R. Fuhrmann

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.

Die Tibialis posterior-Transposition zur Wiederherstellung einer aktiven Fußhebung

After lesions of the peroneal nerve or damage of the tibialis anterior muscle a lack of active dorsiflexion leads to a drop foot deformity. Ober (1933) described a transfer of the posterior tibialis tendon to the dorsum of the foot to restore active extension of the foot. The aim of this retrospective study was to evaluate the results of this method and to compare our results with those in the literature.Between 1992 and 2004 we performed a posterior tibialis tendon transfer in 16 patients with an average age of 40 years. 10 patients suffered from complete peroneal nerve palsy, which was due to a traumatic lesion (n=8) or iatrogenic damage (n=2). 3 patients had an incomplete peroneal nerve palsy caused by iatrogenic lesion (n=2) and lumbar disc herniation (n=1). 3 patients demonstrated a malfunction of the anterior tibial muscle following a compartment syndrome. 14 patients were available for a clinical follow-up after an average of 64 months. Clinical assessment included the hindfoot, muscular strength, pain, limitation of function and subjective satisfaction. The clinical result was evaluated using the Stanmore score (0-100).8 patients were very satisfied and 2 were satisfied with their results, 4 patients were not satisfied. 11 patients had no pain. The active dorsal ankle extension averaged - 5.7° (10 to - 30°). The Stanmore score revealed an average of 62 points with an excellent result in 2, a good result in 5, a fair result in 2 and a poor result in 5 patients.Transfer of the posterior tibial muscle to restore active dorsiflexion of the foot is a therapeutic option. As it is known from the literature objective results were mostly fair, but there was a high degree of satisfaction among the patients.

Die Bandersatzplastik bei lunotriquetraler Instabilität mit einem distal gestielten Streifen der Extensor-carpi-ulnaris-Sehne

OBJECTIVE Stabilization of the lunotriquetral junction. INDICATIONS Dynamic and static chronic instability without fixed dislocation of the carpals. CONTRAINDICATIONS Chronically fixed dislocation of the carpals, ulnar impaction syndrome, osteoarthritis of the joint between hamate and triquetrum and other parts of the wrist joint, rheumatoid arthritis, chondrocalcinosis. SURGICAL TECHNIQUE Restoration of the palmar portion of the lunotriquetral ligament using a distally based strip of the extensor carpi ulnaris tendon with temporary fixation of the lunotriquetral junction with K-wires. POSTOPERATIVE MANAGEMENT Immobilization for 8 weeks with a radial cast that includes the first metacarpophalangeal joint. Removal of the K-wires after 8 weeks and exercise. RESULTS The procedure with rare complications reliably restores stability of the lunotriquetral junction. Reduction of grip strength, pain during exercise, and a reduced range of motion persist. Overall, the results are predominantly good and excellent.

Die Bandersatzplastik bei lunotriquetraler Instabilität mit einem distal gestielten Streifen der Extensor-carpi-ulnaris-Sehne@@@Ligament reconstruction for lunotriquetral instability using a distally based strip of the extensor carpi ulnaris tendon

OBJECTIVE Stabilization of the lunotriquetral junction. INDICATIONS Dynamic and static chronic instability without fixed dislocation of the carpals. CONTRAINDICATIONS Chronically fixed dislocation of the carpals, ulnar impaction syndrome, osteoarthritis of the joint between hamate and triquetrum and other parts of the wrist joint, rheumatoid arthritis, chondrocalcinosis. SURGICAL TECHNIQUE Restoration of the palmar portion of the lunotriquetral ligament using a distally based strip of the extensor carpi ulnaris tendon with temporary fixation of the lunotriquetral junction with K-wires. POSTOPERATIVE MANAGEMENT Immobilization for 8 weeks with a radial cast that includes the first metacarpophalangeal joint. Removal of the K-wires after 8 weeks and exercise. RESULTS The procedure with rare complications reliably restores stability of the lunotriquetral junction. Reduction of grip strength, pain during exercise, and a reduced range of motion persist. Overall, the results are predominantly good and excellent.

Die Arthroskopie des distalen Radioulnargelenks@@@Arthroscopy of the distal radioulnar joint

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.

Degenerative Erkrankungen des 1. Zehenstrahls

Die Spreizfusdeformitat ist gekennzeichnet durch das facherformige Auseinanderweichen der randstandigen Mittelfusstrahlen. Hieraus resultiert eine Vorfusverbreiterung, die mit Zehendeformitaten, insbesondere einer Hallux-valgus-Fehlstellung, ggf. auch einer Hallux-valgus interphalangeus-Fehlstellung, einhergehen kann. Die krankhafte Storung der knochernen Konfiguration und die Achsenabweichung der Groszehe bedingen wiederum eine regional veranderte Belastung des Vorfuses, die zur Entwicklung einer Transfermetatarsalgie oder Kleinzehendeformitaten fuhren kann. Prinzipiell kommen zur Behandlung der Hallux-valgus-Fehlstellung konservative oder operative Therapiemasnahmen infrage. Die Abwagung zwischen beiden Behandlungsalternativen muss anhand patientenspezifischer Voraussetzungen (Begleiterkrankungen, Anforderungsprofil usw.) erfolgen. Dabei ist zu berucksichtigen, dass die konservativen Behandlungsmasnahmen ausschlieslich symptomorientiert sind. Durch eine operative Therapie kann hingegen die Wiederherstellung der physiologischen Vorfuskonfiguration mit orthograder Ausrichtung der Groszehe erreicht werden. Degenerative Erkrankungen im Groszehengrundgelenk (Hallux rigidus) und im Groszehenendgelenk fuhren zu einer schmerzhaft eingeschrankten Abrollfunktion des Fuses. Die Gelenkdegeneration kann mit einer begleitenden Zehenfehlstellung (z. B. Hallux valgus oder Hallux malleus) einhergehen. Zur Behandlung stehen sowohl konservative Behandlungsmasnahmen als auch stadienorientierte operative Therapiekonzepte zur Verfugung. Die Entscheidung, welches Therapieverfahren im Einzelfall indiziert ist, orientiert sich an klinischen und rontgenologischen Befunden sowie den funktionellen Anforderungen an den Fus. Das Behandlungsziel bei Hallux rigidus und der Arthrose im Interphalangealgelenk der Groszehe besteht unabhangig vom gewahlten Therapiekonzept darin, dem Betroffenen ein weitgehend schmerzfreies Abrollen des Vorfuses zu ermoglichen. Degenerative Erkrankungen im tarsometatarsalen Ubergang (Arthrose des Metatarso-Cuneiforme-Gelenks) sind vergleichsweise selten und konnen sowohl bei physiologischer Mittelfuskonfiguration als auch bei einer Spreizfusdeformitat auftreten. Die hieraus resultierenden belastungsabhangigen Beschwerden lassen sich durch eine Schuhzurichtung oder eine operative Masnahme (Versteifung des Gelenks) behandeln. Postoperativ ist nach allen Eingriffen am 1. Strahl eine fruhfunktionelle Nachbehandlung mit sofortiger Belastung des Fuses anzustreben. Weiterhin sind uber mehrere Wochen befundangemessene Masnahmen (redressierende Verbande, Physiotherapie) erforderlich, um den Rehabilitationsprozess zu beschleunigen und das intraoperativ erreichte Korrekturergebnis langfristig zu stabilisieren. Bei den nachfolgend skizzierten Operationstechniken handelt es sich zum Teil um komplexe und technisch anspruchsvolle Eingriffe. Weichteilschwellungen, Bewegungseinschrankungen und eine mehrwochige Rehabilitation sind regelhaft vorhanden und mussen dem betreffenden Patienten praoperativ in verstandlicher Art und Weise erlautert werden, um unrealistischen Erwartungen an das Operationsergebnis vorzubeugen.