsal approach. Thirty-one patients, one woman and 30 men, were reviewed retrospectively at a mean of 42 (12–77) months. All patients received pre- and postoperative CT scans to assess bone union. In addition to demographic data, the range of motion, grip strength, DASH score, Krimmer score, Mayo wrist score and radiological parameters (carpal height, scapholunate and radiolunate angles) were recorded. Bone union was achieved in 21 patients. The average DASH score in patients with bone union was 12 and that in patients with persistent non-union it was 30. No progression into carpal collapse or increase of scapholunate angles was detected. Our study demonstrates that acceptable union rates can be achieved with non-vascularised bone grafts, and this technique compares favourably with other reports in the literature.

Der distal gestielte Suralislappen zur Defektdeckung posttraumatischer und chronischer Hautweichteilläsionen am „kritischen“ Unterschenkel

Summary. Vascular diseases and/or sequelae of various systemic diseases are frequently associated with therapy-resistant soft tissue lesions in the lower extremity. Neurovascular pedicled island flaps without the need for the sacrifice of major vessels offer the possibility to save the lower limb from amputation. The long pedicle allows for a wide, tension-free arc of rotation. Major studies of clinical applications at the critical lower extremity have not been reported yet. 14 patients with chronical ulcerations in problematic areas (e. g. ankle, tibia) underwent definitive reconstruction using this flap. Complications were mostly observed at the donor site. In one patient major amputation was neccessary due to the development of sepsis. In all other cases adequate coverage and limb salvage was achieved. Excellent padding, variable size and the modest nature of the flap enlarges the variety of plastic-reconstructive procedures in the lower extremity.Zusammenfassung. Angiopathien und/oder die Manifestation von Spätsyndromen diverser Systemerkrankungen sind oft Ursachen therapieresistenter Hautweichteildefekte an der unteren Extremität. Neurovasculär gestielte Insellappen ohne die Notwendigkeit des Einschlusses großkalibriger Gefäße können durch einen adäquaten Hautweichteilersatz auch amputationsgefährdete Extremitäten retten. Der distal gestielte Suralislappen kann aufgrund seines großen Aktionradius speziell an Problemzonen (Knöchel, Tibiakante etc.) eingesetzt werden. Größere Studien über die Anwendungsmöglichkeiten an der gefährdeten, kritischen unteren Extremität sind bisher nicht publiziert, so daß der Einsatz dieser Lappenplastik an einem Kollektiv von 14 Patienten überprüft wurde. Komplikationen wurden vor allem im Bereich der Hebestelle gesehen, in einem Fall mußte der Unterschenkel als Ultima ratio bei Sepsis amputiert werden. In allen anderen Fällen konnte die Extremität durch den distal gestielten Suralislappen adäquat versorgt bzw. erhalten werden. Die gute Weichteilpolsterung, die variable Größe sowie die Genügsamkeit des Lappen erweitern die Palette plastisch-rekonstruktiver Verfahren an der „kritischen“ unteren Extremität.

The Reconstruction of the Mutilated Hand

The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.