46. Jahreskongress SGH 46 ème Congrès annuel SSCM

Transkript

1 Kongresshaus KK Thun Abstracts 46. Jahreskongress SGH 46 ème Congrès annuel SSCM 14. CH-Kongress SGHR 14 ème Congrès suisse SSRM Kultur- und Kongresszentrum Thun (KK Thun) November novembre

2 Inhaltsverzeichnis / Sommaire Kongressfakultät Corps scientifique du congrès 3 Freie Mitteilungen SGH Communications libres SSCM 4 23 Freie Mitteilungen SGHR Communications libres SSRM Workshops SGHR Ateliers SSRM Impulsreferat (R), Symposien (S), Lecture (L) SGHR Exposé introductif (R), symposia (S), lecture (L) SSRM

3 Kongressfakultät/Corps scientifique du congrès Tagungsleitung/Direction d organisation PD Dr. med. Esther Vögelin Präsidentin SGH Présidente SSCM Dr. med. Bettina Juon Mitglied SGH Membre SSCM Nora Käser Vorstandsmitglied SGHR Membre du comité SSRM Véronique van der Zypen Präsidentin SGHR Présidente SSRM Wissenschaftliche Leitung/Direction scientifique Dr. med. Dietmar Bignion Mitglied SGH Membre SSCM Dr. med. Cesare Fusetti Mitglied SGH Membre SSCM Dr. med. Michaël Papaloïzos Vorstandsmitglied SGH Membre du comité SSCM PD Dr. med. Andreas Schweizer Mitglied SGH Membre SSCM PD Dr. med. Esther Vögelin Präsidentin SGH Présidente SSCM Maja Drotschmann Mitglied SGHR Membre SSRM Gabriele Versümer Bücker Past-Präsidentin SGHR Ancienne présidente SSRM Katrin Voss Mitglied SGHR Membre SSRM Administrative Organisation / Organisation administrative Healthworld (Schweiz AG), Sennweidstrasse 46, 6312 Steinhausen Tel , Fax , toni.vonwyl@healthworld.ch, 3

4 Freie Mitteilungen SGH Communications libres SSCM FM 1 10 year follow-up of pyrocarbon implants for proximal interphalangeal joint replacement Lisa Reissner 1, Stephan F. Schindele 1, Stefanie Hensler 1, Miriam Marks 1, Daniel B. Herren 1 ( 1 Zürich) Introduction: Short and mid-term results of anatomical resurfacing using a pyrocarbon prosthesis (Ascension Orthopedics) showed reasonable clinical results with a high migration rate radiographically due to problematic implant fixation. The aim of the study was to investigate the subjective, clinical and radiographic long-term results after 10 years, and to compare them with the 2 year follow-up. Methods: In a prospective, consecutive case series, 17 PIP- Pyrocarbon implants in 14 patients were assessed subjectively by a VAS pain scale, clinically and radiographically pre-operative, at a mean follow up of 20.1 months (± 5.4) and 9.7 years (± 0.5). The indication for the joint replacement arthroplasty was degenerative osteoarthritis in 15 cases, chondrocalcinosis in one patient and post-traumatic in another patient. Results: One patient died before the 10 year follow up. One patient needed a revision surgery, due to implant failure. All other implants remain in situ. After a mean follow-up of 9.7 years no further migration of the implants were observed in comparison with the average 20.1 month follow-up. Radiolucent lines remained identical with an average of 2.1mm (± 0.9). The average total range of motion of all replaced joints was 35 preoperatively, 38 at the 2 year follow-up and decreased significantly to 27 at the final follow up (p 0.01). The average grip strength was 21 kg pre-operatively, which increased to 26 kg at the 2 year follow-up and decreased again significantly at the final follow-up to 17 kg (p=0.001). Significant pain relief was noted in all patients from 7.6 pre-operatively to 1.4 at 2 years of follow-up and 0.8 at final follow-up (p 0.001). Discussion: To our knowledge this case series is the longest consecutive follow-up of PIP-Pyrocarbon implants. Compared to the results at the 2 year follow-up, the observed implant migration remained stable over time although no signs of secondary osteo-integration were observed. The range of motion decreased with longer follow-up and was, with less than 30, disappointing for most patients. However overall patients satisfaction remained high due to permanent pain-relief. Nevertheless, we no longer perform this kind of arthroplasty due to only moderate clinical results and potential complications with implant migration. FM 2 Arthroplastie unipolaire en pyrocarbone dans l arthrose interphalagienne proximale Jean-Yves Beaulieu 1, Stéphane Kämpfen 1, Philippe Vostrel 1, Gontran Sennwald 1 ( 1 Geneve) Introduction : L arthrose IPP quelle soit d origine posttraumatique ou rhumatologique entraine une perte de fonction importante au niveau de la main. La prise en charge thérapeutique peut comprendre la réalisation de dénervation, d arthrodèse ou encore d arthroplastie. Les arthroplasties consistent en la mise en place d implant devant permettre la mobilisation indolore des articulations. Il existe différents types d implant : soit un spacer en silicone, soit un remplacement bipolaire articulaire. Nous vous présentons une courte série de 4 patients ayant bénéficiés d un remplassement unipolaire en pyrocarbone par un implant proximal IPP Ascencio. Matériel et méthode : 5 implants condyliens proximaux IPP Ascencio ont été posés chez 4 patients. Il s agissait de 3 femmes et un homme. La moyenne d âge était de 61 ans (38-74 ans). Dans 4 cas il s agissait d arthrose essentielle et dans un cas une arthrose post traumatique IPP. Tous les patients on bénéficié d une voie d abord palmaire. L implant proximal était implanté après résection de la tête de P1 et la base de P2 n étant pas modifiée. L évaluation c est faite sur le score du quick dash la force de serrage les mobilités articulaires et l analyse radiographique. Résultats : La revue moyenne des cas est à 24 mois (6-60mois). 3 index, 1 majeur et 1 annulaire furent implantés dans deux cas sur les mains dominantes. Aucun patient n a présenté de complication majeure. A la revue le score moyen du quick dash était de 24 (9-31). Les patients ne présentaient plus de douleur au repos. Les mobilités en moyenne en flexion étaient de 72 et un déficit d extension de 5 en moyenne. Dans 3 cas on retrouvait un clinodactisme latérale ulnaire en moyenne de 10 (0-20). Le contrôle radiographique permet de mettre en évidence dans tous les cas une densification corticale autour de la tige prothétique sans migration de l implant. Tous les patents présentaient un remaniement de la base de P2 s installant dans les premiers mois post opératoire mais stable au dernier recul. Conclusion : Le remplacement unipolaire de la tête de P1 dans les arthroses IPP par un implant en pyrocarbone donne des résultats prometteurs. Nous l incluons désormais dans nos possibilités thérapeutiques. FM 3 Case studies of a constrained finger joint system for interphalangeal (PIP) joints Eva Ståhl Wernersson 1, Håkan Håkanson 1, Göran Lundborg 1, Anders Björkman 1 ( 1 Malmö SE) Arthroplasty can be used for patients suffering from rheumatoid arthritis or arthrosis (both primary and posttraumatic) in the metacarpohalangeal (MCP) joints or in the interphalangeal (PIP) joints. A new design of a constrained finger implant system with a joint mechanism and bone anchorage screws has been developed. The system is designed for long endurance and to prevent luxation and instability. The joint resists the large forces applied occasionally to the joint. 4

5 The joint consists of two titanium screws which are fixated in the phalangeal bones. The joint has plates with pins that firmly fit into the screws. The plates are constrained with a ball of plastic material. The flexion of the joint is preset by the design of the ball. The PIP joint allow for 90 degrees of flexion, however, deviation is limited to a couple of degrees. The first patient was operated on using this arthroplasty system in June By May 2012, 47 MCP joints and 15 PIP joints have been implanted in 26 patients. We will present three patients operated on using this system in four PIP joints. The follow up period is 2 to 26 months. The three patients show good clinical results with decreased pain and improved range of motion. We conclude that the titanium screws osseointegrate and the joint mechanism allows for a good range of motion resulting in considerable pain reduction and improved mobility in the fingers of the patients. Ledbo êj-bild.jpg FM 4 Die PIP-Prothese -Was haben wir gelernt?- Nicole Schmelzer-Schmied 1, Robert Vogt 1, Mark Aerni 1 ( 1 Münsterlingen) Einleitung: Bei der Versorgung einer Bouchardarthrose durch eine PIP-Prothese gibt es Einiges zu beachten. Im Laufe der letzten 10 Jahre, konnten Erfahrungen gesammelt werden, die zur Verbesserung der Ergebnisse nach Operation und so zur Patientenzufriedenheit beitragen. Ziel dieser Studie war es, Fehlerquellen bei der Operation ausfindig zu machen und den Verlauf nach PIP-Implantation zu dokumentieren, sowie klinische und radiologische Ergebnisse hinsichtlich verschiedener Einflussgrößen zu untersuchen. Material/Methode: Im Rahmen einer retrospektiven Studie, wurden 58 Patienten mit 77 PIP-Prothesen (SBI-Avanta) im Hinblick auf klinische und radiologische Parameter untersucht. Unter anderem wurden die ROM, die Patientenzufriedenheit anhand des Quick-Dash und die Kraft gemessen. Dabei wurden 2 Gruppen gebildet. Patienten, die in den Jahren operiert wurden, wurden mit Patienten, die zwischen operiert wurden verglichen. Ergebnisse: Insgesamt sind die Ergebnisse nach Implantation einer PIP-Prothese sehr gut. Die radiologische Lockerung, die Schwanenhalsdeformität sowie die Patientenzufriedenheit konnte in den letzten Jahren verbessert werden. Unsere Ergebnisse zeigen, dass es von Vorteil ist, auf Tricks zu achten. Unter anderem sollte die Kontaktfläche der Prothese genügend groß sein, das intraoperative Gelenkspiel leicht. Ein positiver Faktor scheint außerdem das Zementieren der Prothese zu sein. Dennoch sollte die Indikation zur Implantation einer PIP-Prothese gut überlegt sein. FM 5 Hemi-hamate autograft arthroplasty for acute and chronic PIP joint fracture dislocations Nicole Lindenblatt 1, Angelo Biraima 1, Ivan Tami 2, Pietro Giovanoli 1, Maurizio Calcagni 1 ( 1 Zürich; 2 Gravesano- Lugano) Introduction: Treatment of fracture dislocations of the PIP joint represents a hand surgical challenge. In hemihamate arthroplasty, the palmar joint surface is reconstructed using an osteochondral graft from the hamate and the immediate stability permits early movement. Material and Methods: We performed hemihamate reconstructions in 10 patients (mean age 35 years), who sustained fractures of the base of the middle phalanx of 50% surface and dorsal PIP dislocations. Outcomes were assessed by clinical exam and x-ray. Evaluation criteria were range of motion of PIP and DIP joints, grip strength, joint alignment, complications and donor site morbidity. Results: Mean follow-up was 8 months (range 3-14). Fractures mostly involved the 4th and 5th fingers, all patients were male. Indications were subluxation and comminution in acute cases of < 6 weeks (5 patients) and chronic pain and morning stiffness in chronic cases (3 patients). 2 patients had no pain and underwent revision surgery to prevent secondary osteoarthritis. Operative treatment was performed in average after 67 days (range days) after injury. Average PIP motion was 71 degrees (range 0-90), DIP motion was 55 degrees (range 10-90) with a mean PIP flexion contracture of 5 degrees (range 0-20). Grip strength averaged 95% of the opposite hand. 3 patients had revision surgery (2x arthrolysis PIP joint, 1x neurolysis R. dorsalis N. ulnaris). Conclusions: Hemi-hamate autograft arthroplasty represents an effective procedure to address severe PIP joint fracture-dislocations. It restores the comminuted articular surface in chronic injuries and in the acute injury it is a challenging but valuable alternative to extension block spliniting. However, donor site morbidity and revision surgery have to be taken into account. PostopPIPHamatum.jpg 5

6 FM 6 Ein Jahr Follow-up nach Rekonstruktion komplexer PIP Gelenks Defekte Thomas Meszaros 1, Bettina Juon 1, Nicole Badur 1, Esther Vögelin 1 ( 1 Bern) Einleitung: Komplexe Defekt-Läsionen des proximalen interphalangeal (PIP) Gelenkes bei Handwerkern sind für den behandelnden Handchirurgen eine Herausforderung. Falls immer möglich ist eine primäre Rekonstruktion der defekten Knorpel-Knochen-, Sehnen- und Bandstrukturen zum Erhalt der Beweglichkeit anzustreben. Material: 5 Handwerker im Alter von 21 bis 57 mit komplexen PIP Gelenkes Defekten wurden primär rekonstruiert. Der Zeigefinger war vier mal betroffen und der Kleinfinger einmal. Alle Patienten hatten einen osteochondralen Defekt (3x Grundphalanx Kopf, 2x Mittelphalanx Basis) und zusätzlich eine Läsion des Streckapparates. Die Seitenbänder waren in 4 Fällen betroffen. Die Rekonstruktion des Knorpel-Knochen- Defektes wurde mit einem freien, autologen osteochondralen Graft durchgeführt: der Defekt der Grundphalanx wurde mit einem Graft des Os Metatarsale III, der Basis Os Metacarpale IV oder dem Grundphalanx Kopf der II. Zehe rekonstruiert. Die Rekonstruktion der Mittelphalanxbasis erfolgte in 2 Fällen mit einem Hemihamatum-Graft. Eine Strecksehnenrekonstruktion mittels freiem Sehnentransplantat war in 3 Fällen nötig, die Bandläsionen wurden ebenfalls versorgt. Die Nachbehandlung wurde in allen Fällen nach Early Active Short Arc Motion (SAM) durchgeführt. Resultate: Durchschnittlich zeigte sich nach 3 Monaten ein Range-of-motion von 73 (Flexion/Extension: ), nach 6 Monaten von 83 (F/E: ) und nach 1 Jahr von 88 (F/E: ). Alle Patienten konnten ihren angestammten Beruf wieder im Vollzeitpensum ausführen und waren mit dem erreichten funktionellen und kosmetischen Resultat zufrieden. Zusammenfassung: Eine primäre Rekonstruktion komplexer PIP Gelenkes-Defektläsionen mit autologem osteochondralen Graft in Kombination mit Sehnen- und Bandrekonstruktionen gefolgt vom intensiver frühfunktioneller Handtherapie erzielt auch bei Handwerkern ein gutes funktionelles Resultat. FM 7 3D assisted planning and performance of corrective osteotomy Andreas Schweizer 1, Ladislav Nagy 1 ( 1 Zürich) Introduction: Malunions at the hand may lead to pain, reduced range of motion, instability and joint degeneration justifying corrective osteotomy. The procedure is challenging due to the minuteness of the bones, restricted access and the aimed accurateness of <1mm for intraarticular malunions. To improve planning and precision of the intervention 3D visualisation, calculation and intraoperative guiding devices were developed. We present this new technique on the basis of a case series. Methods: CT based 3D reconstructions (segmentation; software mimics, materialise) of the malunited bone and the intact opposite bone (mirrored) were used to plan and perform the osteotomy virtually. Intraarticular osteotomies (distal radii n=6) were performed in an outside-in technique. Multiple drill-holes which were connected to complete the osteotomy planes were performed by individualised drilling-guides (rapid prototyping; software 3-matic, materialise) using the juxtaarticular bone surface for exact positioning. The reposition was controlled either by a second guide or direct step measurements. Extraarticular corrections (metacarpal bones n=2) were performed with individualised guides fitting to the bone surface. Drill holes were set in a defined pre-planned position considering the exact amount of malposition of the fragments and the screw-hole positions of an angle stable implant (Synthes). After the osteotomy the plate was used as a reposition tool by simply assembling/screwing the fragments to the plate in the correct position. Results: All interventions could be performed as planned. The steps of the intraarticular malunions were corrected to considerably less than 1mm and general joint congruency was restored. The extraarticular cases showed an accuracy of 1-2mm and less than 2. In all patients pain was reduced and range of motion was increased. Conclusion: 3D assisted corrective osteotomy with drilling guides is a precise and reliable method. Additionally it is the only possible method to correct intraarticular malunions on the palmar side of the distal radius and facilitates considerably correction of multiplanar deformations. Os metakarpale V Doppelosteotomie mit Bohrguide (grün/planung; weiss/intraop), Situation postop. mit überlagertem gespiegeltem Knochen der Gegenseite (grün) sowie der 3 korrigierten Fragmente (blau, rot, violett) FM 8 Die dekomprimierende Radiusverkürzung bei Ulna- Minus-Varianz Christian Ziegler 1, Jochen Mayer 1, Ralf Richter 1, Hermann Krimmer 1 ( 1 Ravensburg DE) Einleitung: Neben der relativ häufigen Ulna Plus Varianz mit all ihren möglichen Pathologien, sieht man wesentlich seltener auch das Bild einer ausgeprägten Ulna Minus Varianz. Hieraus kann bei einer Inkongruenz des distalen Radioulnargelenkes eine ausgeprägte Schmerzhaftigkeit resultieren. In der Vergangenheit wurde bezüglich einer chirurgischen Intervention eher zugewartet. Heute ist die dekomprimierende Radiusverkürzung eine vielversprechende Methode um Schmerzen und eine allenfalls mögliche Arthrose im distalen Radioulnargelenk zu vermeiden. 6

7 Ziel: Vorstellung der ersten klinischen und radiologische Resultate bei 6 Patienten nach dekomprimierender Radiusverkürzungsosteotomie bei primärer Ulna Minus Varianz. Das Operationsverfahren ermöglicht durch eine Keilosteotomie mit Verkürzung einen Radialshift. Die Inkongruenz im distalen Radioulnargelenk wird korrigiert im Sinne einer schmerzreduzierenden Dekompression. Material und Methoden: In einer retrospektiven Studie werden die ersten Ergebnisse nach dekomprimierender Radiusverkürzung über einen palmaren Zugang mit einem minimalen follow up von 6 Monaten vorgestellt. Resultate: Die Beweglichkeit im Handgelenk für Flexion und Extension war bei allen Patienten postoperativ uneingeschränkt. Ebenfalls ergab sich für die Pro- und Suppination im distalen Radioulnargelenk keine Einschränkung. Der schmerzbedingte Leidensdruck (präoperativ VAS 7,8) konnte durch diese Methode 12 Monate postoperativ deutlich reduziert werden (VAS 1,8). Ein Patient war mit dem Vorgehen so zufrieden, dass die Gegenseite ebenfalls operiert wird. Zusammenfassung: Die Ergebnisse dieser Operationsmethode zeigen erfreuliche Resultate bezüglich Funktion, Schmerzen und der hieraus resultierenden Patientenzufriedenheit. Neben der Schmerzreduktion ist von einem präventiven Charakter dieses Vorgehens mit Vermeidung der langfristig zu erwartenden Arthrose auszugehen. Radiusverkuerzung1.jpg FM 9 A radiolucent, carbon fibre reinforced synthetic plate for distal radius fractures: first experience Jürg Sonderegger 1, Gerd Laub 1, Marc Wieder 1 ( 1 Grabs) Introduction: Steel and titanium are widely and successfully used implant metals in traumatology. However, some disadvantages are related to metallic implants: They provoke artefacts in computed tomography (CT) and magnetic resonance imaging (MRI). Also, bone healing might be difficult to monitor in x-ray studies due to the invisibility of the bone underlying the implant. Furthermore, hardware removal still remains an issue, especially with titanium implants. In order to avoid these problems carbon fibre reinforced polyetheretherketone (PEEK) implant material has been developed. The main advantages of this synthetic material are radiolucency, artefact-free imaging, good fatigue properties and biocompatibility. In spine surgery carbon fibre reinforced PEEK implants have been successfully used and documented for the last few years. Recently palmar plates for distal radius fractures have been developed. Material and Methods: Three consecutive cases of dorsally displaced extraarticular distal radius fracture were stabilized with a palmar semi-rigid carbon fibre reinforced PEEK plate with angular stable screw fixation (icotec AG, Altstätten, Switzerland). Integrated radiopaque tantalum filaments and metallic screw tips allow correct placement of the plate and make the implant visible under image intensifier. A clinical and radiographic follow up was performed at 2 and 6 weeks, and at 3 and 6 months. Results: The range of motion at final follow up was comparable to the contralateral wrist and all patients were pain free. Bony union was achieved in all cases. We did not record any infections, secondary dislocations, tendon ruptures or other complications. Discussion: We present our first experience on a new carbon fibre reinforced synthetic palmar plate for distal radius fractures. The implant might represent an interesting alternative to metallic implants. Potential advantages are radiolucency, no adherence to surrounding tissues and no artefacts in CT and MR imaging. A disadvantage of the implant is the missing multidirectional screw fixation, making it difficult to use in complex fracture situations. Radiusverkuerzung2.jpg 7

8 FM 10 Corrective Osteotomy of the Distal Radius with or without Bone Grafts Alexander Kozlowski 1, Vinh-Thuan Ly 1, Martino Meoli 1, Jörg Grünert 1 ( 1 St Gallen) Malunion of distal radius fractures still represents a common complication. Corrective osteotomy of the distal radius improves function and can lead to significant pain relief. Early correction of the deformity should be preferred as it shortens the time of morbidity. The new anatomical, locking implants not only provide stable fixation and improve postoperative management, but also early functional rehabilitation. Based on these implants there is no more need for a prolonged immobilization. As the modern implants provide safe fixation, the discussion of whether to use interposition bone grafts (cortical or cancellous) is still open. Some illustrative cases are presented and recommendations are elaborated. ap.jpg Korrekturosteomie.jpg FM 11 New radiographic method to determine screwlength using volar locking plate in distal radius fracture Luzian Haug 1, Bernhard Glodny 2, Christian Deml 2, René El Attal 2, Martin Lutz 2 ( 1 Luzern; 2 Innsbruck AT) lat.jpg Verletzungen von Extensorensehnen nach volarer Plattenosteosynthese bei distalen Radiusfrakturen ist ein bekanntes Problem und in der Literatur bereits öfters beschrieben. Ursächlich sind hierfür meist zu lange Schrauben, welche die dorsale Kortikalis überragen und in die Strecksehnenfächer reichen. Intraoperativ ist es wegen der komplizierten Anatomie und dem Tuberculum Lister schwierig mit einer anteroposterior und lateralen Röntgenaufnahme die Schraubenlänge korrekt zu beurteilen. In einer axialen Röntgenaufnahme entlang der Achse des Radius kann man zu lange Schrauben genau erkennen. In welchem Winkel die Aufnahme durchgeführt werden soll, ist Ziel dieser Studie. Methode Bei sechs Kadaverarmen wurde jeweils eine volare distale Radiusplatte implantiert. Die Schraubenlänge 8

9 wurde durch einen dorsalen Zugang genau kontrolliert und unter Sicht die Überlänge gemessen. In einer ersten Serie wurde die Schraubenlänge so gewählt, dass die dorsale Kortikalis gerade nicht penetriert wurde. In der zweiten Serie wurden sämtliche Schrauben durch eine 2 mm längere Schraube ersetzt. Bei beiden Serien wurden axiale Röntgenaufnahmen des distalen Radius in 5 -Schritten durchgeführt - beginnend bei 0 Grad (Einfallswinkel α) [vgl. Bild]. Zusätzlich fertigten wir bei jeder Serie eine Computertomographie an. Ergebnisse Der Vergleich zwischen den axialen Röntgenaufnahmen und der tatsächlich gemessenen Schraubenlänge zeigte eine statistisch signifikante Korrelation bei einem Einfallswinkel von 5-20 in beiden Serien. Der beste Einfallswinkel stellte sich jedoch bei 15 heraus, wobei 24 der 25 Schrauben in der zweiten Serie als korrekt zu lang erkannt wurden. Die aus der Computertomographie angefertigen 3D- Rekonstruktionen mit identischem Versuchsaufbau, zeigten zwar eine gleiche Korrelation bei jedoch geringerer Messgenauigkeit, da die Streuungsartefakte in der CT mehr ins Gewicht fielen. Schlussfolgerung Die Schraubenlänge bei der volaren Plattenosteosynthese bei distalen Radiusfrakturen kann durch eine axiale Röntgenaufnahme exakt beurteilt werden. Die beste Korrelation mit der tatsächlichen Schraubenlänge konnte bei einem Einfallswinkel von 15 gefunden werden. Standardaufnahmen des Handgelenkes (a.p. und seitlich) ist die Fraktur oft nicht sichtbar und wird deshalb häufig als Handgelenksdistorsion fehlinterpretiert. Zur Diagnosestellung und Therapiebeginn kann es Wochen dauern. Die nicht erkannte oder nicht behandelte Fraktur des Hamulus heilt oft in Form einer Pseudarthrose aus und führt zur Persistenz der Beschwerden. Die Empfehlungen zur Therapie dieser Fraktur basieren auf retrospektiven Studien mit kleinen Fallzahlen. Standardgemäss werden bei der operativen Therapie der Fraktur des Hamulus die Resektion des Hamulus oder die offene Reposition und osteosynthetische Versorgung von einem palmaren Zugang aus durchgeführt. Die osteosynthetische Versorgung scheint aufgrund der erhaltenen besseren Grobkraft im Ergebnis günstiger zu sein. Material und Methoden Im Folgenden wird über zwei Fälle mit älteren (6,5 Wo und 7,5 Wo) Hamulusbasisfrakturen berichtet, die nach einem erfolglosen konservativen Therapieversuch, durch einen minimalinvasiven Zugang von dorsal mit einer kanülierten 2,2 mm Schraube versorgt wurden. Nach einer postoperativen Ruhigstellungszeit von sechs Wochen waren die Frakturen nach CT-Kriterien fest. Nach Remobilisierung des Handgelenkes fand sich keine Minderung der Beweglichkeit oder der groben Kraft. Sowohl die berufliche Tätigkeit mit hohem manuellen Belastungsprofil, als auch sportliche Tätigkeiten werden in beiden Fällen uneingeschränkt weitergeführt. Schlussfolgerung Die beiden dargestellten Fälle ermutigen dazu auch ältere, zu spät diagnostizierte, oder nicht heilende konservativ behandelte Frakturen des Hamulus osteosynthetisch zu versorgen. In beiden Fällen konnte die Fraktur mit einer kanülierten Schraube durch einen minimalinvasiven Zugang von dorsal bei sorgfältiger Plazierung der Schraube ohne die Gefährdung des motorischen Astes des N. ulnaris verschraubt werden. Weitere, aufgrund der geringen Fallzahlen ggf. multizentrische Studien sind nötig, um die Wertigkeit des Verfahrens festzustellen. FIGURE1.jpg FM 12 Versorgung veralteter Hamulusfrakturen mit kanülierter Schraube minimalinvasiv von dorsal Roman Blazek 1, Tomas Kniess 2, Sandra Vossen 1, Thomas Maurer 1 ( 1 Langenthal; 2 Solothurn) Einleitung: Die Fraktur des Hamulus ossis hamati ist eine seltene Fraktur der Handwurzel. Sie wird mit einer Häufigkeit von 2-4% der Handwurzelfrakturen angegeben. Auf den 9

10 Bild 1. jpg FM 14 Is the Michigan Hand Questionnaire a valid tool to assess patients with 1st CMC OA? Miriam Marks 1, Daniel Herren 1, Stephan Schindele 1, Rob Nelissen 2, Thea Vliet Vlieland 2 ( 1 Zürich; 2 Leiden NL) Bild 2.jpg FM 13 Die piezoelektrische Osteotomie Dominik Hoigné 1, Jörg Hainich 1, Jörg Grünert 1 ( 1 St. Gallen) Die piezoelektrische Osteotomie ermöglicht weichgewebeschonendes Operieren auf engstem Raum. Die Technik ist in der Kieferchirurgie etabliert. Inzwischen sind die Indikationen auf weitere Gebiete ausgeweitet worden. Wir haben zwei Geräte von zwei Anbietern (Synthes und Piezosurgery ) in der Handchirurgie getestet und berichten von den Erfahrungen. In schwierigen Situationen haben sich die Vorteile der piezoelektrischen Technik deutlich gezeigt. So konnte eine Swanson-Prothese trotz Versagen der Reamer bei ausgeprägter Sklerose mit der piezoelektrischen Technik problemlos implantiert werden. Die Technik der piezoelektrischen Osteotomie sollte einem Handchirurgen bekannt sein, auch wenn dringende Indikationen eher selten sind. Background The Michigan Hand Questionnaire (MHQ) is a self-administered questionnaire on hand function which, in contrast to other commonly used hand function questionnaires, yields results for each hand separately. The MHQ has been translated into German.1 Its reliability and validity in patients with carpometacarpal osteoarthritis (CMC OA) have not been proved for either the English original or the German version. Objectives To investigate the internal consistency and convergent construct validity of the German MHQ for patients with CMC OA. Methods Baseline data from consecutive patients included in a prospective, observational study on conservative and surgical treatment of CMC OA were used. All patients were asked to complete the MHQ, which consists of 37 items including six subscales: hand function, activities of daily living (ADL), pain, work performance, aesthetics, and satisfaction with hand function. The total score as well as the subscale scores are normalised and range from 0 to 100; higher scores indicate better performance, except for pain, where a higher score denotes more pain. Patients also filled in the Disabilities of Arm, Shoulder and Hand Questionnaire (DASH). Internal consistency was measured by calculating Crohnbach s alpha. To investigate the convergent construct validity, correlations between the MHQ, its subscales and the DASH were calculated using Spearman s correlation coefficient. Results 90 female and 19 male patients with a mean age of 64 years (SD ± 9.1) were included in the study. The total mean score of the MHQ was 55 (SD ± 14.1) for the affected hand and 67 (± 11.7) for the nonaffected hand, with 0.03% missing items in total. No patient obtained either the minimum or the maximum total score. Internal consistency ranged from α = 0.5 for the MHQ pain subscale to α = 0.89 for the ADL subscale. ADL (r=-0.74**), work (r=-0.64**) and satisfaction (r=-0.64**) as well as the total score (r=- 0.72**), correlated well with the DASH, whereas hand function (r= -0.45**) and pain (r= 0.32**) showed modest, yet statistically significant correlations (**=p 0.01). The aesthetics subscale did not correlate significantly with the DASH (r=-0.1). Conclusions The German MHQ seems to be an internally consistent and valid questionnaire for measuring hand function in patients with CMC OA. Its responsiveness in this particular patient group needs to be determined in future research. References 1 Plast Reconstr Surg. 2011; 128: 39e-40e Piezo Abstract SGH.jpg 10

11 FM 15 One step treatment of type II and IIIA thumb hypoplasia: results at 4 years Thierry Christen 1, Gilles Dautel 2 ( 1 Lausanne; 2 Nancy FR) Thumb hypoplasia treatment requires considering every component of the malformation. Type II and IIIA hypoplasia share common features such as first web space narrowing, hypoplasia or absence of thenar muscles and metacarpophalangeal (MP) instability. We believe that these three components can be effectively handled in a single procedure combining a first web enlarging plasty, a MP joint ligamentoplasty and an opponensplasty. Therefore, the goal of this retrospective study was to investigate the clinical results of this combination of surgical steps. The first web space was widened with either a four flap Z-plasty or a kite flap associated to a Dufourmentel flap for closure of t he donor site. The first web was kept abducted by an omega shaped K-wire between the first and second metacarpals. Opposition was restored by using a opponensplasty with the ring finger flexor digitorum superficialis. The same tendon was employed to stabilize the MP joint on its ulnar and/or radial side according to clinical testing findings. Abnormal tendon interconnexions (pollex abductus) were severed when present. Fifteen patients (18 thumbs) were included in the study. The mean follow-up was 45 months. Widening of the first web space was achieved in all cases. The mean post-operative opposition score was 6 according to Kapandji s scale. Stability of the MP joint was improved in all but one patient. Functional evaluation by the Manske standardized set of manual tasks showed effective gross grasp between the thumb and fingers while fine manipulation remained limited for three children. In conclusion, one-step surgical handling of type II and IIIA thumb hypoplasia yields favorable and durable results. Deficiencies considered minor such as radial collateral ligament laxity can be corrected without additional morbidity. FM 16 Syndactylies in Cleft Hands: Is a routine angiogram needed before surgery? Daniel Weber 1, Beat Simmen 1, Paul Smith 2 ( 1 Zürich, 2 London) Syndactyly of the first web can frequently be observed in cleft hands (Manske type III). Due to the unequal length of the thumb and index, adduction deformity of the thumb and angulation of the index finger can be progressive during growth. Therefore, most surgeons attempt early separation of these syndactylies. Many reports focus on the technique of opening the first web space and closure of the central cleft. However, little has been reported on possible vascular compromise of the index during separation. We report on two children with Manske type III cleft hands who had intra-operative complications during attempted release of the 1st web space that was performed without previous angiography. The first patient had a well developed thumb and index with a simple complete syndactyly. During attempted separation, no palmar digital arteries of the index were found next to the intact digital nerves and the procedure had to be abandoned. The second patient had a similar anatomy: Intraoperatively, only a single minute digital artery to the index was found. After syndactyly release, the index had a prolonged poor recapillarisation. However, the patient had a good long-time outcome. The observation, that some patients with cleft hands have a syndactyly of the thumb and index on one hand and an absent or severely hypoplastic index on the other hand underline, that the blood supply to the index may be precarious. Relatively few reports on angiography of cleft hands have been published. Upton mentioned in his 2004 publication a large series of 20 hands with 16 cases who had a common digital artery from the palmar arch which supplied the radial side of the index and ulnar side of the thumb. This arcade became the limiting structure when opening the 1st web space. Our observations suggest that preoperative angiography may be warranted prior to separation of syndactyly release of the first web in Manske type III cleft hands. FM 17 Treatment options for the upper extremity in children and adolescents with cerebral palsy Daniel Weber 1, Claudia Rota 1, Maurizio Calcagni 1, Beth Padden 1 ( 1 Zürich) Cerebral Palsy (CP) can affect all four limbs. Since many pediatric and orthopedic colleagues are aware of the great potential of Botulinum toxin (BTX) and surgery to improve lower limb function, most children and adolescents with CP are offered an intensive rehabilitation program in Switzerland. However, only few children are enrolled in specialized programs for the upper limbs, because the potential of this treatment is not well known and patients are sometimes tired after extensive rehabilitation programs for the lower extremities. The aim is to present a series of children who received treatment with BTX, surgical muscle releases and muscle transfers to improve hand function and to systematically illustrate indications, contraindications and prerequisites for treatment. Between 2006 and 2011, 37 children and adolescents were assessed in our interdisciplinary upper extremity CP clinic. Most of them were referred from our rehabilitation clinic or our pediatric orthopaedic surgeons and therefore, in this highly selected group of patients, treatment with BTX was offered in 27 patients (no indication was seen due to dystonia in 3, no potential for improvement because function was too 11

12 poor in 5 and too good to be improved in 2 patients). Eight patients were operated, 2 operations are pending and 2 patients did not wish surgery although we saw an indication. No complications were seen after surgery and patients were satisfied with the result. Only few children and adolescents with CP classify for BTX treatment of the upper extremity and even fewer have an indication for surgery. However assessment by an interdisciplinary team may allow identifying a selected group of patients in whom function and positioning of the hand can be improved reliably. FM 18 postoperative function Can We Save the Arm? A 38-Year-Old Man withmorbus Ollier (Enchondromatosis) and Secondary Chondrosarcoma Elisabeth A Kappos 1, Jörg Grünert 2 ( 1 Basel; 2 St. Gallen) Chondrosarcoma patients often have far progressed tumors which demand amputation of an extremity to fullfil the needs of an oncologically correct surgery. With this case we were able to show that preservation of functionality and body aesthetics is possible even in locally very far progressed tumors. To reach an optimal outcome, without unreasonable risks for the patients safety, sensitive preoperative planning and a well functioning interdisciplinary cooperation between surgeons, oncologists, radiologists and anesthesiologists is crucial. Following interdisciplinary agreement, radical surgery may sometimes be necessary to provide adequate treatment. Performed by a skilled surgical team, functionality can be preserved and ability to work regained. Radical surgery might not only be curative in this case but constitute a huge functional and aesthetic gain for the patient. postoperative Rx FM 19 Macroreplantations of the Upper Extremity : A series of 11 patients Franck Marie Leclère 1, Lukas Mathys 1, Bettina Juon 1, Esther Vögelin 1 ( 1 Bern) intraoperative situs postoperative function Introduction: Depending on the level of amputation, distal or proximal to the wrist, it is classified as micro- or macroreplantation. In 1990 we presented a 10 ten year experience in macroreplantation. This complementary study was performed to review our experience with special attention to technical considerations and outcomes. Material and Methods: Between January 1990 and December 2010, eleven patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4 ± 18.2 years (range, 19 to 76 years). There were two through elbow, two proximal forearm, four midforearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5 ± 6.3 years (range 2-21 years) 12

13 Results: All but one were successfully replanted and regained limb function Chen I in 4 cases (36%), Chen II in 3 cases (27%), Chen III in 2 cases (18%), and Chen IV in one patient (9%). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries. Conclusion: Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at replantation centers Results: Average follow-up was 5 months. All flaps healed uneventfully with no flap necrosis or infection. In 44 cases, pulp s volume was restored without disturbances of nail growth. Five complications (9%) were observed (pain, soft nail and nail deformities). Only nail deformity required reoperation. All patients were satisfied with the overall aesthetic and functional outcome, regardless of the amputation zone. Discussion: Shortening of fingernail leads not only to poor cosmetic result but also to reduced pulp stability and sensitivity. Distal fingertip amputations require combined reconstructions addressing both palmar and dorsal defects. The eponychial plasty permits nail salvage even in case of defects proximal to the lunula and is a simple, safe, time-effective technique that can per performed on an emergency basis. FM 21 Okklusionsverband: Nachweis der Regeneration nach Amputation der Fingerkuppe Susanne Habelt 1, Urs Hug 1, Elvira Bodmer 1, Luzian Haug 1, Rik Osinga 1, Elmar Fritsche 1, Urs Von Wartburg 1 ( 1 Luzern) Leclère_11 REPLANTATIONS_Fig. 1_.doc_.jpg Leclère_11 REPLANTATIONS_Fig. 2_.doc_.jpg FM 20 Primary functional and aesthetic restoration of distal fingertip amputations with eponychial flap Richard Fakin 1, Angelo Biraima 1, Klein Holger 1, Pietro Giovanoli 1, Maurizio Calcagni 1 ( 1 Zürich) Introduction: Fingertip injuries often include defects to fingernails and their reconstruction should be addressed within primary surgical approach. Present series retrospectively evaluates forty-five fingertip defects with at least a half of the fingernail involved where nail-complex salvage has been performed by dorsal eponychial plasty. Methods: Forty-five eponychial flaps were performed. In 33 cases, the procedure was combined with palmar island flaps for pulp reconstruction in the same operation. Form, sensitivity, nail growth, aesthetics and complication rate were analysed. Einleitung Eine Fingerkuppenamputation definierten Ausmasses kann sowohl mit einer lokalen Lappenplastik als auch mit einem Okklusionsverband behandelt werden. Bisher ist nur wenig bezüglich der Bestimmung des regenerierten Weichteilvolumens nach Behandlung mit Okklusionsverbänden bekannt. Unsere Gruppe konnte letztes Jahr zeigen, dass die sonographisch gemessene Weichteildicke der regenerierten Kuppen durchschnittlich ca. 90% der gesunden Gegenseite erreicht. Unser nächstes Ziel ist, die Volumenzunahme des Weichteilgewebes während der Therapie mittels Wasserverdrängung quantitativ zu zeigen. Methode Als Pilotfall wurde bei einem 20-jährigen Schreiner eine Zeigefingerkuppenamputation mit ossärer Beteiligung der Okklusiv-Verband angewendet. Zu Beginn der Behandlung erfolgte eine Volumenbestimmung des verletzten Endgliedes. Dazu wurde der Finger bis zur DIP-Gelenksfalte in ein mit steriler Kochsalzlösung gefülltes Gefäss getaucht. Das aus dem Gefäss verdrängte Wasser entsprach also dem Endgliedvolumen. Anschließend wurde ein Okklusionsverband (OpSite Folie, selbstklebend Polyurethan-Folie, Smith and Nephew,UK) angelegt, der wöchentlich gewechselt wurde. Distal wurde ein kleines Reservoir belassen, über die Folie wurde ein TubeGaze-Verband angelegt. Nach 6 Wochen bzw. nach vollständiger Heilung mit intaktem Epithelüberzug der regenerierten Fingerkuppe erfolgte eine erneute Messung der verdrängten Flüssigkeit in gleicher Art und Weise. Der Handwerker nahm seine Arbeit nach 7 Wochen zu 100% wieder auf. Ergebnis Nach Abschluss der Behandlung wurden 3.5 ml mehr Wasser verdrängt als am Unfalltag. Zusammenfassung Zusammenfassend handelt es sich bei der Verwendung des Okklusionsverbandes weder um ein operatives noch um ein konservatives Behandlungsverfahren im herkömmlichen Sinne. Viel eher sollte von einem 13

14 regenerativen Konzept gesprochen werden, wobei es nicht zu einer Narbenbildung im Sinne der Reparation sondern eben zu einer Regeneration des Weichteilgewebes kommt. Wir planen, alle mit dem Okklusiv-Verband behandelten Patienten der anfänglichen und abschliessenden Endglied- Volumenmessung zu unterziehen und die entsprechende Serie am Kongress vorzustellen. FM 22 Couverture par lambeau cutané de doigt sacrifié dans le traitement des rétraction digitales sévères après brûlures Philippe Cuénod (Genève) Les brûlures sévères de la main sont fréquentes, surtout chez les enfants, dans les pays en voie de développement. Elles surviennent fréquemment en raison de l usage de la cuisine faite au feu et par le manque de précautions élémentaires dans la prévention des accidents. Le traitement initial traditionnel consiste souvent à draper la main fermée en poing dans un pansement serré, entraînant des cicatrices importantes et rétractiles. La correction secondaire est difficile, car la libération des brides laisse des pertes de substance cutanée étendues. Pour minimiser le recours à des greffes de peau totale, il est parfois possible d utiliser en lambeau la peau d un doigt sacrifié, qu on aura amputé en désossant la peau. Le choix du doigt se porte naturellement sur celui qui est le plus rétracté et le moins fonctionnel. Deux exemples cliniques viennent illustrer l usage de cette technique. FM 23 Are health insurances and bureaucracy pulling back surgeons from patient care?a fight against time Stefano Lucchina 1, Cesare Fusetti 1 ( 1 Locarno) Purpose: all over the world by the 1980s observers have continued to describe our profession in retreat, plagued by bureaucracy, diminished prestige and deep personal dissatisfaction. Previous surveys related to other specialities in other countries report an increasing dissatisfaction with virtually all aspects of practice, including income, workload and time consumed by administrative tasks. This is the first report comparing the time spent to complete both administrative and scientific tasks. Methods: the experience of a certified hand surgeon with a private practice located in Locarno s Hospital is presented. During a period of one month all the activities undertaken by the surgeon inside the hospital were recorded and divided into 14 tasks. Three were the places considered: the private office, the emergency room (ER) and the operating room (OR). All data records related to the time spent for each activity were collected permanently by the physician assistant. The time recorded was rounded off to the next 15 minutes. The pure scientific tasks (ST group) included visits of inpatients, outpatients and in the ER, time spent for surgery, clinical research or phone calls. The pure administrative tasks (AT group) included the reading, dictation or word processing or letters or reports, certificates for health insurances, requests for surgical instruments, writing or supervision of invoices, data collection sheets or statistics. The miscellaneous tasks (MT group) included replays to intramoenia e- mails and humanitarian activities. Results: the average time of work per week was 67 hours. The average time spent for ST group was 66,8%, for AT group was 27,4% and for MT group was 5,8%. The time spent to address AT was 8-fold the time spent for clinical research and article readings. Writing certificates and invoices-related matters only require almost 15 hours per week. Conclusions: our data confirm previous surveys that health insurances and bureaucracy rob patients of doctor s time. The reams of time-consuming paperwork that is out of proportion to time spent caring for patients, fights for reimbursement or loss of autonomy from insurers and fear of malpractice suits can push doctors to retire or cutting back their hours. In the long run for people attending the Medical school the choice of specialities with less demanding schedules, more regular hours and less bureaucracy could represent an unavoidable risk. FM 24 Ausgedehnte Weichteilinfektion mit seltenem Schimmelpilz führt zu Oberarmamputation Fallvorstellung Adrian Schneider 1, Madeleine Rothen 1, Helen Segmüller 1, Lukas Mathys 2, Esther Vögelin 2 ( 1 Biel; 2 Bern) Opportunistische Weichteilinfekte mit Schimmelpilzen sind äusserst seltene und schwer therapierbare Erkrankungen, welche fast ausschliesslich bei immunsupprimierten Patienten vorkommen und zunehmends an Bedeutung gewinnen. In der Literatur sind nur wenige Fälle beschrieben. Anhand eines konkreten Fallbeispieles mit protrahiertem Krankheitsverlauf, welcher schliesslich in einer Oberarmputation endete, möchten wir die Pathogenese und möglichen Therapieoptionen darstellen. FM 25 Unexpected finding in a swollen metacarpophalangeal joint of the thumb after pinbrick injury Pascale Brei-Thoma 1, Bettina Juon 1, Hans-Rudolf Ziswiler 1, Esther Vögelin 1 ( 1 Bern) Introduction: Synovial chondromatosis is a rare cause of swelling in the wrist or small joints in hands. In most cases it affects knees and hips. It is characterized by metaplastic cartilage formation of synovial membrane of joints, bursae or tendon sheath with rare tendency to malignancy. Nevertheless surgical excision often leads to recurrence in up to 60%. There is only little literature found. We present a case of a 32 year old patient with the disease affecting the MP joint of the thumb. 14

15 Case report: A 32 year old female nurse presented a swollen, occasionally aching metacarpophalangeal joint of the thumb for five months. Pain, swelling and constraint of motion were severely intensified after a pinprick injury close to the joint with a sterile needle during her job as a nurse. Radiography was without pathology. Ultrasonography showed a thickened synovial tissue without signs of synovitis. Aspiration was not successful. No pathologic serologic findings could be presented through our colleagues of the Rheumatologic Department. Conservative treatment with non-steroidalanti-rheumatics, splinting and intraarticular steroid injection were without success. Finally, one year after the accident, a diagnostic partial synovectomy with removal of loose bodies was performed. Microscopic examination confirmed the suspicion of a synovial chondromatosis. Meanwhile the patient suffers of recurrence. Therefore reoperation with postoperative synoviorthesis was planned as a next step. Conclusions: Synovial chondromatosis is a rare differential diagnosis of a swollen joint. When encountering this condition, complete excision is essential. However additional therapeutic steps like synoviorthesis have to be considered to further reduce recurrences. operative finding.jpg FM 26 Riesenlipome des Daumens einfach nur Fett?2 Fallbeschreibungen und Literaturübersicht Philipp Honigmann 1, Mathias Häfeli 1, Doris Babst 1, Valerie Decrouy 1, Daniel Kalbermatten 1, Dirk J. Schaefer 1 ( 1 Basel) Lipome sind benigne Tumoren und können überall am und im Körper auftreten. Sie sind zwar die häufigsten benignen Weichteiltumore der Extremitäten, treten aber nur in 5% an den Händen und in 1% an den Langfingern und noch seltener am Thenar auf. Der klinische Verdacht kann einfach mittels Ultraschall oder MRI erhärtet werden. Grundsätzlich werden lipomatöse Tumoren in benigne, intermediäre und maligne Formen unterteilt. Es ist wichtig, das gut-differenzierte vom atypischen Lipom zu unterscheiden, da letzteres bereits eine intermediäre maligne Form darstellt. Zur histologischen Differenzierung zwischen Lipom und Liposarkom gehören mittlerweile auch zytogentische Analyse, mit denen eine spezifischere Differenzierung möglich ist. Als Riesenlipome werden Lipome bezeichnet, die eine Grösse über 5 cm erreichen. Diese Grösse wird als kritisch bezeichnet, da Weichteiltumoren diesen Ausmasses malignitätssuspekt sind. Lipome, die ausserhalb des Fettmantels (z.b. intra- oder intrermuskuläre) auftreten, sind immer suspekt. Nicht selten kann hier ein Liposarkom verborgen sein. Wir berichten über zwei Fälle mit Riesenlipomen des Thenars, deren spezifische Diagnostik, Behandlung und histologische Differenzierung mittels zytogenetischer Analyse. FM 27 Transfer a Toe Yes or No? Case Report Alexandre Kämpfen 1, Dirk J. Schaefer 1 ( 1 Basel) In 2010 a 6 month old boy was presented to our clinic with a monodactylous symbrachydactyly of the left hand. The well informed parents asked for possibilities of improvement. Evaluation with x-ray showed a normal first metacarpal and a bony core in the capitate. No evidence of a syndromal aetiology was present. As symbrachydactyly is an agenesia and in itself completed. It is not an amputation and therefore it is acceptable because of adaptation. The biggest problems are cosmetics and aesthetics of gesture statically and dynamically. Contradictory to this, for two handed tasks, like opening a zipper, with total absence of a pinch grip our patient would have a handicap for lifetime. With informed consent of the parents we intended to upgrade the function of the left hand to help his dominant right. In order to allow an adaptation of the forming cortical representation to the new basic hand at 18 months of age we transferred a toe and constructed a deeper first web space. Technically the anastomosis was feasible despite the youth of child. Tendon repair was performed by Pulvertaft sutures and nerves were coapted end-to-side on the median nerve. One year postoperative results are promising. Functionally the boy can now open packages to eat candies, hold toys with his left and manipulate with his right hand. The pinch grip is strong, normal pain reaction and sensibility. Range of Motion in the MTPJ is The donor site is well tolerated and the patient was able to use his Bobby Car on the fourth postoperative day. One year postoperative his gait pattern is normal. In conclusion we prefer doing microsurgical toe transfer for creation of a basic hand early to maximize the cognitive imprinting along with the development of a controlled pinch in the contralateral hand. The optimum time in relation to technical feasibility in our opinion is month of age. FM 28 Ecthyma contagiosum an Orf(ph)an disease? Rahel Meier 1, Matthias Hoffmann 1, Andreas Sommacal 1, Michael Engels 2, Katja Boggian 1, Jörg Grünert 1 ( 1 St. Gallen; 2 Zürich) Introduction: Ecthyma contagiosum or orf is caused by a DNA parapoxvirus (Parapoxvirus ovis) 15

16 particularly adapted to epidermal cells. It is an uncommon human viral infection usually causing cutaneous lesions upon direct contact with an infected animal. Timely recognition of this usually benign and self-limiting infection avoids overtreatment. Careful patients history is crucial for accurate diagnosis. Case Presentation: A 48 year old woman presented herself with a bloodshot papulo-bulleous cutaneous lesion at her right index finger. Two weeks before she first noticed a fissure and developed a singular indolent papule with a progressive accompanying erythema after 4 days. The patient s history was significant for having fed lambs, but she could not remember having been injured. The lesion was sparingly debrided. Histological examination revealed inflammatory cellular infiltrates and eosinophilic intracytoplasmatic inclusion bodies in epithelial cells. Parapoxvirus was detected by real-time PCR confirming the diagnosis. Further evaluation of the lamb demonstrated typical mucous eschar, and diagnosis and epidemiological linkage was confirmed by Parapoxvirus rt-pcr positivity. The patient s lesion healed within 3 weeks without sequelae. Discussion: Orf disease is endemic in sheeps and goats but artiodactyls in general are susceptible. In Switzerland orf seems to be rather sporadic but reliable surveillance data is lacking. Human infections may be more common than reported given the benign disease course. Transmission occurs usually by direct contact but the virus remains contagious in the environment for years. Ecthyma contangiosa clusters have been described in shepards communities. The disease course is usually self-limited with spontaneous healing. Nevertheless more severe cases due to disease dissemination have been described in immunocompromised individuals. Diagnosis is mainly made by the patients history and the disease course that is characterised by different stages (erythematous papule target nodule/pustule crust). Timely recognition of human orf may prove beneficial since complications are mainly due to overtreatment. FM 29 Die Daumenköcherschiene beim Skidaumen: das entscheidende Detail Noémie Devaux 1, Esther Bohli 1, Helen Segmüller 1 ( 1 Biel) Sowohl bei der konservativen Behandlung der Teilläsion des Ligamentum collaterale ulnare am MP-I- Gelenk als auch nach der operativen Bandnaht erfolgt die weitere Behandlung mit einer Daumenköcherschiene. Dabei wird Wert gelegt auf die freie Beweglichkeit des IP-Gelenkes in der Schiene. Bei den entsprechend kurzen Hebelarmen sind damit die Supinationskräfte beim Pinchgriff nicht neutralisiert. Um die Rotationsstabilität im MP-Gelenk beim Pinchgriff zu gewährleisten, wird eine radialseitige Schienenverlängerung vom IP-Gelenk bis zur Nagelwurzel angelegt. Die Schienenmodifikation wird vorgestellt. FM 30 Under pressure bilateral endoscopic forearm fasciotomy in chronic exertional compartment syndrome Beate Wilmink 1, Ingo Eisenbarth 1, Renato Fricker 1 ( 1 Bruderholz) Introduction: Chronic exertional compartment syndrome (CECS) in the upper limb is most often related to activities like motocross-racing, climbing, gymnastics, field hockey or heavy labour, including both forearms in almost every patient. Fasciotomy is the only therapeutic option so far; and open, minimally-invasive and endoscopic methods are described. Case: We report the case of a 33-year-old right-handed male patient with a medical history of juvenile-onset diabetes. He was working as an unskilled demolition worker and complained of labour-induced tenderness and pain in both forearms, recurrent swelling of the fingers and a loss of grip strength. Carpal tunnel release (CTR) was performed after neurophysiological confirmation of carpal tunnel syndrome. Symptoms diminished subjectively, but never disappeared completely. 3 months later, the patient`s complaints had reached initial intensity. Tenderness and induration of forearm flexor muscles was most obvious in clinical examination immediately after work. Symptoms persisted in spite of intensive ergotherapeutic treatment. CECS was suspected, and fasciotomy of the flexor compartement of both forearms was performed endoscopically. Intraoperative findings revealed a rigid fascia especially in the distal third. Results: Wound healing was uneventful and after 4 weeks the patient resumed his original work. At oneyear-follow-up he reported no limitations or pain in his daily activities or at work. Clinical examination revealed a bilaterally equal range of motion of elbow and wrist joints, a grip strength slightly higher on the right dominant side (Jamar: 50/50/46 kg on the right side, 45/45/40 kg on the left side), and a slight widening of the otherwise unremarkable scars. Conclusion: Chronic exertional compartment syndrome of the forearm is usually a diagnosis of exclusion (due to missing diagnostic criteria) and was suspected in the present case with persistent symptoms after CTR and obvious induration of the forearm flexor muscles after exertion. Fasciotomy was perfomed endoscopically, using special instruments originally designed for ulnar nerve release at the elbow. This technique combines safety by providing full visual control and minimal invasiveness, and therefore presents a safe and low-risk treatment option with a short rehabilitation period, allowing even a heavy manual labourer to resume work soon. FM 31 Case Report: Makroamputationen aller Extremitäten bei Waterhouse-Friedrichsen-Syndrom Thuan Ly 1, Alexander Kozlowski 1, Adrian Schneider 1, Jörg Grünert 1 ( 1 St. Gallen) Die Makroamputation einer Extremität führt zu einer sehr hohen psychischen und funktionellen Beeinträchtigung. Das Ziel der Rehabilitation ist - sofern 16

17 möglich - die Wiederherstellung der körperlichen Integrität mit Reintegration in den Lebensalltag und die Wiederaufnahme der Arbeitstätigkeit oder berufliche Umschulung. Anhand eines extremen Fallbeispiels mit gleichzeitigem Verlust aller Extremitäten bei Waterhouse-Friedrichsen Syndrom im Rahmen einer fulminanten Pneumokokken Sepsis wollen wir die Möglichkeiten und Grenzen der rekonstruktiven Chirurgie und prothetischen Versorgungen aufzeigen. FM 32 Rezidivnerventumor am Handrücken versorgt durch ein Nerven-Conduit ein Fallbeispiel Sandra Vossen 1, Roman Blazek 1 ( 1 Langenthal) Einleitung: Seit wenigen Jahren sind resorbierbare kollagene Nerven Conduits zur Versorgung von Defektstrecken peripherer Nerven kommerziell erhältlich. In der Literatur finden sich kleine Fallserien, die gute bis sehr gute Ergebnisse sowohl bei der Versorgung von digitalen Defektverletzungen als auch bei der Versorgung von schmerzhaften Neuromen berichten. Material und Methoden: Wir berichten von einer 32 jährigen Patientin, die zunächst wegen eines intraneuralen Neurofibroms am Handrücken operiert wurde. Nach Resektion des Tumors erfolgte eine Rekonstruktion des Nervens mit einer Nerventransplantation eines Seitenastes N. antebrachii medialis. 7 Monate später stellte sie sich mit wieder aufgetretenen deutlichen Schmerzen (VAS 4-6) und einer Hyperpathie am Handrücken vor. Ein kleines Knötchen war im schmerzhaften Bereich tastbar. Bei der Revisionsoperation fand sich erneut ein kleiner Tumor, der in der histologischen Aufarbeitung einem Neurom entsprach. Die Rekonstruktion der Defektstelle erfolgte mit einem Nerven Conduit, das, obwohl der kleinste kommerziell erhältliche Durchmesser verwandt wurde, unter dem Mikroskop noch weiter verkleinert werden musste. Drei Monate postoperativ waren die Schmerzen und die Hyperpathie vollständig verschwunden. Es kam zu einer Resensibilisierung des Versorgungsgebietes des operierten Hautastes. Schlussfolgerung: Auch bei der Versorgung kleinster Nerventumore lässt sich ein Nerven Conduit erfolgreich verwenden. Eine Anpassung des Durchmessers auf kleinere Dimensionen kann problemlos durchgeführt werden. Intraoperatives Bild.JPG FM 33 Avascular necrosis of the metacarpal head report of two cases and review of the literature Christoph Erling 1, Thomas Buchegger 2, Gautier Emanuel 1, Georges Kohut 1, Peter Wahl 1 ( 1 Fribourg; 2 Lausanne) Following repetitive traction trauma, two industrial butchers presented avascular necrosis (AVN) of the third metacarpal head (MCH). Whereas this disease is well known since the first description by Mauclaire in 1927, and is named after the description by Dieterich in 1932, the circumstances of these two cases are particular and appear to be the first description of such association. One case was treated with debridement and bone grafting, whereas the other case had only conservative treatment. At one year, both had good functional results. However longer follow-up is not available yet. The literature regarding diagnostics and treatment option of this disease is reviewed and discussed considering our cases. FM 34 Nerventransfer an der unteren Extremität Lukas Mathys 1, Bettina Juon 1, Nicole Badur 1, Esther Vögelin 1 ( 1 Bern) Einleitung Nerventransfers an der oberen Extremität sind bereits eine akzeptierte Option für die Behandlung von entsprechenden Nervenläsionen nebst der Nervenrekonstruktion und den Sehnentransfers. Im Bereich der unteren Extremität ist die Literatur bezüglich Neurotisation noch spärlich, die bisherigen Behandlungsmodalitäten sind häufig unbefriedigend im Ergebnis. Material und Methode 7 Patienten wurden bisher an unserer Klinik mittels Nerventransfers an der unteren Extremität behandelt, 6 mal bei Peroneusläsion (viermal Neurotisation des N. peroneus durch Äste des N. tibialis, zweimal Neurotisation des lateralen Gastrocnemiuskopfes durch den N. peroneus und Transfer des entsprechenden Muskels auf die Strecksehnen), einmal bei hoher Femoralisläsion (Transfer des Gracilisastes des N. obturatorius auf einen Muskelast des N. femoralis). Resultate Die Mehrheit der Eingriffe liegt zwischen einem und zwei Jahren zurück und lässt deswegen noch keine Aussagen zum abschliessenden Erfolg zu, da die Reinnervation bedeutend länger dauert als an der oberen Extremität. Ein Patient mit Gastrocnemiustransfer (welcher vier Jahre zurückliegt) zeigt ein funktionell gutes Ergebnis, er ist nicht mehr auf die Schiene angewiesen. Die restlichen Patienten, deren Operation noch keine zwei Jahre zurückliegt, zeigen Reinnervationszeichen, die Funktion des Streckapparates ist jedoch noch nicht ausreichend, um ohne Schiene auszukommen. Ein Patient zeigt eine progrediente Schädigung des Nervenstranges an der dorsalen unteren Extremität unbekannter Ursache. Diskussion 17

18 Ermutigt durch die positiven Ergebnisse der Neurotisation an der oberen Extremität und durch single-case-ergebnisse in der Literatur haben wir dieses Verfahren auf die untere Extremität angewandt. Die bisherigen Verfahren (Arthrodese, Sehnentransfer) nach häufig erfolgloser Nervenrekonstruktion sind nicht befriedigend, die Patienten entsprechend auf ihre Schiene angewiesen. Der bisherige Verlauf zeigt, dass die Rehabilitation deutlich länger dauert (bei vergleichbarer Innervationsstrecke) als an der oberen Extremität und das Ergebnis weniger Nuancen in der Beurteilung zulässt (alles oder nichts). Only in 3 cases (15%) there was no subjective improvement during the first 6 months. Satisfaction on a VAS scale from 0 (not satisfied) to 10 (very satisfied) was amounted 7.7 pts. Summary: Endoscopic decompression of the ulnar nerve does represent a simple and low complication procedure to relieve the nerve in the elbow area over a long distance. The recovery of the nerve takes place slowly and is dependent on the severity of nerve damage. Not in all cases, a complete nerve recovery could be expected. FM 36 Anatomical landmarks for peripheral neural blocks of the forearm and the wrist: A cadaveric study Tatjana Lanaras 1, Nadja Alexandra Müller 1, Magdalena Vich 1, Pietro Giovanoli 1, Maurizio Calcagni 1 ( 1 Zürich) Image1.jpg FM 35 Endoscopic decompression of the ulnar nerve in Cubitaltunnel syndrome. Stephan F. Schindele 1, Miriam Marks 1, Sebastian Kluge 1, Andreas Eggspühler 1 ( 1 Zürich) Introduction: After carpal tunnel syndrome the Cubitaltunnel syndrome is the second most common compressions-syndom of a peripheral nerve. The site of compression in the area of the elbow can be localized electrophysiologically mostly accurate. After failed conservative treatment decompression with / without anterior translocation of the nerve is a common method to relieve the nerve over a long distance. Using a endoscopic technique the postoperative rehabilitation time should be shorter. Aim: In a prospective consecutive case series study with electrophysiological course, the results of endoscopic decompression of the ulnar nerve are presented in Cubitaltunnel syndrome. Material & Methods: Between 8 / 2008 to 3 / 2010 we performed at our institution an endoscopic decompression of the ulnar nerve in 22 patients. Preoperatively a clinical and electrophysiological examination was performed in all patients. Clinical follow up were performed 6 and 12 weeks and finally a clinical and electrophysiological examination after 6 months. For the statistics for predominantly nonnormally distributed data we use the Spearman coefficient, Mann-Whitney U and Wilcoxon test. Results: The surgical procedure was performed without complications in all patients. 20 patients over 6 months could be included for the entire follow-up. As early as 6 weeks postoperatively all patients showed a slight improvement of symptoms.at final follow-up 6 months postop in 10 cases (50%) a normal sensibility in the ring- and smallfinger could be documented. The two-point discrimination averaged 4.9 (± 0.94). In 14 cases (82%) the strengh of the ulnar innervated intrinsic muscles was normal. Purpose: Peripheral neural blocks are an important diagnostic tool for the treatment of pain associated with neuroma formation. A failed block may have a great impact on therapy and therefore on the development of chronic neuropathic pain syndromes. Literature still cannot provide sufficient data to ensure a standardized technique for peripheral neural blocks according to anatomical landmarks. Methods: This study was performed on five formalinpreserved cadaveric upper limbs. The superficial branch of the radial nerve (SBRN), the dorsal branch of the ulnar nerve (DBUN), the lateral, medial and dorsal antebrachial cutaneous nerve (LACN, MACN and DACN) as well as the palmar branch of the median nerve (PBMN) were dissected. As reference points served the ulnar and radial styloid process, the Lister tubercle, the medial and the lateral epicondylus of the humerus. The distance between the above mentioned nerves related to the reference points was measured with a digital caliper while keeping the wrist and the elbow in a fixed position. Results: For the SBRN the mean distance on a straight line from the Lister tubercle to the medial epicondylus was 85mm. Measuring from the styloid process of the radius to the lateral epicondylus the DBUN was found on a mean distance of 27mm. On a line between the medial and lateral epicondylus the LACN was located on a mean distance of 50mm. On a mean distance of 32mm from epicondylus lateralis to the medial one the DACN was located, while the MACN could be found 14mm radial from the medial epicondylus. For the PBMN the measurement included a mean distance of 45mm from the radial styloid to the medial epicondylus and from this point perpendicularly a mean distance of 21mm. Conclusion: Due to landmarks, identified by skin surface palpation combined with simple measurements the precise location of a peripheral neural block can be optimized. Clinical Relevance: The precise neural block of a certain peripheral nerve is of prime priority for distinct diagnosis and treatment of pain associated with neuroma formation. 18

19 FM 37 Regenerative cell injection in denervated muscle reduces atrophy following nerve repair Dominique Schaakxs 1, Daniel Kalbermatten 2, Wassim Raffoul 1, Mikael Wiberg 3, Paul J. Kingham 3 ( 1 Lausanne; 2 Basel; 3 Umeå SE) INTRODUCTION: Functional muscle recovery after a peripheral nerve injury is far from optimal due to atrophy of the muscle arising from prolonged denervation. We hypothesised that injecting regenerative cells in denervated muscle would reduce atrophy. METHODS: A rat sciatic nerve lesion was performed and Schwann cells (SC) or adipose derived stem cells, untreated and induced to a Schwann cell-like phenotype (dasc), were injected into the gastrocnemius muscles. Nerves were either repaired immediately or capped to prevent muscle reinnervation. One month later, functionality was measured using a walking track test and muscle atrophy was assessed by examining muscle weight and histology. RESULTS: In both experimental models (repair and capping of the nerve), cell injection groups displayed significantly higher muscle weight than the sham groups. Animals subjected to nerve injury followed by repair and injection of growth medium in the muscle showed greater than 60% weight reduction compared with the contra-lateral side. Injections of untreated ASC did not enhance muscle weights. However, significantly less muscle atrophy was observed in the dasc (p<0.01 for nerve repair, p<0.001 for capping of nerve) and in the SC groups (p<0.001 for nerve repair, p<0.001 for capping of nerve). Nerve repair also resulted in increased muscle weights compared with the no-repair groups. Histological and functional analysis confirmed these results. The repair sham group showed both fast and slow muscle fibers with less than 20% area size compared with the contra-lateral side. In animals treated with injections of dasc or Schwann cells there was a significant increase in muscle fiber size. The rats in the dasc and Schwann cell injection groups also showed significantly better functional results in the walking track test when compared with the sham group. The times required for the rats to cross the ladder were reduced and there was an increased accuracy of foot placement. DISCUSSION & CONCLUSIONS: Our results indicate that injecting stem cells or Schwann cells reduces muscle atrophy occurring as a result of denervation. Adipose derived stem cells appear to be a promising, clinically relevant cell population, for treatment of traumatic nerve injuries. FM 38 Adipose-derived stem cells in rodents enhance early peripheral nerve regeneration Mathias Tremp 1, Moritz Meyer Zu Schwabedissen 1, Arne Fischmann 1, Elisabeth Artemis Kappos 1, Dirk Johannes Schaefer 1, Daniel Felix Kalbermatten 1 ( 1 Basel) Introduction: Adipose-derived stem cells (ADSCs) are envisioned as promising cell sources with the capability to regenerate nerve fibers. In this study we investigated whether human or rodent ADSCs injected into a fibrin conduit enhance peripheral nerve regeneration in an immunocompetent rat model. Methods: ADSCs from the neck and perineural region of adult female Sprague Dawley rats were isolated and expanded in culture and characterized. Furthermore, murine ADSCs were transdifferentiated toward a Schwann-cell like lineage (SC-like cells). Human ADSCs were acquired from six patients undergoing lipectomy. 35 Female Sprague Dawley rats (five groups of 7 animals, 8 weeks old) were anaesthesized and the left sciatic nerve exposed. The nerve was transected and the fibrin conduit of 14-mm length and 2-mm lumen was connected to the axotomised nerve stumps. For comparison the conduit was prepared with 5 different solutions: culture medium alone, rat ADSCs and human ADSCs from the superficial and deep layer and SC-like cells (each 1 x 106cells PKH26 labelled). After two weeks the nerves were harvested and morphological (immunohistochemistry) and imaging analysis (MRI) were performed. Results: The isolated ADSCs and SC-like cells were positively characterised by immunocytochemistry and FACS. Immunohistochemical analysis (S100, PGP 9.5) showed a better regenerative capacity in the rat ADSCs group (4.7±0.4mm and 4.6±0.2mm, respectively) and differentiated rat ADSCs (4.7±0.1mm and 4.3±0.1mm, respectively) compared to the negative control group (3.8±0.2mm and 3.6±0.2mm, respectively). Furthermore, human ADSCs from the deep layer (4.3±0.2mm and 4.2±0.2mm) had a higher regenerative ability than culture medium alone or human ADSCs from the superficial layer (3.6±0.2mm and 3.6±0.2mm). Using a clinical 3T MRI scanner with human wrist coils we were able to visualize the graft as a small black outline, distal and proximal sutures and small hyperintensity indicating the growth cone. Conclusions: Rat ADSCs and murine SC-like cells have a better regenerative capacity than culture medium alone or human ADSCs. However, human ADSCs from the deep layer promoted nerve regeneration more than culture medium alone. In addition, MRI with human approved equipment was able to visualize the fibrin conduit and growth cone which can be a valuable clinical tool to measure nerve regrowth. FM 39 Muscle-in-vein tubulization for a 3.5 cm nerve reconstruction in the palm. A case report. Daniele De Spirito (Lugano) Background Nerve grafting is still considered the gold standard for nerve reconstruction when a gap is present, such as in delayed repair with neuroma resections. Even though this technique offers good nerve regeneration, it requires a nerve to be sacrificed with a subsequent loss of sensation in a different area and it also causes the formation of a neuroma in the donor site. In order to 19

20 avoid these complications, different tubulization techniques have been proposed and the use of muscle in vein is one of them. Patient and methods A 38 year old patient had a complex injury to his dominant right hand involving both soft tissues and bone. Even though the recovery of finger function was poor, his most important problem was the presence of an acute pain in the palm irradiating to the index finger, due to a big neuroma of ulnar collateral nerve. In order to eradicate pain as well as to improve peripheral sensibility, we performed the resection of the neuroma and we reconstructed the nerve by means of a musclein-vein tube of 3.5 cm in length. Results Immediately after the operation the pain disappeared. At 24 months follow up the patient recovered a good sensibility (according to modified American Society for Surgery of the Hand guidelines) in the area of previous complete anaesthesia and he obtained a better overall function of the hand, even if the movement limitations still remained. Conclusion and discussion Although muscle-in-vein technique is not so commonly adopted as a nerve reconstruction, it has several advantages, such as easy fashioning of the tube, a good recovery of sensibility, the absence of donor site morbidity and the absence of extra costs. Because of the encouraging results in several experimental and clinical applications as well as in our limited clinical experience, we think that this technique is a good option for sensitive nerve reconstruction in the hand as an alternative to autogenous nerve grafts, even with significant gap, as in the case we reported. FM 40 Platelet rich plasma and prominin-1 peptide: A new treatment approach for lymphedema Paolo Erba 1, Maximilian Ackermann 2, Reto Wettstein 1, Christopher Senaldi 1, Moritz Konerding 2, Wassim Raffoul 1 ( 1 Lausanne; 2 Mainz DE) Background: Lymphedema of the upper extremity is a very frequent pathology which affects up to 49% of breast cancer patients necessitating lymph node dissection and/or radiotherapy (Kissin MW et al, 1986). Currently no effective therapy is available so that patients present with a lifelong debilitating swelling of the hidden extremity. This leads to impaired function, is associated with an increased risk of severe soft tissue infections and may cause severe spine deformations due to body imbalance. Fibrosis is a key component of lymphedema and has been shown to impair lymphatic regeneration, lymphatic endothelial cell proliferation and migration, interfere with tubule formation and impair lymphatic function (Clavin NV et al, 2008). One of the mechanisms through which fibrosis acts is by impeding the interaction of Vascular endothelial growth factor-c (VEGF-C) with its receptors VEGFR-2 and VEGFR-3 (Goldman J et al, 2007). With the aim to develop new treatment strategies for lymphedema, we studied the effect of VEGF-related therapies on the regeneration of lymph vessels. Methods: Platelet-Rich Plasma (PRP) is an autologous cocktail of growth factors which includes VEGF. Prominin-1 Peptide (P-1) is a newly developed aminoacid sequence which has shown to improve the binding between VEGF in its receptors and thereby dramatically improve VEGF function. PRP and P-1 were studied in regard of angiogenesis (anti-cd31 staining), microcirculation (Laser Doppler Imaging), lymphangiogenesis (anti-lyve1 staining), microvascular architecture (corrosion casting) and wound healing (digital planimetry) in a murine tail lymphedema model. Saline was used as control group. Results: Wounds treated by PRP and P-1 healed faster and showed a significantly increased epithelialization mainly from the proximal margin. Fourteen days after surgery wound agiogenesis was comparable among groups whereby wound microcirculation was found to be increased in PRP and P-1 groups. The application of PRP and P-1 induced a significantly increased lymphangiogenesis. Conclusions: PRP and P-1 represent a promising approach to improve regeneration of lymphatic vessels, restore disrupted lymphatic circulation and treat or prevent lymphedema alone or in combination with currently available lymphedema therapies. FM 41 Approche chirurgicale des douleurs neuropathiques post-opératoires ou posttraumatiques. Valérie Decrouy-Duruz 1, Thierry Christen 1, Wassim Raffoul 1 ( 1 Lausanne) Le traitement chirurgical des douleurs neuropathiques est controversé voire méconnu, hormis dans les cas de syndromes canalaires typiques. Dans le service de chirugie plastique et reconstructive du CHUV, une étude rétrospective avait montré que sur une cohorte de 54 patients avec douleurs neuropathiques post-opératoires, 80% d entre eux présentaient une diminution des douleurs après neurolyse et excision-enfouissement du névrome (Espinoza et al., 2010). Fort de cette expérience positive, le service s est vu entrer en étroite collaboration avec les médecins spécialistes de l antalgie : ceux-ci adressent des patients qu ils ont euxmême sélectionnés pour des douleurs neuropathiques bien systématisées. Ainsi, entre 1996 et 2011, 548 patients ont bénéficié d une intervention chirurgicale portant sur un nerf: une partie d entre eux (286 cas) présentaient un syndrome canalaire de localisation variable, les 262 autres patients souffraient de douleurs neuropathiques post-opératoires ou post-traumatiques. Une étude rétrospective portant sur ce dernier groupe de patients est menée, évaluant et confrontant les résultats du traitement chirurgical en fonction de divers paramètres tels que le type de lésion objectivée, sa localisation et l étiologie en cause. Les résultats préliminaires sont extrêmement encourageants et montrent qu une sélection rigoureuse des patients avec douleurs neuropathiques assure au traitement chirurgical par neurolyse un taux de succès important, particulièrement en présence d une lésion de type névrome terminal. 20