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Objective: Resuspension of the first metacarpal bone using the extensor carpi radialis longus muscle tendon. Prevention of contact between the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Preservation of motion., Indications: Pain after preceeding resectional arthroplasty due to proximalisation of the first ray. Radiologically demonstrated contact between the base of the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Instability of the first ray at the site of the suspension., Contraindications: Proven specific reasons: neuropathical complaints and dysaesthesia in the region supplied by the superficial branch of the radial nerve, tendinitis of the flexor carpi radialis tendon etc. SURGICAL TECHNIQUE: Distalisation of the first ray after mobilisation and debridement at the base of the first metacarpal bone with resection of scar tissue, Resection of the pre-existing tendon plasty and contouring the base of the first metacarpal bone with removal of osteophytes. Interposition of tendon material between the base of the first and second metacarpal bones., Postoperative Management: Immobilisation in a forearm cast including the thumb metacarpophalangeal joint for 6 weeks., Results: Of 21 patients treated using this procedure, 15 (13 women, 2 men, average age 59 (51-70) years) were evaluated retrospectively on average 4 (2-10) years postoperatively. Opposition of the thumb was nearly normal. Grip strength and strength of pinch grip did not differ significantly from the contralateral side. Pain at rest and exercise (evaluated by a visual analogue scale from 0-10) was postoperatively significantly reduced. On plain X‑rays the distance between the base of the first metacarpal bone and the distal scaphoid pole was significantly increased as a sign of a successful distalisation. Ultimately, 12 patients postoperatively returned to work, 10 to their original occupation. No patient required additional procedures.

Objective: a) Fixed-angle bridging of the wrist between radius diaphysis and metacarpus by percutaneous or minimally invasively inserted threaded pins and a frame (fixator) placed above the skin level (external); b) retention of fracture fragments by ligamentotaxis; c) temporary stabilization after bone loss at wrist and distal forearm., Indications: a) Initial treatment of fractures near the wrist or soft tissue injuries in multiple trauma patients; b) fractures of the distal radius and the distal ulna; c) dislocation of the carpus; d) infections of the wrist; e) instability after resection in the wrist area; f) fractures with impending or manifest compartment syndrome; g) fractures with extensive loss of soft tissues and lacking coverage of implants., Contraindications: a) Pathological changes at the site of pin application, as long as no alternative site is possible: infections, fractures, osteoporosis, tumors; b) fractures that are closed and not reduceable; c) exclusively intra-articular distal radius fractures; d) lack of compliance by the patient., Surgical Technique: Insertion of two threaded pins into the radial shaft proximal to the radiocarpal joint and two pins into the second metacarpal bone. Assembly of the fixator frame in advance of the definitive reduction. Subsequently, final reduction and fixation in the desired position by tightening of the screws on the fixator frame., Postoperative Management: Pin care and changes of wound dressing every 2-3 days RESULTS: Reliable, low complication procedure for temporary fixation of the wrist for many indications.

Objective: Restoration of proximal interphalangeal joint stability with preservation of mobility by reconstruction of the middle phalanx base using an osteochondral graft from the carpometacarpal joint surface of the hamate., Indications: Acute and older isolated destruction of the palmar middle phalanx base >25%., Contraindications: Destruction of the head of the proximal phalanx, advanced chondropathia of the head of the proximal phalanx, extensive soft tissue injury with loss of skin coverage at the proximal interphalangeal joint., Surgical Technique: The fractured middle phalangeal base is debrided and the defect is replaced by a size-matched autograft from the dorsal carpometacarpal hamate osteoarticular surface that is secured in place with miniscrews., Postoperative Management: Immobilization for 2 weeks in a below-elbow cast in intrinsic plus position. Subsequent immobilization by a splint including the distal and proximal interphalangeal joint., Results: Healing was achieved in 100% with restoration of joint congruity in 12 of 13 cases and slight subluxation in 1 case. Follow up was possible in 9 cases after 22 ± 16 (5-51) months. The average range of motion in the reconstructed joint achieved 0/9/73°, grip strength 82% of the unaffected side. Of the 9 patients, 5 developed a mild flexion contracture of the proximal interphalangeal joint. The DASH score achieved 4 ± 3 (0-8) points, pain at rest was 1 ± 2 (0-5), pain at exercise 2 ± 2 (0-5) on a visual analogue scale (0-10). All patients were satisfied and willing to undergo the procedure again. According to the literature, reconstruction of the base of the middle phalanx by using an osteochondral graft from the hamate is a reliable procedure to restore stability and mobility of the joint.

Objective: Bony fusion of the trapeziometacarpal joint., Indications: High demands concerning stability and strength of the thumb in primary or secondary osteoarthritis (e.g., posttraumatic osteoarthritis following injuries to the carpometacarpal joint of the thumb); instability in the absence of osteoarthritis due to malformations, ligamentous laxicity, and joint hypermobility; malformations; improvement of hand function in neurological disorders; salvage procedure after carpometacarpal arthroplasty provided bone stock is sufficient., Contraindications: Osteoarthritis or stiffness of adjacent joints, activities demanding maximal mobility of the thumb, insufficient bone stock., Surgical Technique: Resection of the articular surfaces of the trapeziometacarpal joint via a dorsal approach. After temporary K‑wire transfixation, application of a dorsal T‑shaped plate (fixed angled or not), replacement of the K‑wire with a lag screw., Postoperative Management: Immobilization for 8 weeks (radial below-elbow cast including the thumb metacarpophalangeal joint); standard radiographs on second postoperative day and after 8 weeks; removal of stitches after 2 weeks; with bony healing after removal of the cast, guided exercises to increase strength and mobility; full loading for manual tasks after 3 months., Results: With regards to strength, stability, and pain reduction, results are rated as good and excellent with a high degree of patient satisfaction. Disadvantages are implant-related complications and nonhealing of the fusion in an average of 13% of patients. Nevertheless, the procedure is still indicated in young manual workers who tolerate some limitations of mobility.

Objective: Refixation of the triangular fibrocartilage complex (TFCC) to the ulnar capsule of the wrist., Indications: Distal TFCC tears without instability, proximal TFCC intact. Loose ulnar TFCC attachment without tear or instability., Contraindications: Peripheral TFCC tears with instability of the distal radioulnar joint (DRUJ). Complex or proximal tears of the TFCC. Isolated, central degenerative tears without healing potential., Surgical Technique: Arthroscopically guided, minimally invasive suture of the TFCC to the base of the sixth extensor compartment., Postoperative Management: Above elbow plaster splint, 70° flexion of the elbow joint, 45° supination for 6 weeks. Skin suture removal after 2 weeks. No physiotherapy to extend pronation and supination during the first 3 months., Results: In an ongoing long-term study, 7 of 31 patients who underwent transcapsular refixation of the TFCC between 1 January 2003 and 31 December 2010 were evaluated after an average follow-up interval of 116 ± 34 months (range 68-152 months). All patients demonstrated an almost nearly unrestricted range of wrist motion and grip strength compared to the unaffected side. All distal radioulnar joints were stable. On the visual analogue scale (VAS 0-10), pain at rest was 1 ± 1 (range 0-2) and pain during exercise 2 ± 2 (range 0-5); the DASH score averaged 10 ± 14 points (range 0-39 points). All patients were satisfied. The modified Mayo wrist score showed four excellent, two good, and one fair result. These results correspond to the results of other series., Conclusion: Transcapsular refixation is a reliable, technically simple procedure in cases with ulnar-sided TFCC tears without instability leading to good results.

Objective: Bony healing of dislocated distal radius fractures after open reduction and internal stabilization by locking screws/pins using palmar approach., Indications: Extraarticular distal radius fractures type A2/A3, simple extra- and intraarticular fractures type C1 according to the AO classification, provided a palmar approach is possible., Contraindications: Forearm soft tissue lesions/infections. As a single procedure if a volar approach not possible., Surgical Technique: Palmar approach to the distal radius and fracture. Open reduction. Palmar fixation of the plate to radial shaft with single screw. After fluoroscopy, distal fragments fixed using locking screws., Postoperative Management: Below-the-elbow cast for 2 weeks. Early exercise of thumb and fingers, wrist mobilization after cast removal. Complete healing after 6-8 weeks., Results: Ten patients averaged 100% range of motion of the unaffected side after 43±21 months. No complications observed. DASH score averaged 12±16 points; Krimmer wrist score was excellent in 7, good in 2, and fair in one.

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.

Neoangiogenesis represents an essential part of bone regeneration. Therefore the improvement of neovascularization is the subject of various research approaches. In addition autologous mesenchymal stem cells concentrate in combination with bone substitute materials have been shown to support bone regeneration. In a rabbit model we examined the proposed synergistic effect of hyperbaric oxygen therapy (HBOT) and bone marrow concentrate (BMC) with porous calcium phosphate granules (CPG) on neoangiogenesis and osseous consolidation of a critical- size defect. The animal groups treated with HBOT showed a significantly higher microvessel density (MVD) by immunhistochemistry. Furthermore HBOT groups presented a significantly larger amount of new bone formation histomorphometrically as well as radiologically. We conclude that the increase in perfusion as a result of increased angiogenesis may play a key role in the effects of HBOT and consequently promotes bone healing.

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.

Objectives: Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV)., Indications: The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots., Contraindications: The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue., Surgical Technique: The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper's chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons., Postoperative Management: Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free., Results: From March 1999 to January 2010 a Boyes' transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47 ± 17 (13-73) years. The interval between radial palsy and tendon transfer was an average of 79 ± 144 (4-543) months. The final follow-up was performed at an average of 82 ± 35 (32-165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36 ± 24 (11-85) points. Although disability of varying degrees persisted in all patients, Boyes' transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.

Objectives: The aim is correction of claw deformity of the fingers by intrinsic paralysis., Indications: Indications are claw deformity of fingers caused by palsy or functional loss of the interosseus or lumbrical muscles as far as the function of the superficial and deep flexors of the finger is intact., Contraindications: Contraindications are loss or paralysis of finger flexors supplied by the median nerve, fixed extension or flexion contracture of the finger joints, osteoarthritis and other malfunctions of the finger joints, no active flexion and extension of the interphalangeal joints due to compromised tendon gliding. Relative: Upper ulnar nerve palsy with functional loss of the deep flexor of the small and ring finger and possibly of the middle finger., Surgical Technique: The operation technique involves detachment of the flexor digitorum superficialis IV tendon (FDS IV) distal to Camper's chiasm, division of the tendon into separate strips, interweaving of each tendon strip into the proximal part of the A2 pulley of the affected fingers. In cases of claw deformity of all fingers it may be advantageous to apply the superficial flexor tendon of the long finger in addition to the FDS IV tendon as otherwise the FDS IV tendon has to be divided into four strips resulting in relatively thin tendon strips. If the FDS III and IV tendons are applied, the two strips of the FDS IV tendon are used for lassoplasty of the small and ring fingers and the FDS III tendon for lassoplasty of the middle and index fingers., Postoperative Management: Postoperative management includes immobilization of the operated fingers by a dorsoulnar forearm plaster cast including the metacarpophalangeal joints which are flexed to 70°. After 2 weeks replacement of the cast by a thermoplastic splint for another 4 weeks. During the whole period exercises for the finger and thumb should be carried out., Results: From April 2003 to June 2012 a total of 17 patients, 8 female and 9 male were surgically treated for claw deformity. The dominant hand was affected in seven patients. The average age was 46 ± 15 (22-80) years, the average interval from onset of ulnar palsy to lassoplasty was 61 ± 91 (3-288) months. The final follow-up was performed after an average of 42 ± 32 (2-112) months. Claw deformity was resolved in 14 out of the 17 patients. The grip strength was on average 58 ± 28 % (11-96 %) of the unaffected hand, the mean disabilities of the arm, shoulder and hand (DASH) score was 32 ± 18 (5-68) points and the degree of patient satisfaction 7 ± 2 (0-10). According to own results and those in the literature lassoplasty can be recommended for the treatment of claw deformity.

Several studies evaluated hip fracture incidences and its predictors and trends using hospital discharge registries. However, this source does not provide patient-related data, therefore the hospital changes or re-hospitalisations cannot be identified as "double counting". If double counting differs with age, sex, region, and time, the estimates may be biased. Aim of our study was to evaluate the magnitude of multiple counting and, in particular, its variation with age, sex, region, and calendar year. We used data of a German-wide health insurance (1.6 million members). Between 1998 and 2009, we assessed all hip fractures (ICD 9: 820, ICD 10: S.72.0-2) in individuals aged 50 years or older and calculated the probability to be a patient's "first" fracture in each calendar year. Using multiple logistic regressions, we estimated the influence of age, sex, region, and calendar year. The probabilities of a "first fracture" per patient and year varied between 86.7 % (95 % confidence interval 83.9-89.2 %, year 2003) and 93.9 % (90.9-96.2 %, year 1998). Age (odds ratio per 5 years 0.89; 95 % CI 0.86-0.92), region (East vs. West Germany: 0.65; 0.52-0.81), and calendar year (per year 0.97; 0.95-0.99) were significantly associated in the multiple regression. The probability to have multiple counting of hip fracture events varied significantly with age, region, and calendar year. It should be discussed that analyses which do not account for this may provide invalid estimates and conclusions when differences between age groups and regions or trends are analyzed.