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ABSTRACT: The aim of this study was to make a mid-term evaluation of an unconstrained pyrocarbon prosthesis (Ascension®) in the treatment of idiopathic degenerative arthritis of the proximal interphalangeal joint of the hand.
13 implants (10 patients) were clinically and radiologically studied after a follow-up period of 71 months (range: 48-92 months).
The average ROM was 52° (± 27°STD). A luxation of the components did not occur and all implants are still in-situ. However, X-ray examination was unremarkable in only six fingers. In seven patients significant radiolucent lines (≥ 1 mm) were detected. Three prosthesis demonstrated axial subsidence and in one patient a loosening of the proximal component with axial rotation was observed.
The results of this study show a high complication rate after an average of 6 years after implantation. Radiolucent lines in half of the cases may be explained by a lack of osteointegration of the prosthesis. The average ROM differs significantly from patient to patient, which has to be taken into account when discussing different treatment options.
Zeitschrift fur Orthopadie und Unfallchirurgie 04/2012; 150(3):324-8. · 0.52 Impact Factor
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ABSTRACT: Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL) = Littler II).
Rheumatoid swan neck deformity Nalebuff stages I-III (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin.
Advanced radiologic changes of the PIP joint (Larsen 3-4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis.
Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2 pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed.
Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12 weeks. The splint must allow full PIP flexion and limit extension over 20-30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4-6 weeks and start of mobilization. Passive extension over 20-30° of flexion only after 12 weeks.
From 2004-2007, 30 PIP joints in 20 rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2 pulley was not necessary in any of the cases. After a mean of 22 months, 26 PIP joints in 17 patients could be followed up. In 12 PIP joints, the deformity was partially contracted, in two joints contracted. In 10 joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1 patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.
Operative Orthopädie und Traumatologie 07/2011; 23(3):232-40. · 0.46 Impact Factor
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ABSTRACT: Successful four-corner fusion after scaphoid excision provides pain relief und preserves an acceptable movability of the wrist. However, this treatment option for advanced carpal collapse is not without complications, such as malunion, hardware impingement or incomplete correction of lunate extension. K-wires, staples, Herbert screws or, recently, locking plates are all possible fixation techniques after scaphoid excision. Only a few studies including mid-term results using K-wires are available. The aim of our study was to evaluate clinical and radiological mid-term results after scaphoid excision and four-corner arthrodesis using K-wires for stage II and III scapholunate and scaphoid non-union advanced collapse.
Twelve wrists of 11 patients (4/SNAC II degrees, 3/SNAC III degrees, 0/SLAC II degrees, 5/SLAC III degrees) were treated operatively by scaphoid excision and four-corner arthrodesis. Four K-wires were used for osteosynthesis. After an average follow-up of 60.25 months, reexamination included subjective, objective and radiological values. Clinical examinations covered wrist motion, grip strength and pinch strength. These parameters were compared with preoperatively collected data and values of the unaffected side. The DASH score (disabilities of the arm, shoulder and hand), Cooney score and the visual analogue scale (VAS 0-10) were analysed. Radiographic assessment of consolidation was verified by conventional X-rays. The carpal height was compared to the preoperative value by assessing the Youm index.
All patients were satisfied, pain relief was reported and displayed on VAS from 7.4 (5-10) to 1.4 (0-5). The mean flexion-extension arc of 76.3 +/- 28.8 degrees (59.7% of the opposite wrist), preoperatively 75 +/- 17.3 degrees, was documented. The average total arc of ulnar and radial deviation was 37.5 +/- 9.2 degrees (51% of the opposite wrist). The preoperative value was 33.5 +/- 9.8 degrees. Further clinical evaluation yielded a mean grip strength of 39.3 kp (89.5% of the anaffected side) and pinch strength of 7.6 kp (81.7%). Total DASH score and Cooney score averaged 15 and 74.17 points, respectively. Osseus consolidation was observed radiologically in all patients already after 6 weeks. The Youm index decreased from 0.55 +/- 0.054 to 0.51 +/- 0.057. The radiolunate joint space remained unaltered in height. There were no infections. Except for wire removal, no additional surgery was necessary.
Scaphoid excision and four-corner arthrodesis for advanced collapse of the wrist enjoy great satisfaction by the patients, with a high degree of pain reduction. This method shows persistent strength and movability in mid-term-results. Compared to alternative fixation techniques, the use of K-wires is a low-risk and low-cost treatment option, although removal of the K-wires is commonly necessary.
Zeitschrift fur Orthopadie und Unfallchirurgie 02/2010; 148(3):332-7. · 0.52 Impact Factor
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ABSTRACT: The aim of this study was to assess the results of operative treatment for rheumatoid swan neck deformity using Littler's technique consisting in the reconstruction of the oblique retinacular ligament.
From 2004 to 2007 twenty rheumatoid patients with 30 PIP-joints affected by swan neck deformity underwent surgical correction. In all cases the tenodesis described by Littler was used. Modification of the operative procedure because of insufficiency of the Cleland ligament or the A2-pulley was in no case necessary. Twenty six PIP-joints in 17 patients could be examined after an average follow-up of 22 months. In two PIP-joints the deformity was contract and in 12 PIP-joints partially contract. In 10 joints a dorsal arthrolysis had to be performed and in one a lengthening of the central slip. All PIP-joints were transfixed in 30 degrees flexion. After 6 weeks the transfixing wire was removed and active PIP- joint mobilisation was allowed. Active extension was limited to 20 degrees of flexion until the end of the 12 (th) postoperative week. During this time an extension blocking splint was used. After the 12 (th) week free active and passive mobilisation of the PIP-joint was allowed. In a retrospective study pre- and postoperative range of motion, X-ray findings, pain and patient's content were examined.
Swan neck deformity was corrected in all cases. Preoperative hyperextension of 21 degrees on average was corrected to 24 degrees of flexion. Thereby the ROM of 48 degrees was shifted from the extension sector to a ROM of 51 degrees towards the flexion sector. Recurrence of the deformity or complications were not noted. Pain could be reduced except in one patient. Radiologic changes were classified Larsen grade 2.2 before and 2.3 after operation.
With the oblique retinacular ligament repair described by Littler reliable results can be achieved in rheumatoid swan neck deformity. It is indicated in contract and non-contract rheumatoid swan neck deformity when th PIP-joints are radiologically in a stage of less than Larsen grade 3. It corrects the deformity at the level of the PIP-joint as well as the DIP-joint.
Handchirurgie · Mikrochirurgie · Plastische Chirurgie 02/2010; 42(1):65-70. · 0.88 Impact Factor
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ABSTRACT: The complex regional pain syndrome type I (CRPS I)-formerly named Sudeck's atrophy or reflex sympathetic dystrophy (RSD)-describes a complex of symptoms with chronic, poorly controllable pain, autonomic, sensomotor and trophic alterations. It is mainly caused by trauma or surgery. We describe the rare case of a spontaneous manifestation of a CRPS I in an adolescent patient with typical clinical and radiological findings and the recurrence of symptoms after a one-year symptom-free interval. Symptoms were resolved by an intense multimodal therapy concept. The likely psychosocial origin in this case is discussed. Clinical appearance, diagnostic means and therapy of the CRPS are described.
Zeitschrift für Rheumatologie 12/2005; 64(8):581-5. · 0.46 Impact Factor
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ABSTRACT: We report the results of a new bone-tendon ligamentoplasty for the reconstruction of chronic injuries of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb. The mean follow-up period was 36 months. Using the Glickel grading system, seven patients had excellent results and one patient had good results. The mean loss of pinch strength was 10% compared with the contralateral thumb. The mean loss of motion at the MP joint was 8%. This technique successfully restores the desired long lasting stability while maintaining mobility of the thumb's metacarpophalangeal joint.
Chirurgie de la Main 11/2005; 24(5):217-21. · 0.53 Impact Factor
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ABSTRACT: Das komplexe regionale Schmerzsyndrom Typ I (CRPS I)—früher auch als Morbus Sudeck oder als sympathische Reflexdystrophie
(SRD) bezeichnet—beschreibt einen Symptomenkomplex mit chronischen, oft schwer beherrschbaren Schmerzen, autonomen, sensomotorischen
und trophischen Störungen. Auslöser sind zumeist Traumen oder operative Eingriffe. Das seltene spontane Auftreten eines CRPS
Typ I und dessen Wiederaufflammen nach einem einjährigen beschwerdefreien Intervall wird im folgenden Fall einer jugendlichen
Patientin vorgestellt. Die intensive multimodale Therapie brachte Beschwerdefreiheit. Eine im Vordergrund stehende psychosoziale
Genese wird diskutiert. Klinik, Diagnostik und Therapie des CRPS werden beschrieben.
The complex regional pain syndrom type I (CRPS I)—formerly named Sudeck’s atrophy or reflex sympathetic dystrophy (RSD)—describes
a complex of symptoms with chronical, poorly controllable pain, autonomic, sensomotoric and trophic alterations. It is mainly
caused by trauma or surgery. We describe the rare case of a spontaneous manifestation of a CRPS I in an adolescent patient
with typical clinical and radiological findings and the recurrence of symptoms after a one-year symptomfree intervall. Symptoms
were resolved by an intense multimodal therapy concept. The likely psychosocial origin in this case is discussed. Clinical
appearance, diagnostic means and therapy of the CRPS are described.
Zeitschrift für Rheumatologie 10/2005; 64(8):581-585. · 0.46 Impact Factor
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ABSTRACT: Preiser's disease--first described by Preiser in 1910--presents the rare avascular necrosis of the carpal scaphoid. There is no consensus with regard to cause and therapeutic procedure to this day. The initially postulated idiopathic origin of the disease is controversial and rare. It is mainly caused by trauma or repetitive microtrauma, but can also occur as a complication of drug therapy. The rare occurrence of necrosis of the carpal scaphoid following chemotherapy is presented. The treatment was resection of the scaphoid and mediocarpal arthrodesis. Clinical appearance, diagnostic work-up, and therapy of the disease are discussed.
Der Orthopäde 10/2005; 34(9):938-40. · 0.51 Impact Factor
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ABSTRACT: The aim of this study was the analysis of long-term carpal changes after radiolunate arthrodesis.
Pre- and postoperative X-rays of 91 wrists in 78 patients with rheumatoid arthritis, who were treated for carpal instability with a radiolunate arthrodesis, were examined concerning the midcarpal joint and the Larsen grade. The mean follow-up was 60 months.
After radiolunate arthrodesis the midcarpal joint space remained unchanged in 28%. In 35% secondary arthritis and in 37% further arthritic destruction occurred. The mean Larsen grade increased from 3.2 to 3.8. Six wrists needed complete arthrodesis 25 to 87 months after the primary procedure and one was treated by total wrist replacement. Adaptive changes of the carpus during progressive disease and in secondary arthritis were recognized. Three types of joint lines could be identified: in 35% of the wrists a "perilunar", in 22% a "radio-midcarpal" and in 3% a purely "midcarpal" joint line. In 40% no specific joint line could be identified.
After radiolunate arthrodesis the carpus remains unchanged in the long run in nearly a third of cases. But even if secondary arthritis or further arthritic destruction occurs as in the remaining cases, the carpus shows an amazing capacity for adaptation. A new intracarpal joint line may develop or the midcarpal joint re-establishes itself.
Zeitschrift für Rheumatologie 09/2004; 63(4):326-30. · 0.46 Impact Factor
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ABSTRACT: Ziel der Arbeit war, die radiologischen Anpassungsformen des Karpus im Langzeitverlauf nach radiolunrer Arthrodese zu untersuchen. Pr- und postoperative Rntgenbilder von 91 Handgelenken bei 78 Patienten mit rheumatoider Arthritis, die wegen einer karpalen Instabilitt Instabilitt eine radiolunre Arthrodese erhielten, wurden hinsichtlich der Entwicklung des Mediokarpalgelenkes und des Larsen- Stadiums untersucht. Die Nachuntersuchungszeit betrug durchschnittlich 60 Monate. Nach radiolunrer Arthrodese bleibt das Mediokarpalgelenk zu 28% unverndert. In 35% kommt es zu einer Sekundrarthrose und in 37% zu einer Zunahme der arthritischen Vernderungen. Dies spiegelt sich auch in einer Zunahme des Larsen-Stadiums von durchschnittlich 3,2 auf 3,8 wider. Dennoch zeigt der Karpus erstaunliche Fhigkeiten zur Anpassung, indem er eine neue Gelenklinie entwickelt oder den mediokarpalen Gekenkspalt wieder aufbaut.
Objective:
The aim of this study was the analysis of long-term carpal changes after radiolunate arthrodesis.
Methods:
Pre- and postoperative X-rays of 91 wrists in 78 patients with rheumatoid arthritis, who were treated for carpal instability with a radiolunate arthrodesis, were examined concerning the midcarpal joint and the Larsen grade. The mean follow-up was 60 months.
Results:
After radiolunate arthrodesis the midcarpal joint space remained unchanged in 28%. In 35% secondary arthritis and in 37% further arthritic destruction occurred. The mean Larsen grade increased from 3.2 to 3.8. Six wrists needed complete arthrodesis 25 to 87 months after the primary procedure and one was treated by total wrist replacement. Adaptive changes of the carpus during progressive disease and in secondary arthritis were recognized. Three types of joint lines could be identified: in 35% of the wrists a perilunar, in 22% a radio-midcarpal and in 3% a purely midcarpal joint line. In 40% no specific joint line could be identified.
Conclusion:
After radiolunate arthrodesis the carpus remains unchanged in the long run in nearly a third of cases. But even if secondary arthritis or further arthritic destruction occurs as in the remaining cases, the carpus shows an amazing capacity for adaptation. A new intracarpal joint line may develop or the midcarpal joint re-establishes itself.
Zeitschrift für Rheumatologie 07/2004; 63(4):326-330. · 0.46 Impact Factor
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ABSTRACT: Silicone synovitis is an important clinical entity recognized in rheumatoid patients after arthroplasties with silicone implants. It is a foreign body reaction to particulate material (silicone elastomer) characterized clinically by the re-occurrence of pain, stiffness and swelling at the site of arthroplasty after initial relief of symptoms. Whereas silicone synovitis is a rare complication in metacarpophalangeal implants, it is an important one in the wrist implant. Long-term follow-up studies have revealed that the rates of fracture and subsidence are high and that the implants deteriorate with time necessitating operative revisions in up to 50% of cases. Indications should therefore be restricted to a painful wrist in the elderly, very low demand patient with insufficient bone stock to permit total wrist arthroplasty with a metal-on-plastic design. Severe preoperative deformity and the need for use of ambulatory aids may further limit the indication. The unusual case of direct perforation of silicone particles from the wrist into the tendon sheath of the M. flexor pollicis longus inducing a tumor-like synovitis and a secondary carpal tunnel syndrome is presented. The importance of silicone synovitis and the indication at present for implantation of a silicone wrist spacer in the rheumatoid patient are discussed.
Zeitschrift für Rheumatologie 07/2004; 63(3):230-4. · 0.46 Impact Factor
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ABSTRACT: The ulnar head has a central function in stabilizing the wrist. In the treatment of caput ulnae syndrome, the radiocarpal joint must, therefore, always be considered. The integrity of the ulnar head and TFCC are of major importance for the rheumatoid wrist. Therefore, surgical treatment should be carried out early, and is indicated for drug-resistant synovitis and monarthritis of the wrist. Early synovectomy of the radiocarpal and distal radioulnar joint (DRUJ) can be done as an open procedure or, when extensor tendon synovitis is absent, as an arthroscopic procedure. In most cases, however, treatment of manifest caput ulnae syndrome, sometimes even with rupture of the extensor tendons, is necessary. In these cases, resection of the ulnar head together with a dorsal wrist stabilization is indicated. Less often, arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated. When choosing the procedure, the type and stage of wrist changes have to be considered. The DRUJ usually has to be treated together with the radiocarpal joint. Its isolated treatment is rarely indicated.
Der Orthopäde 07/2004; 33(6):692-7. · 0.51 Impact Factor
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ABSTRACT: The indices for ulnar translation described by Chamay et al. (1983, Annales de Chirurgie de la Main, Vol. 2, pp. 5-17), and Bouman et al. (1994, Journal of Hand Surgery Vol. 19B, pp. 325-329), and for carpal height described by Youm et al. (1978, Journal of Bone and Joint Surgery, Vol. 40A, pp. 423-431) and Bouman et al. (1994) were compared in pre- and postoperative wrist X-rays of 91 patients with rheumatoid arthritis undergoing radiolunate arthrodesis. Both indices described by Bouman had a higher applicability and sensitivity than the Chamay and Youm indices and are recommended for use with the rheumatoid wrist. However false-negative values may result when the Bouman index for ulnar translation is used to follow up radiolunate arthrodesis.
The Journal of Hand Surgery British & European Volume 05/2004; 29(2):144-7. · 0.04 Impact Factor
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ABSTRACT: Der ungewhnliche Fall einer direkten Perforation von Silikonpartikeln aus dem Handgelenk in die Sehnenscheide des M. flexor pollicis longus mit Ausbildung einer tumorsen Synovialitis und sekundrem Karpaltunnelsyndrom wird vorgestellt. Klinisches und radiologisches Bild sowie Bedeutung der Silikonsynovialitis und der heutige Stand der Indikationen fr die Implantation von Silikon-Handgelenksspacern werden diskutiert.Silicone synovitis is an important clinical entity recognized in rheumatoid patients after arthroplasties with silicone implants. It is a foreign body reaction to particulate material (silicone elastomer) characterized clinically by the reoccurrence of pain, stiffness and swelling at the site of arthroplasty after initial relief of symptoms. Whereas silicone synovitis is a rare complication in metacarpophalangeal implants, it is an important one in the wrist implant. Long-term follow-up studies have revealed that the rates of fracture and subsidence are high and that the implants deteriorate with time necessitating operative revisions in up to 50% of cases. Indications should therefore be restricted to a painful wrist in the elderly, very low demand patient with insufficient bone stock to permit total wrist arthroplasty with a metalon-plastic design. Severe preoperative deformity and the need for use of ambulatory aids may further limit the indication. The unusual case of direct perforation of silicone particles from the wrist into the tendon sheath of the M. flexor pollicis longus inducing a tumorlike synovitis and a secondary carpal tunnel syndrome is presented. The importance of silicone synovitis and the indication at present for implantation of a silicone wrist spacer in the rheumatoid patient are dicussed.
Zeitschrift für Rheumatologie 01/2004; 63(3):230-234. · 0.46 Impact Factor
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ABSTRACT: Two hundred and seventy-three patients with carpal tunnel syndrome without advanced neurophysiological changes (distal motor latency below 11 ms) were randomized to treatment by open carpal tunnel release with, or without, epineurotomy. Patients were examined clinically and by nerve conduction studies preoperatively and at 3, 6 and 12 months postoperatively. We found no statistically significant difference between simple decompression and decompression combined with epineurotomy with regard to either the clinical or the neurophysiological outcome.
The Journal of Hand Surgery British & European Volume 11/2003; 28(5):450-4. · 0.04 Impact Factor
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ABSTRACT: Early specific radiologic changes of rheumatoid arthritis can usually be detected in the hands and feet. Later stages of the disease process show a typical centripetal spread of the affected joints, i.e., shoulder, elbow, and knee. For prognostic assessment of cubital rheumatoid arthritis, conventional radiography still remains the gold standard. X-rays allow objective scoring and thus classification into standardized stages. A concentric destruction of the rheumatic joint as compared to deformity in the degenerative joint is the typical radiologic symptom to look for. For soft tissue assessment, ultrasound (US) should be the diagnostic tool of choice. Due to the thin surrounding soft tissue layer, as well as the advanced high-resolution technology, bony structures can also be well demonstrated in any plane. In the early arthritic stages, particularly the small changes, e.g., minimal erosions of the cortical area, are very well detectable by US. The use of "color" allows good evaluation of the synovial inflammatory status. Modern imaging methods such as computer- assisted tomography (CAT) scan and magnetic resonance imaging (MRI) are restricted to a few set indications and should not be chosen for routine examination. More invasive methods such as arthrography are no longer indicated for assessment of cubital rheumatoid arthritis.
Der Orthopäde 09/2003; 32(8):691-8. · 0.51 Impact Factor
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ABSTRACT: In der Regel treten die ersten rntgenmorphologisch-
typischen Vernderungen bei der rheumatoiden Arthritis an Hnden
und Fen auf. Im weiteren Krankheitsverlauf werden zentripetal
die Knie-, Ellenbogen und Schultergelenke mit in den
Entzndungsprozess einbezogen. Das konventionelle Rntgenbild
ist immernoch der Goldstandard fr die Beurteilung des
Krankheitsverlaufs der rheumatischen Kubitalarthritis. Die
Bilder erlauben ein objektives Scoring mit einer Klassifizierung
durch Einteilung des Schweregrades in Stadien. Das
Rntgenleitmerkmal der Arthritis ist die konzentrische
Destruktion des Gelenks und nicht die Deformierung wie bei der
Arthrose.Zur Weichteildiagnostik sollte primr die Sonographie
durchgefhrt werden.Auch die knchernen Strukturen sind wegen
des geringen Weichteilmantels und der verbesserten,
hochauflsenden Technik in jeder Schallebene sehr gut zu
beurteilen. Gerade Anfangsstadien der Arthritis mit geringen
Vernderungen im Bereich der Kortikalis, wie z.B. minimale
erosive Vernderungen sind sonographisch gut abzubilden.Durch den Einsatz der "Farbe" bei der Dopplertechnik lsst
die Sonographie Rckschlsse auf die Floriditt der vorliegenden
Entzndung der Gelenkhaut zu. Computertomographie (CT) und
MR-Tomographie (MRT) beschrnken sich auf wenige gezielte
Fragestellungen. In der Routinediagnostik sollten sie nicht
eingesetzt werden. Die Arthrographie hat bei der Beurteilung der
rheumatischen Kubitalarthritis keine Bedeutung mehr.Early specific radiologic changes of rheumatoid arthritis
can usually be detected in the hands and feet. Later stages of
the disease process show a typical centripetal spread of the
affected joints, i.e., shoulder, elbow, and knee. For prognostic
assessment of cubital rheumatoid arthritis, conventional
radiography still remains the gold standard. X-rays allow
objective scoring and thus classification into standardized
stages. A concentric destruction of the rheumatic joint as
compared to deformity in the degenerative joint is the typical
radiologic symptom to look for.For soft tissue assessment, ultrasound (US) should be the
diagnostic tool of choice. Due to the thin surrounding soft
tissue layer, as well as the advanced high-resolution
technology, bony structures can also be well demonstrated in any
plane. In the early arthritic stages, particularly the small
changes, e.g., minimal erosions of the cortical area, are very
well detectable by US. The use of "color" allows good evaluation
of the synovial inflammatory status.Modern imaging methods such as computer- assisted
tomography (CAT) scan and magnetic resonance imaging (MRI) are
restricted to a few set indications and should not be chosen for
routine examination. More invasive methods such as arthrography
are no longer indicated for assessment of cubital rheumatoid
arthritis.
Der Orthopäde 07/2003; 32(8):691-698. · 0.51 Impact Factor
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ABSTRACT: Complex regional pain syndrome type I (CRPS type I)--formerly termed Sudeck's atrophy or reflex sympathetic dystrophy (RSD)--causes chronic, poorly controllable pain, autonomic, sensorimotor disorders,and serious trophic alterations in the later stages. It develops in the distal extremities mostly after minimal trauma or surgical intervention and rarely spontaneously. The severity of symptoms is disproportionate to the causative event. The latest scientific findings show that the previously called reflex sympathetic dystrophy (RSD), which was supposed to be a result of a hyperreactive autonomic nervous system,is a very complex syndrome that occurs on different integration levels of the nervous system. Sympathetically maintained pain (SMP) may be facultatively characteristic, but is not to be misunderstood as an underlying mechanism. A neurogenic inflammation reaction has recently been discussed, just as had been postulated by Paul Sudeck long before. That was the reason why the International Association for the Study of Pain (ISAP) introduced the more descriptive term "complex regional pain syndrome" (CRPS) type I in 1994. Due to the complexity of the process necessitating qualified knowledge, it is important to immediately refer patients to a specialized pain OPD or clinic. The diagnosis of CRPS type I is based upon a carefully taken case history and a clinical examination by an experienced practitioner. Imaging diagnostic tools and laboratory findings are of no or only low predicative value. The question of whether SMP exists after diagnosing CRPS type I is eminent for therapy planning. Therefore, diagnostic regional anesthetics are still important in spite of their uncertain prognostic relevance. Physical therapy, occupational therapy, medical treatment, and psychotherapy play an important role in the primary treatment of CRPS type I as noninvasive procedures. Despite heavy criticism, invasive sympathetic block, subsequent to adequate diagnostics, is an important part of the therapeutic concept. A multimodal therapeutic concept, which includes all available possibilities, is absolutely necessary to avoid grave permanent disabilities caused by insufficient or failed therapy. Nevertheless, already established as well as new treatment modalities have to be critically observed by further randomized, prospective control trials.
Der Orthopäde 06/2003; 32(5):418-31. · 0.51 Impact Factor
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ABSTRACT: Das komplexe regionale Schmerzsyndrom Typ I (CRPS Typ I) – früher auch als Morbus Sudeck oder als sympathische Reflexdystrophie
(SRD) bezeichnet – beschreibt einen Symptomenkomplex mit chronischen, oft schwer beherrschbaren Schmerzen, autonomen, sensomotorischen
und im weiteren Krankheitsverlauf auftretenden trophischen Störungen. Es betrifft überwiegend die distalen Extremitäten, wird
meist durch geringe Traumen oder kleinere Operationen ausgelöst und tritt selten auch spontan auf.
Die Ausprägung der auftretenden Störungen steht dabei nicht im Verhältnis zur Schwere der schädigenden Ursache.Neuere Erkenntnisse
haben gezeigt, dass es sich um ein äußerst komplexes Syndrom handelt, das sich auf verschiedenen Integrationsebenen des Nervensystems
abspielt.Der sympathisch unterhaltene Schmerz (“sympathetically maintained pain”, SMP) stellt dabei ein fakultatives Merkmal
dar, ist aber nicht als kausaler Mechanismus zu verstehen.Der bis in die 1990er-Jahre gebräuchliche Begriff der SRD wurde
daher verlassen. Eine neurogene Entzündungsreaktion, wie sie bereits von Paul Sudeck postuliert wurde,wird erneut diskutiert.
Dies hat dazu geführt, dass die “International Association for the Study of Pain” (IASP) 1994 den deskriptiven Begriff des
“complex regional pain syndrome” (CRPS I) einführte.
Aufgrund der Komplexität des Geschehens und der daher erforderlichen Fachkompetenz ist es wichtig, den Patienten bereits bei
Verdacht auf Vorliegen eines CRPS frühzeitig in eine Schmerzambulanz oder -klinik zu überweisen. Die Diagnostik beim CRPS
Typ I basiert auf einer sorgfältigen Anamnese und klinischen Untersuchung durch einen erfahrenen Untersucher, da apparative
und laborchemische Methoden keine oder nur geringe Aussagekraft besitzen. Die Frage, ob bei diagnostiziertem CRPS Typ I ein
SMP vorliegt, ist für die Therapieplanung entscheidend,weshalb die fachgerecht durchgeführten diagnostischen Sympathikusblockaden
trotz ihrer fraglichen prognostischen Relevanz nach wie vor von Bedeutung sind.
Physiotherapie, physikalische Therapie, Ergotherapie, medikamentöse Therapie und Psychotherapie spielen in der primären Behandlung
des CRPS I als nichtinvasive Maßnahmen eine wichtige Rolle. Nach entsprechender Diagnostik hat die invasive Sympathikolyse
trotz häufiger Kritik ihren festen Platz gefunden. Entscheidend ist ein multimodaler Therapieansatz unter Ausschöpfung aller
zur Verfügung stehenden Möglichkeiten, da bei unzureichender oder gar ausbleibender Behandlung für den Patienten die Gefahr
einer schwerwiegenden Behinderung auf Dauer besteht. Sowohl die bereits praktizierten als auch die neueren Therapieansätze
bedürfen aber einer kritischen Überprüfung durch weitere prospektiv-randomisierte, kontrollierte Studien.
Complex regional pain syndrome type I (CRPS type I) – formerly termed Sudeck's atrophy or reflex sympathetic dystrophy (RSD)
– causes chronic, poorly controllable pain, autonomic, sensorimotor disorders,and serious trophic alterations in the later
stages. It develops in the distal extremities mostly after minimal trauma or surgical intervention and rarely spontaneously.The
severity of symptoms is disproportionate to the causative event.
The latest scientific findings show that the previously called reflex sympathetic dystrophy (RSD), which was supposed to be
a result of a hyperreactive autonomic nervous system,is a very complex syndrome that occurs on different integration levels
of the nervous system.Sympathetically maintained pain (SMP) may be facultatively characteristic, but is not to be misunderstood
as an underlying mechanism.A neurogenic inflammation reaction has recently been discussed, just as had been postulated by
Paul Sudeck long before.That was the reason why the International Association for the Study of Pain (ISAP) introduced the
more descriptive term “complex regional pain syndrome” (CRPS) type I in 1994.
Due to the complexity of the process necessitating qualified knowledge, it is important to immediately refer patients to a
specialized pain OPD or clinic.The diagnosis of CRPS type I is based upon a carefully taken case history and a clinical examination
by an experienced practitioner. Imaging diagnostic tools and laboratory findings are of no or only low predicative value.The
question of whether SMP exists after diagnosing CRPS type I is eminent for therapy planning.Therefore, diagnostic regional
anesthetics are still important in spite of their uncertain prognostic relevance.
Physical therapy, occupational therapy, medical treatment, and psychotherapy play an important role in the primary treatment
of CRPS type I as noninvasive procedures. Despite heavy criticism, invasive sympathetic block, subsequent to adequate diagnostics,
is an important part of the therapeutic concept. A multimodal therapeutic concept, which includes all available possibilities,
is absolutely necessary to avoid grave permanent disabilities caused by insufficient or failed therapy.Nevertheless, already
established as well as new treatment modalities have to be critically observed by further randomized,prospective control trials.
Der Orthopäde 04/2003; 32(5):418-431. · 0.51 Impact Factor
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ABSTRACT: A stable and pain-free wrist is a prerequisite for normal hand function. Since the wrist joint is involved early in rheumatoid disease and progress is rapid, operative treatment is of major importance. It is indicated not only for treatment of established osseous changes with instability, deformation, and extensor tendon ruptures but for early treatment of drug-resistant synovitis and monarthritis of the wrist.A considerable number of operative procedures is available: arthroscopic or open synovectomy of the radio- and midcarpal as well as the distal radioulnar joint, possibly with resection of the ulna head, partial arthrodeses, complete arthrodeses,and arthroplasty. When choosing the procedure, type and stage of wrist changes as well as the pathobiomechanic situation have to be considered. The individual course of the disease and patient requirements have to be taken into account.Thus, for long periods of time a pain-free stable wrist can be preserved, albeit sometimes with only limited but functional mobility.
Der Orthopäde 01/2003; 31(12):1159-67. · 0.51 Impact Factor
