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Background: Surgical procedures of the hand are increasingly performed in an ambulatory setting. Postoperative analgesia is based empirically on the painfulness of individual surgical procedures without these having been examined systematically., Patients and Methods: The painfulness (visual analogue scale) of 722 surgical procedures of the hand and wrist (1 July 2021 to 30 June 2023) was assessed until day 5. Analgesia was conducted empirically in accordance with WHO principles. The primary endpoint was the pain sensation on the first postoperative day in bone and joint procedures compared with soft tissue or endoscopic procedures as well as hardware removals. Secondary endpoints were pain sensation in correlation with gender, age, duration of the procedure and preoperative analgesia., Results: Bone and joint procedures were associated with significantly (p<0.001) more pain (5.42±2.8) compared with other procedures (3.47±2.6). Female (p=0.001) and younger patients (R>0.2) as well as longer procedure duration (R>0.2) showed a weak association with higher postoperative pain, whereas preoperative consumption of opioids was moderately associated with higher opioid intake (R=0.34). Overall, pain decreased continuously from the evening of the procedure (4.4±2.8) until day 5 (3.7±2.7; 2.8±2.4; 2.1±2.1; 1.6±1.9; 1.3±1.7) CONCLUSION: This data provides a scientific basis for pain medication supply following surgical procedures of the hand and wrist in an ambulatory setting. A broad range of pain perception must be considered, even in seemingly minor surgical procedures., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background Various operative approaches exist for osteoarthritis of the trapeziometacarpal joint. The aim of this two-centre study was to compare the results of Lundsborg's resection arthroplasty with the implantation of the Pyrocardan ® spacer. Patients and methods We treated 20 patients with symptomatic osteoarthritis of the trapeziometacarpal joint in stage III / IV (Eaton-Littler classification). Twelve patients received Lundsborg's resection arthroplasty (centre 1), and in 8 patients a Pyrocardan ® spacer was implanted (centre 2). Both groups were comparable regarding patients´ age, the preoperative pain level, the osteoarthritis stage according to Eaton-Littler, and the duration from the onset of symptoms until surgery. Patient data were retrospectively collected from patient records, and we performed a follow-up examination at least 18 months postoperatively, thereby evaluating the DASH sore, the postoperative time until freedom of symptoms, the pain level according to the visual analogue scale, grip force (Jamar dynamometer), pinch force, and patients' treatment satisfaction (0-10; 10 = highest satisfaction). Results Both groups had a similar length of follow-up with 23.6 ± 5.2 months for the resection group and 26.1 ± 4.0 months for the spacer group. The duration of the operation was 31 ± 5 min for the resection group and 29 ± 7 min for the spacer group (p > 0.05). The DASH score was 21.9 ± 6.2 in the resection group and 18.3 ± 5.0 in the spacer group (p > 0.05). The pain level at the current follow-up was 1.5 ± 0.83 in the spacer group and 1.0 ± 0.74 in the resection group (p > 0.05). The time until freedom of symptoms was significantly shorter in the spacer group with 3.7 ± 1.9 months compared to the resection group with 5.7 ± 3.1 months (p = 0.0001). Grip force and pinch force were not significantly different between both groups. Treatment satisfaction was 9.3 ± 1.6 in the resection group and 7.4 ± 3.0 in the spacer group (p > 0.05). Conclusion Over a follow-up period of 1.5 years, both techniques resulted in a satisfactory usability of the operated hand and a clear reduction of symptoms. The implantation of the Pyrocardan ® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms. However, the implantation of the spacer is associated with additional material costs of a few hundred Euros, which are not incurred in resection arthroplasties. The implantation of the Pyrocardan ® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Atypical lipomatous tumours (ALT) are rare semi-malignant adipose tissue tumours with the potential to transform into sarcomas. They may occur throughout the body, although the hands are very rarely involved. We present the case of a 49-year-old man with a lipomatous tumour measuring 8×4 cm at the dorsum of the right thumb. MRI demonstrated an inhomogeneous signal after contrast medium application. The tumour was excised in its entirety. Since histology confirmed the diagnosis of an ALT, the thumb was irradiated. The patient remained free of recurrence. An ALT has to be suspected if a lipomatous tumour is very large. We recommend an MRI prior to surgery in tumours larger than 5 cm. Excision should follow oncologic principles., (© Georg Thieme Verlag KG Stuttgart · New York.)

In order to improve operating room efficiency in our institution, we introduced the wide-wake approach for carpal tunnel releases in 2012. This study examines the effect of this new anaesthetic technique on the work-flow and the duration of operation compared to the previously used axillary plexus anaesthesia.In this retrospective study, we reviewed the surgical case data of all patients in whom carpal tunnel releases had been performed as single procedures. 120 procedures of the year 2011, performed under axillary plexus anaesthesia, were compared to 153 procedures of the year 2012, performed as wide-awake surgery. We hypothesised that an earlier beginning of the first operation of the day with wide-awake surgery. Furthermore, we expected a shorter surgical time as well as a shorter interval between 2 carpal tunnel releases.By introduction of the wide-awake -approach, the first operation began a mean of 11 min earlier (p<0.001). While the surgical time did not change for the hand surgeon himself (10.7 vs. 10.2 min; p=0.478), the surgical time shortened significantly, when residents performed the operation (19.1 vs. 15.9 min, p<0.001). The interval between 2 carpal tunnel releases shortened from 19.8 to 17.7 min (p=0.009). Secure preparation was accomplished by the hypoperfused situs, when the wide-awake approach was applied, even though a tourniquet was not used. In the post-operative control, no complicated wound healings were noted.The wide-awake approach has proven to be reliable for the operating room -efficiency and, likewise, for patient safety. Therefore, we can recommend this technique without restrictions for carpal tunnel releases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The aim of this study was to evaluate the intra- and interobserver reliability of findings in wrist arthroscopies documented by digital photography., Patients and Methods: 102 consecutive wrist arthroscopies were documented by at least 6 photographs: (1) radioscaphoidal joint with radiopalmar ligaments, (2) scapholunate ligament from radiocarpal, (3) TFCC, (4) lunotriquetral joint with ulnar recessus, (5) scapholunate, and (6) lunotriquetral joint from midcarpal. More photographs were taken of additional pathologies. Arthroscopic findings were documented in an arthroscopy form (synovitis: no/yes, articular effusion: no/yes, cartilage lesion: no/yes). Lesions of the scapholunate ligament were classified according to Geissler, scapholunate and lunotriquetral ligament lesions were graded as partial or complete, TFCC lesions were categorised according to Palmer and trampoline effects noted. Three months later the 6 standard photos and then all photos were re-evaluated by the scoping surgeon and two experienced hand surgeons. Cohen's kappa was used as a measure of agreement between findings three months postoperatively and those in the operation report. Further statistical analyses were done, e. g., to compare intra- and interobserver reliability., Results: In general intraobserver reliability (mean kappa 0.44) was better than interobserver reliability (0.28, 0.30). Assessing all available photos (0.47) did not improve reliability compared to assessing only the six standard photos (0.44). On grading scapholunate ligament lesions as partial or complete the interobserver reliability was fair (0.37, 0.30). Using Geissler's classification the interobserver reliability was κ=0.34 and 0.23. There was substantial intra- (0.61) and interobserver reliability (0.63, 0.60) for cartilage lesions. While intraobserver reliability for TFCC lesions was substantial (0.61), interobserver reliability was only moderate (0.31, 0.48)., Conclusion: Even with wrist arthroscopy, the best diagnostic modality for scapholunate ligament, TFCC and carpal cartilage lesions, hand surgeons do not agree in diagnosis and pathology. Therefore, the documentation of arthroscopic findings has to be improved. Digital video documentation of wrist arthroscopy may illustrate wrist pathologies more adequately. However, this still has to be proven by further studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Compression syndromes of the ulnar nerve are more often located proximally in the cubital tunnel than distally in Guyon's canal. In many cases anatomic structures can be found that induce compression. These may be ganglia, tumours, vascular abnormalities, crossing fibrous bands or accessory muscles. The ulnar nerve has therefore to be revised all along its passage through Guyon's canal. When other causes are excluded, it might be necessary to excise an accessory muscle to decompress the ulnar nerve sufficiently., (Georg Thieme Verlag KG Stuttgart New York.)

Purpose: Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid., Method and Material: 37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically., Results: The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain., Conclusion: Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

Ulna-shortening is a widely accepted procedure for the treatment of ulna-impaction syndrome. High rates of non-unions however necessitate improving the operation technique. The new device introduced in this study is a 7-hole plate in which two proximal holes are sliding-holes. By correct placement of two distal screws and two screws in the sliding-holes, rotational stability is guaranteed. The osteotomy is performed while the plate is loosely fixed to the ulna. After fixation of the two distal screws, the sliding-holes facilitate reposition with a good closure of the osteotomy gap. Excentric placement of two more screws and placement of a lag screw across the oblique osteotomy leads to further compression at the osteotomy site. Ulna-variance can be adjusted exactly. So far the plate has been implanted in 15 patients. Ulna-variance was reduced from + 2 to - 2.2 mm. The clinical results are comparable to those of ulna-shortenings in the literature. The sliding-hole plate allows an exact connection with good closure of the osteotomy without malrotation. With this simplified technique, the risk of non-union can be reduced.