Biomedical subjects
Publications and source records attributed to J Geldmacher.
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Enchondroma are the most frequent tumors of the hand. These benign tumours are characterized by slow growth, the lack of clinical symptoms and by accidental discovery. The surgical treatment of enchondroma includes resection of the tumor tissue from the bone matrix, and subsequent filling of the defect with autologous or homologous spongiosa or with sterile plaster of Paris. We showed in a period from 1982 to 1989 that there is no difference with respect to the clinical outcome between our patients receiving autologous spongiosa (n = 25) or plaster filling (n = 35). Owing to its simplicity and lack of additional surgery at the iliac crest, we prefer the method of plaster filling. Animal studies performed by our group have demonstrated that implanted plaster is transformed to spongiosa within four to ten weeks without adverse effects.
Surgical repair is usually indicated for rupture of the ulnar collateral ligament of the MP-joint of the thumb. The pull-out wire technique is commonly used for repair of typically distal ligamentous ruptures or avulsion fractures at the base of the proximal phalanx. The method's disadvantages include skin or soft tissue necrosis beneath the button on the radial side of the thumb. When postoperative swelling subsides, the formerly taught wire loosens and so does the repair. Because of this inherent danger, a special steel sleeve which is drawn over the wire on the radial side of the thumb until bone contact is made was developed. Thus, a strong and unyielding fixation of the ulnar collateral ligament repair or avulsed bone chip is certain. The follow-up for 41 patients treated by this technical modification is presented; there were no complications, including wound infections.
1944 patients with 2418 lacerations of extensor tendons in the hand were treated since 1966. Follow up study was possible in 1031 (53%) patients. The discussion about the best method to evaluate the results of treatment lead to a better scheme for critical examination. The preoperative status was taken into consideration as well as the subjective meaning and brought into harmony with the objective results.
Besides bruises saw injuries of the hand are the most common severe hand injuries. A total of 294 of 400 patients who had a saw injury between 1982 and 1986 were monitored in the course of a followup examination spanning the time of the accident up to re-entry into professional life. Causes of accidents as well as injury patterns, surgical treatment and aftereffects were analysed. The high number of injuries (70.8%) sustained while not working was remarkable as well as the fact that despite the seriousness of the injury 64.6% of the patients were content with the cosmetic results of treatment and 65% satisfied with the recovered function of the injured hand.
A retrospective investigation of the etiology of 132 patients with peripheral ulnar nerve compression was performed. Mainly there was external long-term pressure or compressive lesions near the nerve and disturbances of the osseous structures at the elbow and the wrist.
Disruptions of the palmar plate are frequently overlooked injuries. As the palmar plate stabilises the PIP joint in combination with the collateral ligaments untreated injuries may result in severe complaints. Detailed anatomical and functional knowledge is therefore necessary to diagnose the degree of injury. In addition to ligamentous disruption osseous chips may occur and can be divided into four degrees (Hintringer 1987). By the study of results of 178 cases specific treatment has been established. Surgical intervention is indicated in the presence of an unstable PIP joint, subluxation or osseous chips grade 3 and 4 (Hintringer). The aim should be a painfree and stable joint. Small limitations in movement can be tolerated.
In a prospective, multi-centre, randomized study of 109 patients with metastatic gastro-intestinal adenocarcinomas the response rate, survival time and side-effects of two drug combinations, carmustin +5-fluorouracil and carmustin + ftorafur, were compared (same carmustin dosage in both groups). Response to the treatment was 32.7% in those receiving carmustin +5-fluorouracil, 26.3% in those on carmustin + ftorafur. This difference occurred among the 42 patients with gastric adenocarcinoma (33.3% compared with 25%), as well as in 11 with pancreatic adenocarcinoma, and in 56 with colorectal adenocarcinoma (32.1% and 28.6%). Median survival time for 5-fluorouracil + carmustin was 330 days, double that for ftorafur + carmustin (163 days). Bone-marrow toxicity (leukopenia, thrombopenia) was below 10% for both drug combinations. Alopecia occurred in only a few patients. Gastro-intestinal toxicity was common (20% and 18.5%, respectively), but there was no difference between the two groups. The somewhat lower effectiveness of ftorafur compared with 5-fluorouracil was probably due to the deliberately smaller dosage of the former.
On regard to the butterfly flap plasty of SHAW 1973, we developed a modified technique by enlarging this method. This method will deepen the interdigital fold without transplantation of skin. We have operated between 1976--1979 twenty two patients by this method with a rather good functional and aesthetic result.
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More than 3% of all work-related hand injuries result in partial or total amputation of fingers or hands (of 14621 patients with hand injuries, 479 patients had 878 amputations). When there is no possibility or indication for microsurgical replantation, the aim of the surgical effort is to rebuild a sensitive, vigorous grasp. The different procedures for plastic surgery of the hand are discussed.
The incidence of gout has increased in recent years. For effective treatment an interdisciplinary approach is necessary. Medical therapy can be effectively supported by surgical removal of the tophi. This way normalisation of the uric-acid-pool can be achieved more quickly without additional harmful effects on the kidneys. Especially in the area of the hand surgical extirpation of the tophi can be gratifying, though it may be a difficult task. Severe restrictions in function of the hand can be corrected. This is demonstrated by the case of a 56 year old patient.
A case of neurilemmoma in bone localized in the proximal phalanx of the right thumb is described. There are less than 40 cases of this typoe of tumor to be found in the literature. The majority of them were localized in the jaw and maxillary bones. The tumor usually grows slowly, histories of up to 20 years duration being described. Clinical symptoms are not characteristic. X-ray examination shows cystic bone defects. The origin of the neurilemmoma in bone is believed to be cells of SCHWANN of the paravasal nerves, which accompany the nutrient artery. Microscopically two types of cells can be distinguished in the tumor. The neurilemmoma in bone is probably always benign. The therapy of choice is local excision of the tumor.
Between 1967 and 1976, 269 tumors of the hand were treated. Among the 56 epithelial tumors the malignant ones played the dominant role whereas they are seldom found in those of soft tissue and osseous skeleton. From the tumors of the hand the "tumorlike lesions" have to be separed according to the recommendations of the World Health Organisation in 1969. In the epithelium the most frequent ones are the verruca vulgaris, the verruca plana, the atheroma, the molluscum contagiosum and the mucoid epithelial cyst. In the soft tissues most common are ganglion, traumatic neuroma, nodular tenosynovitis, giant cell tumor of synovium, hygroma, foreign body granuloma and other inflammatory or metabolic alterations, as for example on the basis of degenerative arthritis or primary chronic polyarthritis. Dupuytren's contracture and keloid are also considered "tumorlike lesions" within the frame of fibromatosis. The osseous skeleton is included in the so-called solitary bone cysts.
Nodular tenosynovitis occurs in a localized and in a diffuse form. The histologie finding are rather variable. According to electron microscopic studies nodular tenosynovitis originates in the synovial membrane. Mainly there are two types of cells to be found in the tumor: Type A, similar to macrophages - type B, similar to fibroblasts. The localized form of nodular tenosynovitis has a higher incidence in woman and occurs predominantly in the hand. The clinical symptoms are not characteristic and usually not very pronounced. More than one tumor in a single patient and also bone erosions caused by nodular tenosynovitis are rare occurrences. A case of a patient with multilocular occurrence of tenosynovitis is described here.
Since 1969, 168 microsurgical interfascicular nerve transplantations have been performed in the Department for Hand Surgery and Plastic Surgery in the Surgical Clinic of the University of Erlangen. Since the end of 1974, the Zeiss Operation Microscope OPMI 2 has been hung from an electrohydraulic ceiling suspension and has proved invaluable. The construction and function of the apparatus is described. Such suspension of the microscope in combination with original Hanau operation lights, facilitates microsurgery in hand and plastic surgical procedure by saving space, reducing operating time and providing a better opportunity of ensuring sterility in the operating field.
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