Markus Gabl

A Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older

BACKGROUND Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting). METHODS A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance. RESULTS There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05). CONCLUSIONS At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.

Vascularized Bone Graft from the Iliac Crest for the Treatment of Nonunion of the Proximal Part of the Scaphoid with an Avascular Fragment

BACKGROUND It was hypothesized that nonunion of the proximal third of the scaphoid associated with avascular necrosis could be treated successfully with a free vascularized bone graft obtained from the iliac crest. METHODS Fifteen patients who had a nonunion of the proximal part of the scaphoid that had been present for an average of two years and three months (range, nine months to seven years) were managed with use of a free vascularized bone graft obtained from the iliac crest. Avascularity of the scaphoid, as assessed on preoperative radiographs, was characterized by loss of trabecular structure, collapse of subchondral bone, and formation of bone cysts. The results of the procedure were assessed in terms of osseous union, pain, active motion of the wrist, and osteoarthritis. Postoperatively, vascularity of the scaphoid was evaluated with use of magnetic resonance imaging and color Doppler ultrasonography. The average duration of follow-up was six years and one month (range, two years and one month to eight years and one month). RESULTS Preoperatively, one patient had had pain with any movement of the wrist and fourteen had had pain after strenuous manual labor or sports activity. The average pain score, derived with use of a 10-point visual analog scale, was 2.4 points (range, 1.0 to 6.7 points). Postoperatively, union was achieved in twelve patients; six were pain-free, and six had occasional pain during strenuous manual labor or sports activity, or both. The average pain score for these twelve patients was 1.1 points (range, 0.0 to 4.2 points) on the visual analog scale. Preoperatively, osteoarthritis was limited to the region between the radial styloid process and the distal part of the scaphoid in fourteen patients and to the radioscaphoid region in one patient. Postoperatively, the degree of osteoarthritis remained unchanged in seven of the twelve patients who had union and progressed to the radioscaphoid region in five. Vascularity, as seen on the imaging studies, was restored in all twelve patients who had union. The nonunion persisted in three patients, all of whom had progressive osteoarthritis leading to carpal collapse. CONCLUSIONS The index procedure was successful in twelve of the fifteen patients who had a symptomatic nonunion of the proximal part of the scaphoid associated with avascular necrosis and osteoarthritis that was limited to the radioscaphoid joint.

First forearm transplantation : Outcome at 3 years

We here report on the surgical procedure, postoperative course and functional results at 3 years following the first bilateral forearm transplantation. A 41‐year‐old male underwent bilateral forearm transplantation on February 17, 2003. After ATG induction therapy, tacrolimus, prednisone and MMF were given for maintenance immunosuppression. At 16 months, MMF was switched to everolimus. Hand function, histology, immunohistochemistry, radiomorphology, motor and nerve conduction and somatosensory‐evoked potentials were investigated at frequent intervals. A total of six rejection episodes required treatment with either steroids, basiliximab, ATG, alemtuzumab or tacrolimus dose augmentation. At 3 years, the patient is free of clinical signs of rejection despite a persisting minimal perivascular lymphocytic dermal infiltrate. No signs of myointimal proliferation in graft vessels were seen. Motor function continuously improved, resulting in satisfactory hand function. Intrinsic hand muscle function was first observed at 16 months and continues to improve. Although discrimination of hot and cold recovered, overall sensitivity remains poor. The patient is satisfied with the outcome. Bilateral forearm transplantation represents a novel therapeutic option after loss of forearms.

Status 5 Years after Bilateral Hand Transplantation

Graft survival and function early after hand transplantation is good. It remains unknown, however, whether long‐term survival is limited by chronic rejection. We here describe the clinical course and the status 5 years after bilateral hand transplantation with emphasis on immunosuppression (IS), function, morphology and graft vascular changes.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases.

Carpal instability may result in progressive degenerative arthritis of the wrist. The surgical goal of the reconstruction of scaphoid nonunion is to achieve bone union and to restore the scaphoid. Many procedures are described to treat scaphoid nonunion for different indications. This retrospective study reports on the anatomical fundamentals, the operative procedure, and the results of 60 patients (21 with recalcitrant scaphoid nonunion that lasted longer than 4 years, 26 with an avascular pole fragment, and 13 with scaphoid nonunion after previous surgery) who were treated by a small free vascularized iliac crest bone graft. All 60 patients have routinely been followed up clinically and with magnetic resonance imaging. Union was achieved in 91.7 percent by improvement of stability and the compromised vascularity of the scaphoid. The bone flap loss rate and persisting nonunion was 8.3 percent, leading to progressive arthritis and carpal collapse. Complaints concerning discomforts caused by the scar were heard from 40.1 percent of the patients, and 31.7 percent complained of discomforts caused by the bony deformity. Bone deformations on the donor site were detected radiologically in 63.3 percent of the patients. In 31.7 percent, an impairment of the lateral femoral cutaneous nerve was noted. Reconstruction of the scaphoid by means of implantation of a vascularized iliac bone graft proved efficient to treat avascular recalcitrant scaphoid nonunion and pseudarthrosis with avascular proximal pole fragments. (Plast. Reconstr. Surg. 108: 664, 2001.)

Disruption of the Finger Flexor Pulley System in Elite Rock Climbers

We treated 13 elite rock climbers for isolated disruptions of the pulleys of the long fingers. Diagnosis and treatment were based on the clinical finding of bowstringing, which was confirmed by magnetic resonance imaging. Eight patients had bowstringing indicating incomplete disruption of the major pulley A2 and were treated nonoperatively (group A). Five patients showed bowstringing indicating complete disruption of the pulley A2. After failed nonoperative treatment, the pulleys were reconstructed (group B). The mechanism of injury and clinical and subjective results were evaluated. At a 31-month follow-up (range, 18 to 43 months), loss of extension in the proximal interphalangeal joint measured 5.6° (range, 0° to 10°) in group A and 4° (range, 0° to 10°) in group B. Circumference of the finger section was increased 4.2 mm in group A (range, 0 to 10 mm) and 4.8 mm in group B (range, 0 to 10 mm). Grip strength decreased 20 N in group A (range, 10 to 50 N) and 12 N in group B (range, 10 to 30 N). Four patients in group A and one in group B had bowstringing at clinical evaluation. On follow-up magnetic resonance images, bowstringing remained unchanged in group A but was reduced in all patients in group B. Good subjective results were seen in both groups.

Carpal Tunnel Syndrome: Diagnosis by Means of Median Nerve Elasticity—Improved Diagnostic Accuracy of US with Sonoelastography

PURPOSE To compare the elasticity of the median nerve (MN) between healthy volunteers and patients with carpal tunnel syndrome (CTS) and to evaluate the diagnostic utility of sonoelastographic measurements of the elasticity of the MN. MATERIALS AND METHODS This study was performed with institutional review board approval and written informed consent from all participants. Hands in 22 healthy volunteers and in 31 patients with symptomatic CTS were studied. The cross-sectional area (CSA) and the elasticity of the MN, which was measured as the acoustic coupler (AC)/MN strain ratio, were evaluated. RESULTS Both hands in 22 healthy volunteers (three men [mean age, 52.7 years; age range, 41-65 years]; 19 women [mean age, 62.2 years; age range, 40-88 years]) and 43 hands in 31 patients with symptomatic CTS (three men [mean age, 69.0 years; age range, 46-88 years]; 28 women [mean age, 61.2 years; age range, 39-92 years]) were studied. Both the AC/MN strain ratio and the CSA in the patients with CTS were significantly higher than those in the healthy volunteers (P < .001). The presence of CTS was predicted by means of AC/MN strain ratio and CSA cutoff values, respectively, of 4.3 and 11 mm(2), with areas under the receiver operating characteristic curves (AUCs) of 0.78 (95% confidence interval [CI]: 0.69, 0.88) and 0.85 (95% CI: 0.78, 0.93). A logistic model that combined the AC/MN strain ratio and the CSA improved diagnostic accuracy for CTS, with an AUC of 0.91 (95% CI: 0.85, 0.97; P < .001). CONCLUSION Sonoelastography provides significant improvement in the diagnostic accuracy of the ultrasonographic assessment of CTS.

World Experience After More Than a Decade of Clinical Hand Transplantation: Update on the Innsbruck Program

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

Bifid Median Nerve in Carpal Tunnel Syndrome: Assessment with US Cross-sectional Area Measurement

PURPOSE To evaluate the accuracy of ultrasonography (US) in the diagnosis of carpal tunnel syndrome (CTS) in patients with a bifid median nerve on the basis of cross-sectional area (CSA) measurements of the median nerve at the level of the carpal tunnel (CSAc), with additional measurements obtained more proximally (CSAp) at the level of the pronator quadratus muscle. MATERIALS AND METHODS This HIPAA-compliant study was approved by the local institutional review board; informed oral and written consent were obtained. Fifty-three wrists in 49 consecutive patients with a bifid median nerve and CTS symptoms and 28 wrists in 27 healthy volunteers with a bifid median nerve were examined by using US. Two independent US examiners who were blinded to prior test results measured median nerve CSA at two levels, CSAc and CSAp. The difference between CSAc and CSAp (ΔCSA) was calculated for each wrist. Receiver operating characteristic (ROC) analysis was performed. RESULTS The study population included 17 men and 32 women (mean age, 55.1 years; age range, 24-78 years). The control population included 13 men and 14 women (mean age, 52.6 years; age range, 24-86 years). Mean CSAc was approximately 5 mm(2) greater in patients with CTS than in healthy volunteers (P < .0001), while mean ΔCSA was 5.8-5.9 mm(2) greater in patients with CTS (P < .0001). A CSAc threshold of 12 mm(2) provided sensitivity and specificity of 84.9% and 46.5%, respectively, while a ΔCSA threshold of 4 mm(2) provided sensitivity and specificity of 92.5% and 94.6%, respectively. ROC analysis demonstrated a significant advantage of ΔCSA (area under ROC curve [A(z)] = 0.95-0.96) compared with CSAc (A(z) = 0.84-0.85) for the diagnosis of CTS (P < .003). CONCLUSION The use of a ΔCSA parameter improves the diagnostic accuracy of US for the presence of CTS in patients with a bifid median nerve.