XІV конгрес Європейських асоціацій хірургів руки проходив з 3-го по 6-е червня у місті Познань, Польща.  У роботі конгресу взяла участь делегація співробітників Тернопільського державного медичного університету ім. І.Я. Горбачевського на чолі з ректором проф. Л.Я. Ковальчуком: доцент Слабий О.Б., доцент Кулянда І.С., доцент Вайда А.Р., доцент Господарський А.Я.,  доцент Шідловський О.В.,  Копитчак І.Р., Коптюх В.В., Коршовський І.Л., Костів С.Я., Сорока Ю.В.

 Конгрес був присвячений актуальним проблемам лікування захворювань та травм кисті, передпліччя та плеча. Конгрес – це одна із найбільш визначних подій для спеціалістів, котрі займаються хірургією руки. Під час роботи конгресу можна було зустріти провідних фахівців не тільки із Західної та Східної Європи, а з багатьох країн світу. Можна було почути багато цікавих нових ідей, обмінятись досвідом із тієї чи іншої проблеми.

 

Відкриття конгресу відбулось у Познанському оперному театрі.

 

Наша делегація на конгресі

 

Переговори ректора Тернопільського медичного університету з ректором Познанського медичного університету. На переговорах досягнуто принципової згоди про стажування викладачів, студентів у Познанському медичному університеті, проведення літніх студій на базі НОК «Червона Калина».

Атмосфера конгресу

 

Під час тренінгу на муляжах.

 

 

ВИСТАВКА СУЧАСНОЇ ОРТОПЕДИЧНОЇ ТЕХНІКИ ТА ІНСТРУМЕНТАРІЮ

 

 

 

Обладнання для реабілітації:

Даний пристрій дозволяє зафіксувати кінцівку пацієнта і виконувати пасивні згинально-розгинальні рухи:

    

 

Обладнання для протезування. Штучна кисть виконує хапальні рухи:

        

 

Обладнання для фіксації та витяжіння:

        

 

Пересувна рентгенустановка:

 

 

Протези та штучні суглоби:

   

 

Наукове засідання, присвячене проблемам сухожиль, наведені дані про особливості відновлення сухожиль, біомеханічні дослідження на трупах, сучасні методики сухожильних пластик, УЗД діагностика при травмах та захворюваннях сухожиль.

 

 

 

 

 

 

На засіданні під назвою «фаланги» розглянуто питання сучасних методів остеосинтезу, ускладнень переломів фаланг, лікування ускладнень, показів до протезування.

 

 

 

 

 

 

 

Засідання під назвою «нерви». Висвітлені сучасні погляди на можливість регенерації нервової тканини. Показані підходи до відновлення ушкоджених нервів. Велика увага приділялась карпальному синдрому та його наслідкам, ендоскопічним технологіям при тунельних синдромах.

 

e

 

 

Заслуговує на особливу увагу засідання під назвою «кисть», де висвітлені сучасні методики лікування вивихів кисті, фаланг кисті. Були показані сучасні малоінвазивні методики лікування переломів кісток зап’ястку під контролем ендоскопічної техніки.

 

Зустріч у готелі з Почесним Консулом України в Познані Лукашом Горовським

Закриття Конгресу відбулось у мальовничому селі недалеко від Познані у музеї села. Учасники конгресу мали нагоду покуштувати традиційну Польську кухню, послухати народну музику, пісні.

 

 

Участь у XІV конгресі Європейських асоціацій хірургів руки була плідною та цікавою. Учасники делегації висловлюють щиру вдячність за сприяння та організацію поїздки ректору Тернопільського медичного університету проф. Л.Я.Ковальчуку та Почесному Консулу України в Познані Лукашу Горовському.

 

Tendon

Relative motion splinting of Zone V & VI extensor tendon repairs

Hirth M.J., Bennett K., Mah E., Farrow H. (Australia)

Introduction

Much discussion continues in search for the best splinting technique post extensor tendon repair. This study compares a simple finger-based splint with the conventional hand and forearm based splint.

Method

Retrospective review of 32 consecutive single finger zone V & VI extensor tendon repairs, comparing two different types of post-operative splinting methods. 14 patients were treated with conventional immobilisation regime of splinting for 4 weeks before mobilisation, avoiding "at-risk" activities for 8 to 10 weeks. Functional mobilisation began at about 7 days post-operatively in 18 patients after application of modified relative motion splint, permitting earlier return to activities of daily living and work.

The modified relative motion splint (mRMS) differs from relative motion splint described by Merritt's(1) in that there is no wrist component. The finger-based splint is designed to keep the injured finger extended by 20° relative to adjacent fingers, and all patients had a night hand and forearm-based splint to prevent unintentional wrist flexion and extension lag. Outcomes were measured using the TAM system recommended by the American Society of Surgery of the Hand.

Results

The average patient's age was 40 in the immobilisation group, 38 in the other. 68.75% (22/32) of patients were manual workers with roughly equal distribution in each group (72% & 64%). In the mRMS group, all were able to perform activities of daily living after the application of mRMS, 11/18 (61%) returned to work (full or light duties) within two weeks and 8/13 (62%) manual workers returned to full duties by 6 weeks. In the immobilisation group, none returned to work within 4 weeks and no manual workers returned to any form of duties by 6 weeks. The modified RMS group achieved better range of motion earlier although results were similar at 12 weeks. There was no incidence of tendon rupture in either group.

Discussion

The application of modified relative motion splint is simple and enables mobilisation to achieve full range of movement earlier. The light design allows true bi-manual activities thus quicker functional return to both daily living and work. This significantly decreases the personal and social costs of this injury. It is best suited for uncomplicated single finger extensor tendon injuries. The assessment at 12 weeks suggests comparable long term outcomes, consistent with some reports from the literature (2).

References

1. W Merritt. Written on Behalf of the Stiff Finger. J Hand Therapy (Am) 1998, Apr-Jun 74-79

2. T Purcell et al. Static Splinting of Extensor Tendon Repairs. J Hand Surg (Br) 25B, 180-182

Nerve

Endoscopic carpal tunnel release in patients older than 65

Lee J.-G., Kang H.J., Her M.S., Choi Y.R., Hahn S.B. (South Korea)

 

INTRODUCTION: The clinical outcome of carpal tunnel release(CTR) in an elderly patient with advanced carpal tunnel disease has been the subject of much controversy. Also the efficancy of endoscopic CTR in elderly patients has been unclear due to poor visualization. Our purpose was to evaluate the satisfaction of patients older than 65 with CTR, especially using the Agee endoscopic technique.

 

MATERIALS AND METHODS: The study was conducted on a total of 35 patients(42 hands) operated with Agee endoscopic CTR by the same surgeon between October 2000 and January 2007, with follow up of at least 1 year (average 18 months) postoperatively. All patients presented with numbness of six months duration or more, a positive Phalen's test preoperatively. And 29 patients(35 hands) presents with thenar atrophy. For evaluation the clinical outcome of CTR, the patients' subjective and objective signs and symptoms were measured at preoperative and post-operative 1 year. Scar tenderness also was recorded. And the modified Boston Questionnaire was used to determine overall hand function, activities of daily living, work performance, pain, etc.

 

RESULTS: The mean age was 67.2 years old. According to patient reports, There were no major neurovascular injury incurred during the performance of the study. Paresthesia, numbness, pain and Phalen's test each improved significantly. None have scar tenderness. But, 26 patients(32hands) complained the remained thenar atrophy. By applying the Boston questionnaire, we found the improvement from 3.43 ? 0.31 to 1.89 ? 0.35 in a symptoms severity score (SSS) and from 3.18 ? 0.39 to 2.21 ? 0.35 in a functional status score (FSS).

 

CONCLUSIONS: Although thenar atrophy did not improve in many cases, symptom severity and functional status did improve from the overall patients treated by endoscopic CTR. We conclude that endoscopic CTR in elderly patients is both a safe and efficacious treatment option.

 

Phalanges & metacarpals

Screw fixation of dorsal fractures of the distal phalanx

Cuénod P. (Switzerland)

 

Treatment of fracture of the base of the distal phalanx varies from splinting to various methods of reduction and fixation.

From may 2000 to august 2006, 26 fractures of the distal phalanx basis have been treated by ORIF with screws in 25 patients by one surgeon. The series included 6 female and 19 male patients with an average age of 39 years. The procedure was undergone in average 16 days after trauma. Ten times the dominant hand was involved. The typical mechanism was the direct blow in the long axis of the finger, mostly through a ball. There were 3 index, 7 long, 7 ring and 9 little fingers involved. 21 digits out of 26 showed a preoperative flexum of 5 to 35°.

At the final control, a residual flexum, ranging from 5 to 20° was noted in 6 cases. The joint was painless in 21 cases with a restored range of motion.

Radiologically the fragment represented 52 % of the joint surface on average, ranging from 40 to 70%. The size of the fragment had an average of 4.3 mm2 (1.125 to 8 mm2). In 18 cases there was a step-off of the joint surface and the diastasis between fragments was 1.26 mm on average (0-3mm). Only one case had a slight volar subluxation.

Immediately postoperatively the reduction was considered anatomic in 21/26 cases. 4/26 had a slight diastasis and 3/26 had a step-off of 0.5 mm. At the final control the fracture was radiologically healed in 23/26 cases. The anatomical reposition was maintained in 19/26 cases. In two cases the small fragment underwent resorption during follow-up without clinical consequences.

Conclusion: Screw internal fixation of distal phalanx basis fractures is a suitable method of treatment, although technically demanding. It allows to restore a congruent joint surface with good functional outcome. If the fragment is smaller than 2 mm2, the screws may be difficult to insert and there is a risk of fragment resorption. The possibility of using screws in this situation depends mostly on the geometry of the fragment.

 

Carpus

Arthroscopic treatment of perilunate dislocations and fracture-dislocations

Kim J.P., Min B.K., Lee J.S., Lee Y.B. (South Korea)

 

Purpose: To review the clinical and radiographic outcome of perilunate dislocations and fracture-dislocations treated with arthroscopic reduction and percutaneous fixation.

 

Methods: Nine consecutive wrists (eight patients) treated with arthroscopic reduction and percutaneous fixation for perilunate dislocations and fracture-dislocations were reviewed retrospectively at a mean of 26. 8 months. There were 3 volar lunate dislocations, and 6 trans-scaphoid perilunate fracture-dislocations. The mean age of the patients was 37.6 years, and 8 patients were men. Delay to surgery was 4.1 days. Six wrists developed carpal tunnel syndrome from the injury, which completely resolved after arthroscopic reduction. The functional and radiological outcomes were determined by independent evaluators.

 

Results: The average injured wrist flexion, extension, radial deviation, ulnar deviation, pronation, and supination were 73%, 76%, 89%, 83%, 97%, and 95%, respectively, of the contralateral uninjured wrist. The average grip strength was 78% of the contralateral wrist. One wrist developed scaphoid nonunion required bone graft. The average scapholunate and lunotriqeutral gap at the last follow-up examination were 1.5 ? 0.6 mm and 1.6 ? 0.3 mm, respectively, which were not significantly different than the corresponding measures of the immediate postoperative x-ray. None of the patients developed arthritis. Assessment of overall patient satisfaction showed 3 excellent results, 5 good results, and 1 fair result. Complication included two pin site irritations that resolved with removal of the pin.

Conclusions: The arthroscopic reduction and percutaneous fixation of acute perilunate injuries provides anatomical reduction and stable fixation. Although long term follow-up need to be observed, all of our patients except one had acceptable pain relief and return of range of motion and strength.

 

Distal radius

Three dimensional analysis of malunited fractures of distal radius

Miyake J., Murase T., Moritomo H., Takeyasu Y., Tanaka H., Sugamoto K., Yoshikawa H. (Japan)

 

Introduction: Malunion is common complication after distal radius fracture. To analyze malunions of distal radius the measurement of tilting angle and radial inclination with plain radiographs is useful for volar-dorsal and radial-ulnar deformity respectively. However rotational deformity must coexist in distal radial malunions. Some studies showed three dimentional reconstructions of the radius using computed axial tomography data have a role in malunion correction, but there is little information about rotational deformity and three dimensional quantification of deformity has not been reported. The purpose of this study is to find the three dimensional deformity pattern of malunited fractures of distal radius using computer assisted three dimensional modeling.

Materials and Methods The materials were 15 patients (4 males and 11 females) with dorsally displaced malunions of the distal radius. The average age was 51 years old (range,18-79y.). The mean interval between injury and examination was 13months (range, 3-53m.). All patients had been treated conservatively with cast. After bony union was obtained they came to our hospital complained with wrist pain, deformity and/or numbness of median nerve region.

The three dimensional bone surface models of whole bilateral radius were created from three dimensional computed tomography data. The proximal part of affected radius was superimposed to the corresponding part of the mirror image of the contralateral normal one, and we evaluated quantitatively three dimensional transformation of distal part of affected side relative to the normal side. The axis of the radius is defined and the three dimensional deformity was quantified in three directions of flexion-extension, radial-ulnar, and rotational deformity using Euler angles method.

Results In 15 patients the average angle of dorsal deformity was 29.0°?12.1°. The average radial angulation deformity was 8.7°?10.6° (range, -5°-27°). Of the 15 patients, 12 patients showed radial angulation deformity and 3 patients had ulnar angulation deformity. Only 6 patients had more than 5° radial angulation deformity. The average pronation deformity was 14.4°?12.1° (range, -2°-45°). Of the 15 patients, 13 patients showed pronation deformity, and 2 patients had minimum supination deformity less than 3°. 7 patients showed more than 15° pronation deformity. There was no correlation among dorsal, radial, and rotational deformity.

Summary We could evaluate dorsally angulated malunion of distal radius fractures three dimensionally. We found they had tendency of pronation deformity in rotation and only half of them had tendency of radial angulation deformity. There is no correlation among doral, radial and pronation deformity.

 

Elbow

Elbow dislocations and fracture-dislocations, clinical outcome of 70 patients with a minimal follow-up of 2 years.

Jager T., Sirveaux F., Ducoulombier Y., Roche O., Molé D., Mansat P. and GEEC (France)

 

Elbow dislocations and fracture-dislocations are quite frequent, and the last ones are often a ? challenge ? for the surgeon in charge.

We report the results of 229 patients, followed in 6 french teaching hospitals for at least 6 months. 153 patients were clinically reviewed. A minimal of 2 years of follow-up was found for 70 patients (mean follow-up 51months), and 104 had complete X-Ray evaluation at final follow up. Patients files were reviewed, patients had a physical examination with range of motion, strenght evaluation and had a functional scoring with MEPS and QuickDASH. Elbow radiographics were done at final follow-up, and elbow arthritis was ranked according to Broberg-Morrey classification.

We focused on the effect of time on the outcome of these elbows which presented dislocation or fracture-dislocation, and on the occurrence of elbow arthritis.

At more than 2 years of follow-up, the ROM was 120.9°, with a lack of extension of 11.3°, MEPS was 88.6 and QuickDASH 14.4. We found no relevant differences between patients before or after 2 years of follow-up, for physical (ROM, strenght) and functional items (MEPS). QuickDASH was better after 2 years. We didn't found arthritis to be more frequent after 2 years.

In that group of patients at more than 2 years of follow-up, we found fracture-dislocations to have a bad impact on the final outcome. ROM was smaller and functional outcome only good (MEPS 84.9) instead of excellent (MEPS 93.1) for simple dislocations.

Incidence of elbow arthritis was significantly lower in cases of fracture-dislocation. ROM, functional scores, and strength are impaired in arthritic elbows. Nevertheless, functional outcome is still fair with MEPS 75.6 and ROM 106.8° for patients with arthritis graded 2 or 3 according to Broberg-Morrey classification.

Final outcome of elbow dislocation or fracture-dislocation seems to be reached quite fast, in fact before 2 years. Elbow arthritis is a problem mainly for fracture-disclocations and seems to appear early during history. It affects the final outcome, which remains still fair.