Theodora Manoli

Evaluation of sensory recovery after reconstruction of digital nerves of the hand using muscle-in-vein conduits in comparison to nerve suture or nerve autografting

Muscle‐in‐vein conduits are a good alternative solution to nerve autografts for bridging peripheral nerve defects since enough graft material is available and no loss of sensation at the harvesting area is expected. The purpose of this study was to compare regeneration results after digital nerve reconstruction with muscle‐in‐vein conduits, nerve autografts, or direct suture.

An improved electrophysiological method to study peripheral nerve regeneration in rats.

After restitution of motor function the grasping test alone is insufficient to figure out any further differences of axonal nerve regeneration of the median nerve in rats. To avoid this problem we developed a standardized electrophysiologic method for testing median nerve regeneration. Threshold, latency, compound muscle action potentials (CMAP) and velocity of neuromuscular transduction were recorded in 54 rats 20 weeks post-operatively. Animals of group 1 served as control group, no transection of the median nerve was carried out. Animals of groups 2 and 3 underwent either primary nerve coaptation or autologous nerve grafting after transection of the median nerve. To ensure validity of the method additional correlation between all parameters was investigated. Reliable electrophysiological results were observed in all animals. As expected, group 1 animals showed lowest threshold and latency and highest CMAP levels. Transection of the median nerve and additional nerve repair leads to significant increase of threshold and latency as well as reduction of CMAP. Furthermore, animals of group 3 showed higher levels for threshold and latency and reduced CMAP levels compared with animals of group 2. The grasping test alone could not demonstrate these slight differences 20 weeks post-operatively. Additionally, we observed strong correlations between threshold, latency and CMAP using the Spearman correlation ranking. We describe the usage of motor neurography as a reproducible and valid tool which should be mandatory for detailed analysis of regeneration in the rat median nerve model.

Efficacy of various durations of in vitro predegeneration on the cell count and purity of rat Schwann-cell cultures.

The efficacy of Schwann-cell cultivation can be enhanced by in vitro predegeneration of the harvested cells compared to immediate culture. The aim of this study was to improve Schwann-cell culture efficacy by comparing three different durations of predegeneration. The sciatic and median nerves of 6-8-week-old Lewis rats were harvested and subjected to either 2-day, 7-day, or 14-day predegeneration in Dulbeccos Modified Eagles Medium supplemented with 10% fetal calf serum and 1% Penicillin/Streptomycin. Afterward, tissue was enzymatically dissociated and placed in a modified melanocyte growth medium. The cell count was determined immediately after dissociation while the cell purity was determined one subculture/trypsinization cycle later after cell attachment to the culture plate by means of optical microscopy and immunocytochemistry. Particular attention was then paid to the Schwann-cell-to-fibroblast relation. The cumulative cell count in the culture was 5.8 x 10(5) for 2-day, 1.12 x 10(6) for 7-day, and 1.48 x 10(6) for 14-day predegeneration. The culture purity was approximately equal for 2- and 7-day predegeneration (88% Schwann cells, 12% fibroblasts after 2 days; 85% Schwann cells, 15% fibroblasts after 7 days). After 14 days, however, cell cultures were significantly debased by fibroblast proliferation (57% Schwann cells, 43% fibroblasts). In vitro predegeneration is a particularly suitable procedural method to increase the cultural Schwann-cell yield. The number of cultivated rat Schwann cells is doubled by 7-day in vitro predegeneration in comparison to 2-day predegeneration. After 14-day predegeneration, however, the culture is significantly debased by fibroblasts. Therefore, 7-day in vitro predegeneration is an advisable predegeneration period.

Nervenrekonstruktion und Nervenersatzoperationen

The surgical treatment of peripheral nerve injuries is still a challenging and highly demanding procedure. Past results have been improved upon by different advances in microsurgical techniques and algorithms. Nevertheless, results are not always satisfying, making secondary procedures necessary. Thus, these secondary procedures such as tendon transfers and arthrodesis of different joints must be taken into account during reconstructive planning. This review gives an overview of peripheral nerve reconstruction (nerve grafting, nerve repair) and the pertinent secondary procedures.ZusammenfassungDie Versorgung von Nervenverletzungen und Nervendefekten stellt eine anspruchsvolle chirurgische Maßnahme dar. Verschiedene Techniken und Algorithmen haben in den vergangenen Jahren zu einer Verbesserung der chirurgischen Ergebnisse geführt. Trotz dieser Verfahren kommt es allerdings immer wieder zu einer Persistenz von Ausfällen und Lähmungserscheinungen. Daher ist es unabdingbar, dass der rekonstruktive Plan des Chirurgen auch so genannte Sekundär- oder Palliativmaßnahmen berücksichtigt, die sekundär zum Einsatz kommen können. Der vorliegende Beitrag gibt eine kurze Übersicht über die Versorgung peripherer Nervenverletzungen, die Nerventransplantation und verschiedene palliative Maßnahmen (Arthrodesen, motorische Ersatzoperationen usw.), die sekundär eingesetzt werden können.AbstractThe surgical treatment of peripheral nerve injuries is still a challenging and highly demanding procedure. Past results have been improved upon by different advances in microsurgical techniques and algorithms. Nevertheless, results are not always satisfying, making secondary procedures necessary. Thus, these secondary procedures such as tendon transfers and arthrodesis of different joints must be taken into account during reconstructive planning. This review gives an overview of peripheral nerve reconstruction (nerve grafting, nerve repair) and the pertinent secondary procedures.

Prospective Case-control Study on the Etiopathology of Kienböck Disease

Background: Multiple hypotheses regarding the cause of Kienböck disease have been proposed in seemingly contradictory small case series and cohort studies with inadequate statistical power. A prospective case-control study was conducted to analyze frequently discussed risk and causal factors. Methods: Eighty-one consecutive patients with Kienböck disease and 198 patients with wrist ganglia were referred to the authors’ clinic between 1990 and 2012, and 2003 and 2011, respectively. Patients with wrist ganglia were chosen as a control group because of the similar age distribution compared with the general population and because the common etiopathologic features of wrist ganglia and Kienböck disease can be excluded. Demographic, occupational, and medical information, including age, sex, handedness, ethnicity, education, occupation and employment status, prior treatment, and medical history were collected. Associated conditions and medication were assessed at a follow-up examination. Results: Sixty-five of 81 patients with Kienböck disease and 70 of 198 controls were included in the study. Both groups were comparable with respect to age distribution and handedness. Employment status and job characteristics were similar in both groups. Hand-arm vibration during work or leisure activity over a period of 2 years was present in 23 percent with Kienböck disease and in 24 percent of 70 controls. Cortisone was used in six of 65 cases with Kienböck disease [controls, zero of 70] for an average duration of 46 months. Conclusions: Trauma, hand-arm vibration, heavy manual labor, and comorbidities were not associated with Kienböck disease. Steroid-associated Kienböck disease in six of 65 cases is consistent with the findings reported for osteonecrosis of other parts of the skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Characteristic features and natural evolution of Kienböck's disease: Five years' results of a prospective case series and retrospective case series of 106 patients

OBJECTIVES Scientific databases index numerous references related to the treatment of Kienböcks disease; yet little is known about the nature of the disease and its pathognomonic features. This study provides a cross-sectional analysis of the pattern and extent of osteonecrosis in a large cohort and a longitudinal analysis to determine the spontaneous disease progression in single patients who have not had surgical management until fragmentation of the lunate. METHODS In a prospective case series, the pattern and extent of osteonecrosis were correlated with the duration of symptoms in all patients with Kienböcks disease confirmed using high-resolution 3-T magnetic resonance imaging (MRI) and ultra-thin section computed tomographic (CT) scan since 2009. Furthermore, a retrospective consecutive case series study was conducted to determine the rate of spontaneous evolution in all consecutive patients treated conservatively in our university hospital since 1990. RESULTS Among the 35 consecutive patients with Kienböcks disease diagnosed in high-resolution 3-T MRI and ultra-thin section CT, 46% (16/35) presented degeneration of lunate cartilage on CT scan in the first 12 months following the onset of symptoms. Median wrist pain duration of patients presenting a fracture of the lunate was 14 months. Thirty-one percent (11/35) of the patients had arthritis of the lunate, yet no fractures at the time of examination. Of 106 consecutive patients with Kienböcks disease and complete records, who did not have surgical intervention until fragmentation of the lunate, three cases were identified with well-documented spontaneous courses from apparently intact lunate morphology until fragmentation within 6 months. CONCLUSIONS Kienböcks disease progresses substantially faster than previously described and, contrary to current classifications, the articular cartilage of the lunate degenerates in early stages. LEVEL OF EVIDENCE Diagnostic accuracy, Level IV.

A novel hand-shaped suprathel simplifies the treatment of partial-thickness burns.

OBJECTIVE: The standard therapy to treat superficial partial-thickness burns of the hand involves the application of skin substitutes such as Suprathel (PolyMedics Innovations GmbH, Denkendorf, Germany), which reduce pain significantly, thus allowing a fast mobilization and leading to a quicker restoration of function. The aim of this study was to simplify the application of Suprathel by using new precut hand-shaped bandages. METHODS: Suprathel sheets have been produced in precut hand shapes that can be applied on the palm or on the dorsum of the hand. During a 6-month study period, 24 patients were treated with Suprathel after a burn injury of the hand. Half the patients received standard Suprathel sheets, and half received the novel hand-shaped Suprathel. Application time and material waste were documented closely. RESULTS: By using the Hand-Suprathel, application time was significantly reduced up to 80% compared with the standard rectangular Suprathel sheets. When the standard Suprathel sheet was reduced to the size and shape of the hand, approximately 40% of the material was discharged. In contrast, almost no material waste occurred by using Hand-Suprathel. CONCLUSION: The use of the new Hand-Suprathel increases efficiency because of its convenient and faster application, as well as by reducing material waste.

Treatment Algorithm and Clinical Outcome of Venous Malformations of the Limbs

BACKGROUND Venous malformations of the limbs are congenital low-flow vascular anomalies. A treatment is reasonable if they are symptomatic or if a progressive lesion may affect functional structures. OBJECTIVE The purpose of this work is the presentation of clinical results after treatment of venous malformations of the limbs according to the standard algorithm used at the University Hospital of Tuebingen, Germany. PATIENTS AND METHODS Between January 2008 and June 2015, patients with venous malformations of the limbs were subjected to either percutaneous sclerotherapy or surgical excision according to this treatment algorithm. Remaining symptoms such as pain level and disturbing appearance before and after treatment as well as overall satisfaction was assessed the earliest 3 months after last treatment. RESULTS Thirty-nine patients with venous malformations of the limbs were subjected to either 1 or more percutaneous sclerotherapies (n = 19) or surgical excision (n = 21). There were no serious complications that needed surgical revision. There was a statistically significant reduction in the pain level and disturbing appearance after both sclerotherapy and surgical excision (p < .05) in 30 cases in total. The overall treatment satisfaction was rated 7.9/10 and 8.8/10 after sclerotherapy and surgical excision, respectively. CONCLUSION A low complication rate with a high patient satisfaction could be achieved after this treatment algorithm for venous malformations of the limbs.

Behandlungsalgorithmus der Kahnbeinpseudarthrose

INTRODUCTION We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. MATERIALS AND METHODS Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. RESULTS Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). CONCLUSION Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.

Comparison of clinical and radiologic treatment outcomes of Kienböck’s disease

PurposeThe clinical outcomes of scaphotrapeziotrapezoid (STT) arthrodesis were compared to radial shortening osteotomy (RSO) to determine if any of the treatment methods was superior. The impact of RSO and vascularized bone grafts (VBG) on disease progression were measured based on X-rays to evaluate if a difference in Kienböck’s disease (KD) progression exists.MethodsOut of 98 consecutive patients treated between 1991 and 2013, 46 had STT arthrodesis, 21 had RSO, 7 had VBG, and 3 had VBG and RSO. Patients treated with STT arthrodesis were compared to RSO regarding post-operative range of motion (ROM), wrist pain on the Numeric Rating Scale (NRS), grip strength, duration of incapacity for work, the Disabilities of the Arm, Shoulder, and Hand (DASH), and the Modified Mayo Wrist scores (MMWS). Radiographic assessment (Nattrass index, radioscaphoid angle, and Ståhl index) was performed to determine disease progression following RSO or VBG. Baseline patient characteristics were comparable in all treatment groups.ResultsThere were no significant differences in post-operative ROM, wrist pain, grip strength, duration of incapacity, DASH score, or MMWS score following STT arthrodesis (n = 27) or RSO (n = 14). The Ståhl index, the Nattrass index, and the radioscaphoid angle suggested disease progression following RSO (n = 14) and/or VBG (n = 6) although the changes were not significant.ConclusionsThe study failed to demonstrate clinically relevant differences between STT arthrodesis compared to RSO. No evidence was found that decompression or revascularization, or the combination of the two, can reverse or halt the course of the disease.Level of evidenceTherapy, level III, retrospective comparative study with prospectively collected data.