Wissenschaftliches Programm: Freitag, 25. November

Background­­­­­

Carpal tunnel syndrome (CTS) in distal radius fractures (DRFx) is a known complication and has been widely reported. However, despite its clinical prevalence, no data has described patients developing CTS after scaphoid reconstruction surgery. Identifying the incidence rate and potential risk factors would allow more insights into considering prophylactic carpal tunnel release (CTR).

Methods

A retrospective local database search of patients that developed CTS after scaphoid reconstruction from August 2002 to December 2020 was performed at our university hospital. We identified 8 patients among a total of 191 scaphoid reconstructions that underwent CTR within an average delay of 18 days postoperatively. A gender and age matched control group (2:1), who underwent scaphoid reconstruction and did not develop CTS, was selected for comparison. Potential risk factors including the surgical approach, premedical history, humpback deformity as well as pre- to postoperative changes in surface and volume of the scaphoid and the carpal tunnel measured in reconstructed CT scans were assessed. Differences between groups was determined using Pearson correlation, whilst risk factors were evaluated via an ANOVA analysis of variance. A p-value <0.05 was considered significant.

Results

The volar Russe surgical approach (p=0.013), pre-operative intrascaphoid angle (ISA) indicating humpback deformity and a significant increase in the postoperative volume and ISA of the scaphoid were correlated (p=0.039) with an increased risk of developing subsequent CTS after scaphoid reconstruction. The overall surface of the scaphoid, the type of bone span, the tourniquet time, as well as time from trauma to reconstruction did not correlate with development of CTS.

Conclusion

We found an incidence of 4.2% of CTS in patients undergoing scaphoid reconstruction. Patients that were operated via a volar approach and needed a high degree of osseous correction leading to a significant volumetric change of the scaphoid - are at risk for developing CTS postoperatively and hence should be subject to a lower threshold decision for prophylactic carpal tunnel release.

Introduction

Systemic Scleroris (SSc) patients frequently suffer from chronic digital ulcers (DU), and skin contractures causing severe impairment of hand function.

Treatment modalities mostly target the vascular manifestations, i.e. Raynaud's phenomenon and digital ulcers. Medical options include calcium antagonists, PDE5 inhibitors or Bosentan, the surgical ones are the injection of Botox or peripheral periarterial sympathectomy.

In 2014 results of treatment of SSc patients with autologous fat grafting were first published, suggesting a promising new method to improve healing of DUs and skin contractures.

Patients and Methods

From November 2015 to May 2017 we treated seven SSc patients with digital Stromal Vascular Fraction (SVF) injections. Liposuctioned fat was processed in a standardized fashion with a cytori cellution machine and the SVF consecutively injected close to each finger's neurovascular bundle.

The following pre- and post-operative data were collected retrospectively: subjective hand function, nail fold capillary microscopy results, modified Rodnan Skin Score (mRSS) as an indicator of overall skin fibrosis, changes in DUs and Cochin Hand Function Scale (CHFS).

Results

Two patients were excluded from the analysis, due to missing follow-up data.

There were no complications from surgery. The mean mRSS was 14.8 pre-, and 11.2 postoperatively.

Two patients had active DUs at the point of surgery, which postoperatively stabilized or healed, but new ones developed on other fingers within a year of surgery. The main concern of the other three patients was skin sclerosis.

Three patients reported a subjective smoothening of finger movement, the other two did not note any improvement in motion at all.

The mean CHFS before surgery was 14 (range 6-31), and 15.4 (range 8-31) after. An actual reduction in the score was noted in one patient only.

Mean semiquantitative score values for capillaroscopic parameters showed a reduction of hemorrhages and capillary ramifications but a slight increase in enlarged and giant capillaries and a rise in capillary loss.

Conclusion

Our case series showed no clear improvement in healing of DUs, capillaroscopic findings, range of motion or hand function.

Thus, despite the small number of subjects, we suggest that previously published promising results of SVF injection in SSc hands should once again be questioned and clear indications for patients which might actually benefit from the treatment should be defined.

Objective: The aim was to analyse the outcomes after combined surface replacing proximal interphalangeal (PIP) joint arthroplasty and distal interphalangeal (DIP) screw arthrodesis (PIP+DIP) and compare them to PIP arthroplasty alone. Our primary hypothesis was that active range of motion (ROM) of the PIP joint does not differ significantly 1 year after surgery between groups.

Methods: We analysed the 1-year data from our prospective finger arthroplasty registry. In the PIP+DIP group, all patients who received a combined PIP surface replacing arthroplasty (CapFlex-PIP, KLS Martin, Germany) and DIP screw arthrodesis at the same finger during the same surgery were included. Propensity score matching was used to match one PIP+DIP patient to five patients with PIP arthroplasty only (control group). Active ROM of the PIP joint, the brief Michigan Hand Outcomes Questionnaire (MHQ) score, and pain at rest (0-10 Numeric Rating Scale) were measured before surgery and 1 year later. Between-group differences were analysed with the Mann-Whitney U test.

Results: We matched 23 PIP+DIP fingers to 115 fingers with PIP arthroplasty only. The mean age was 70 years in both groups. Baseline patient characteristics, ROM and pain before the intervention did not differ between the groups. One year after surgery, the mean PIP ROM was 58° (95% CI: 53-67) in the PIP+DIP group and 65° (CI: 61-68) in the control group (p=0.15). PIP+DIP patients had a 1-year brief MHQ score of 67 (CI:57-77) and patients in the control group had a brief MHQ score of 74 (CI: 70-78) (p=0.18). Pain was 2.2 (CI: 0.9-3.6) and 1.3 (CI: 1.0-1.7) for the PIP+DIP and control group, respectively (p=0.54). One year after surgery, all PIP implants of patients treated with a DIP screw arthrodesis remained in situ.

Conclusion: Combined PIP surface replacement and DIP arthrodesis leads to 1-year outcomes that are similar to those achieved by PIP joint arthroplasty alone. In the case of combined symptomatic osteoarthritis of PIP and DIP joints, a simultaneous intervention with a PIP arthroplasty and DIP arthrodesis can be performed without affecting the result of the PIP arthroplasty.

Background

Mucormycosis (MM) refers to rare infections caused by the fungus Mucorales. They grow in soil and decaying organic material. Mucor infections are often fatal with mortality up to 70%. Early and treatment is key to improve survival. The most common pathogens of Mucor are Rhizopus and Rhizomucor. Lichtheimia corymbifera (LC) is rarer, but known to cause angioinvasive and necrotic infections, mostly in immunocompromised individuals. Soft tissue infections account for 10% of all mucor cases. In healthy patients, MM often follows severe trauma of contaminated wounds. Treatment consists of radical debridement and antifungal agents.

Method

We report 2 patients with digital MM caused by LC.

Pat. 1 is a 77-year-old male with a high-grade B- Cell Lymphoma. He was hospitalized after chemotherapy due to neutropenia and developed a necrotic lesion on the endphalanx of his left small finger. It was first treated as a paronychial infection, but showed progressing necrosis. Debridement and microbiological sampling were performed. After proof of LC, we performed a trans PIP joint amputation.

Pat. 2 is a healthy 39-year-old patient who suffered an amputation of the proximal phalanx of his little finger after handling a bar mower. We performed replantation with PIP arthrodesis, tendon and neurovascular repair. Due to arterial insufficiency, revision was performed on day 1 and 2 after initial surgery. After 7 days, the finger showed mold coating on its radial side and discoloration. We performed an urgent amputation at middle phalanx level. Microbiological sampling proofed LC.

Both patients received i.v. antifungal treatment (Amphotericin B) and wounds healed after 3 weeks. No further complications or dissemination occurred. Patients are well at 6 weeks follow up.

Result

We report two patients with digital LC infection in two different clinical scenarios. Due to the high mortality of MM, aggressive surgical therapy with digital amputation was indicated, followed by anti-fungal treatment.

Conclusion

Digital MM is rare, but potentially fatal. Literature is scarce, only one case with proof of LC exists to our knowledge. Hand surgeons should have a high level of suspicion in case of necrotic lesions in immunocompromised patients and or in non-healing wounds after trauma in farming environment or soil contamination. Radical debridement and amputation may prevent lethal outcome.

First carpometacarpal joint (CMCJ) prosthetic arthroplasty has become a common treatment of first CMCJ arthritis, with high patient satisfaction and good 10-year survival rate^1,2. The ball and socket design is common to total hip prostheses. Heterotopic ossifications (HO) are a well-known complication in the hip, but they have been rarely reported after 1^st CMCJ prosthesis^3,4,5. They might be underestimated and could play a role in postoperative CMCJ stiffness.

Our purpose was to assess the incidence of peri-prosthetic HO and to quantify them. A secondary objective was to evaluate potential risk factors - gender, age, trapezial partial resection, implant type (single or dual mobility), arthritis stage and post-operative time.

All patients operated between 2010 and 2020 were included. The pre-operative radiographs were analyzed for the Eaton stage of arthritis and the post-operative radiographs for peri-prosthetic HO after a minimal follow-up of 6 months.

HO was defined as new bone formation of more than 2mm around the implants on the trapezium and the 1st metacarpal. Below this threshold it was considered as normal bone remodeling after surgery.

HO measurements are made on standardized axial views of the first CMCJ. The surface of the cup serves as a bottom line from which exceeding bone is perpendicularly measured (Fig. 1). In case of several HO, their heights are added.  As X-rays are not routinely scaled, the known cup diameter was used as the scaling mark, its diameter being the same on all views.

The work is still in progress. Our first results show that 16% present HO, most of them on the trapezium, less at the base of the 1st metacarpal. They appear to be more frequent in men than in women, contrasting with the female to male ratio in the series. Our FU ranges from 6 to 36 months. It is too early to say if time plays a role so far.

These preliminary results show that HO after first CMCJ prosthesis are more frequent than reported. The clinical correlation with the occurrence of postoperative stiffness will also be investigated.

References available upon request.

The species of Mycobacterium avium complex (MAC) mainly affect immunocompromised patients. Osteomyelitis caused by MAC show a heterogeneous clinic leading to delayed diagnosis and poorer prognosis and outcome. Clinicians have to consider MAC as an early differential diagnosis.

Case 1: A kidney transplanted 55-year-old female underwent therapeutic and diagnostic synovectomy as she suffered from severe synovitis of flexor tendons and DRUG. No infectious cause could be identified. Postoperatively symptoms persisted and the patient developed an osseous lesion within the distal radius and a perforating abscess on the thenar eminence. Thus, another debridement and open biopsies were performed. M. intracellulare was isolated in bone and synovia biopsies. The affected bone was resected and a Pallacos spacer and antibiotic granulate was implanted. An external fixator was placed over the wrist. An antibiotic regime was established. 5 months later the external fixator and cement spacer were removed, a proximal row carpectomy performed and the distal radius was reconstructed using iliac crest. The patient continued the antibiotic therapy. The reconstructed distal radius healed, the patient was pain free and had a total range of motion of 50°.

Case 2: A 64-year old immunocompromised male suffered a nosocomial infection of the distal radius and carpus with M. chimaera presumably transmitted through aerosols of a heart-lung machine. He presented with arthritis and beginning degeneration of the distal radius and lunate and underwent diagnostic biopsy in which M. chimaera was confirmed. An antibiotic therapy was established. 9 months later the progressive destruction with malalignment in the radiocarpal joint, DRUG and lytic lesion of the lunate lead to a resection of the DRUG and a proximal row carpectomy with Pallacos spacer insertion and wrist fixation with an external fixator. After another 10 months, the spacer was removed and the defect filled with cancellous bone (iliac crest). Due to absorption revision surgery was performed 4 months later with a plate arthrodesis bridging the distal radius stump and the distal carpal row using iliac crest and cancellous bone. The antibiotic therapy was continued. The arthrodesis healed, the patient was pain free and can use his hand in everyday life.

Surgeons need to be alert to the possibility of MAC infections of the bone and encouraged to perform function salvaging operative approaches.

Für die Daumenrekonstruktion  nach traumatischem Verlust stehen eine Vielzahl von Optionen zur Verfügung. Neben dem Zehentransfer vom Fuss, den viele Patienten ablehnen, besteht seit je her die Möglichkeiten der osteoplatischen  Daumenrekonstruktion mit Beckenkammknochen und einer Lappendeckung mit einem gstielten Mc Gregor-Lappen. Diese Art der Rekonstruktion setzt mehrere Operationsschritte voraus mit einer langen Behandlungsdauer. Wenn die osteoplatische Rekonstruktion aber mit einem freien mikrovaskulären Lappen ohne Entnahme am Fuss durchgeführt wird, kann mit einem Eingriff die Rekonstruktion erfolgreich durchgeführt werden. Wir stellen einen solchen Fall als Erstbeschreibung vor.

Ein 57 jähriger Schreiner erleidet eine pluridigitale Fräsenverletzung mit dorsal betonter Amputation des rechten dominanten Daumens auf Höhe Grundglied und eine Amputation des Engliedes am Ringfinger und eine subotale Amputation des Mittelfinger auf Höhe PIP Gelenk. Nach Replantation des Ringfingerendgliedes und Revaskularisation des Mittelfingers erfolgte die Rekonstruktion des Daumens mit einem chimären SCIP Lappen. Da der "Deep branch" und der "Superfical branch" des SCIP Lappens nicht aus einem gemeinsamen Gefäss entsprangen, musst der Lappen als fabrizierte Chimäre durchgeführt werden. Die Knochenkonsolidation erfolgte problemlos mit schnellem Durchbau der Knochenrekonstruktion. Die Weichteile heilten ebenfalls problemlos ab. Es konnte eine sehr gute Funktion erreicht werden.

Die Message für die Gong-Show ist aus diesem Fall, der so in der Literatur nicht beschrieben ist, dass die osteoplastische Daumenrekonstruktion auch ohne Verwendung von Zehen möglich ist und als Variante zur klassischen Osteoplastik des Daumens mit einem freien chimären Lappen eine wertvolle und innovative Ergänzung des Armamentariums darstellt.

Introduction

The management of complex hand injuries may be challenging, especially the anticipation of possible injury progression during emergency surgery if adjacent lesions are missed. We would like to report such a trauma case.

Case report

A 22 year old carpenter cut his wrist with a chop saw at work with a pronounced defect of the distal radius, tendons and skin.  Upon arrival in our emergency department, the primary examination was rushed due to an active bleeding of the radial artery. Intraoperative, a complete lesion of the radial artery, the median nerve, ECRL, FCR, BR, APL, EPB, EPL and FPL  of the thumb were found. There was a substantial osseous defect of the radius styloid, the scaphoid waist and trapezoid. The radial styloid was reconstructed with the bone stock of the distal scaphoid pole forming a part of a neo joint. Radiocarpal ligaments were fixed, nerve and tendons were all repaired and the radial artery was anastomosed. The skin defect was closed by a  local transposition flap and a split skin graft. The wrist was immobilized with splints and active early mobilization of individual joints was started. Early postoperative recovery was uneventful with the exception of the inability to perform dorsal wrist extension. Five months postoperative, a malposition of the carpus was noted. Radiographically, a luxation of the capitate was documented and in retrospect present since the first x-ray 6 weeks after surgery, thus explaining the missing active dorsal wrist extension. Midcarpal instability with the bony defects was not recognized or anticipated. A lunate-capitate fusion was done to restore wrist stability and motion. 14 months  post trauma the patient was able to return back to work as a carpenter with a 60% workload.

Conclusion

After misjudging an injury during the initial emergency surgery, a detective look during follow up consultations is necessary to objectively assess all former injuries. Several doctors of different specialties and seniority missed the luxation of the capitate on the x-ray because they all focused on the radiocarpal joint line and  the reconstructed radius.

Introduction: Interosseous anterior nerve syndrome (AINS), also named Kiloh-Nevin-Syndrom, is a rare syndrome that comprises less than 1% of all upper extremity nerve palsies. Etiology is due to compression or inflammation of the interosseous anterior nerve (AIN), a terminal motor branch of the median nerve. AINS represents an isolated palsy of the flexor pollicis longus (FPL) muscle, the radial aspect of the flexor digitorum profundus (FDP) muscle, and the pronator quadratus muscle. Patients seldomly, as presented in this case report, suffer from an incomplete AINS, which is what makes diagnosis a challenge.

Methods: We report a case of a 62-year-old male who presented at our clinic with an atraumatic acute loss of active flexion in the interphalangeal joint of the thumb. Rupture of the musculus flexor pollicis longus (FPL) tendon was first expected. However, tendinopathy was ruled out with sonography and MRI. Sonography did show swelling and fascicular loosening of the medianus nerve in the proximal forearm. Even without the typical clinical finding of a weak radial flexor digitorum profundus muscle, the presence of a flexor pollicis longus muscles palsy, indicated possible AINS. Neurophysiologic examination verified the diagnosis of an incomplete, acute intraosseous anterior syndrome.

Results: Suspecting an inflammatory genesis of AINS, a conservative approach was the therapy of choice. Seven months after the first presentation of symptoms, FPL function was restored.

Conclusion: Incomplete AINS can be mistaken for a tendinous finger injury. Sonography is a quick an easy tool to identify an intact tendon. When there is a suspicion of AINS, the diagnosis can be verified by electromyography studies.

Fallbericht

Ein 52-jähriger Patient stellte sich in der handchirurgischen Sprechstunde vor mit einer größenprogredienten Schwellung in der ersten Kommissur seiner linken adominanten Hand. Klinisch konnte eine stark druckdolente, gut abgrenzbare, harte Raumforderung in der ersten Kommissur palpiert werden. Nach erfolgreicher, aber für den Patienten schmerzhafter Entnahme zweier Biopsiezylinder ergab die histopathologische Aufarbeitung keinen Hinweis auf Malignität. Aufgrund der mikroskopisch darstellbaren fibro-ossären Läsionen wurde der Verdacht auf einen fibro-ossärer Pseudotumor (FOP) geäußert.

Diskussion

Der fibro-ossäre Pseudotumor (fibro-osseous pseudotumor = „FOP“) ist eine seltene, gutartige Läsion der Weichteile, welche aufgrund der klinischen und morphologischen Ähnlichkeiten mit anderen zum Teil malignen Weichteiltumoren eine diagnostische Herausforderung darstellt. Insbesondere dank histologischer Charakteristika im Wachstumsmuster und der Anordnung von fibroblastischen und ossären Elementen kann histologisch eine Abgrenzung des FOP von Malignomen, aber auch von der Myositis ossificans (MO) erfolgen. So liegen bei einer MO statistisch signifikant mehr fibrinöses Gewebe (p = 0,007) und auch knorpelige Anteile (p = 0,017) vor. Wohingegen der FOP im Vergleich zur MO signifikant mehr unreifes Knochengewebe enthält (p = 0,029). 9 % aller FOP werden unter dem Verdacht auf ein Malignom zugewiesen, wobei die häufigste Fehldiagnose das Osteosarkom ist. Trotz des benignen Charakters des FOP kann dessen vollständige Exzision durch die unmittelbare Nähe zu Nerven, Gefäßen und Sehnen einen anspruchsvollen Eingriff mit Funktionsverlust im Operationsgebiet zur Folge haben. Um unter Umständen folgenschwere Fehldiagnosen zu vermeiden, ist auch bei der FOP eine interdisziplinäre Herangehensweise, insbesondere unter Einbezug von Radiologen und Pathologen, angebracht sowie Kenntnisse der speziellen Morphologie der FOP wünschenswert.

Introduction and Background

Aneurysmatic bone cysts (ABC) represent a rare entity among benign bone tumors (approximately 2% of all bone tumors) while involvement of the hand has been reported in only 3-5% of the cases, where the carpal bones are the least affected. The ABC is reported to have a high recurrence rate, however in the isolated cases involving carpal bones no recurrence of the lesion was found.

Materials and Methods

A 38-year-old male patient presented with pain in the base of the right (dominant) thumb and reduction of active range of motion (aROM) of the thumb for 9 months, without prior trauma. The otherwise healthy office worker did not have any special hand hobby. Conservative measures using splinting, topical and systemic analgesia as well as hand therapy have been unsuccessful. Clinically a painful and immobile swelling dorsal to the first carpo-metacarpal joint as well as a diminished aROM were observed. The diagnostic workup with plain radiographs, CT and MR showed an amorphous cystic bone expansion on the radial margin of the trapezium with no involvement of the cancellous bone or the extensor tendons.

Results

The excisional biopsy confirmed a well-capillarized and undirected spindle cell proliferation with numerous multinucleated giant cells of osteoclast type. Fluorescence in situ hybridization analysis of the USP6 gene revealed a rearrangement in the tumor cells and the diagnosis of aneursymatic bone cyst (solid type) was made. The patient made a full recovery after two weeks of postoperative splinting and could resume his activities without suffering from pain or discomfort. Eight months postoperatively there has been no recurrence.

Discussion and Conclusion

This case of ABC of the trapezium was treated successfully with an excision. ABC is a rare benign tumor, where the carpal bones are the least frequently involved among all known locations while literature supports the lack of recurrence in the carpal bones affected by ABC. Recognizing it in the clinical practice is important to properly address its treatment and postoperative care.

Purpose

In case of a non-reconstructable scaphoid replacement by a patient-specific prosthesis can be considered. Main goals are the biomechanical reconstruction of carpal alignment, -stability and -motion. In this study we provide first qualitative and quantitative results of a four-dimensional computed tomography (4D-CT) assessment comparing the motion of the native cadaver wrist and the same wrist after implantation of a novel patient-specific scaphoid prosthesis.

Methods

A cadaveric wrist was CT scanned and segmented to obtain polygon models of the native Scaphoid and the adjacent carpal bones. Based on the model of the scaphoid, a patient specific scaphoid-prosthesis was produced using additive manufacturing technology. The design included a curved channel through the prosthesis from the volar distal to the dorsal proximal pole for suspension. The wrist was then moved in a hand-shaker and scanned during flexion/extension and radial- and ulnar abduction. Motion was assessed using 4D-CT. From the 4D-CT data the kinematics of the bones were estimated by registration of the carpal shapes to the individual time frames. Subsequently, the prosthesis was implanted by experienced hand surgeons using the technique for anatomical front and back ligament reconstruction (ANAFAB) described by Sandow in 2020. After implantation of the prosthesis, the 4D-CT scan was repeated using the same handshaker, scanning protocol and analysis method.

Results

A good stability during flexion / extension and radial- /ulnar abduction was documented. Movements of the prosthesis compared with the once of the native wrist were almost equal and the SL-interval remained stable during all movements.

Conclusion

A biomechanical reconstruction of wrist movements has to be achieved when replacing the scaphoid. Therefore, we used a modified patient specific design and a well-described technique of ligament reconstruction. Our 4D-CT based analyses showed an anatomical functional suspension and a restoration of carpal alignment.

Purpose

To compare the clinical outcome of computer assisted 3D-reconstructions of the scaphoid using patient-specific guides for primary and revision reconstructions of scaphoid nonunions.

Material and Methods

From 2010 to 2019, a total of 65 patients were treated with patient-specific guides. 50 patients (43 male, 7 female; 26 right and 24 left wrists; mean age 29) were surgically treated with primary scaphoid nonunions in the middle third or the junction between the middle and proximal third. 15 patients with nonunion after previous screw fixation of the scaphoid with or without reconstruction using autologous bone grafts or vascularized grafts (15 male; 10 right and 5 left wrists; mean age 28) were also surgically treated using 3D-planned patient-specific guides and the clinical and radiologic outcomes were compared.

Results

Patients had a postoperative wrist motion of flexion/ extension 59°/ 62° and radial-/ ulnar deviation 18° / 36° in the primary group and flexion/ extension 52°/51° and radial-/ ulnar deviation 15/35° in the revision group. The average grip strength of the operated hand was 37 kg, 84% compared with the contralateral hand in the primary and 39 kg, 85% in the revision group. Consolidation was observed in 46/50 patients (92%) in the primary group after 146 ± 299 days and in 12/15 patients (80%) in the revision group after 144 ± 67 days.

A statistically significant difference was only found for wrist extension, all other measured clinical outcome parameters were comparable.

Discussion

Revision surgery of the scaphoid after previous reconstruction has many obstacles with difficult tenuous vascularity, old screws from previous operations still in place and limited exposure. 3D-planned reconstruction has previously been shown to result in more accurate reduction and allows for precise screw positioning. It now has been shown to result in similar postoperative wrist mobility and grip strength, only wrist extension was reduced compared to primary reconstructions.

Introduction

Perilunate dislocations are severe pan-carpal wrist injuries. In recent years, arthroscopic surgery (AS) has emerged as less invasive treatment method to potentially reach more favorable clinical outcomes than open reduction and internal fixation (ORIF). This study aims to present preliminary results of this novel technique compared to those of ORIF performed at the University Hospital of Bern, Switzerland.

Methods

A retrospective cohort study was conducted assessing all patients undergoing surgery for an acute perilunate dislocation between 01/01/2012 and 31/12/2021. Exclusion criteria were age under 16 years, pre-existing degenerative conditions and history of surgery on the affected or contralateral wrist, severe concomitant injuries that prevent standardized follow-up, and time from trauma to surgery over 21 days. Propensity scores including potential confounding factors were calculated on all included patients using binary logistic regression followed by random 1:1 nearest-neighbour matching to create two treatment groups: AS and ORIF. Functional, radiographic and patient-reported outcomes were compared between the two groups using the independent samples t-test.

Results

A total of 58 patients were operated in the aforementioned timeframe. After assessing exclusion criteria and propensity score matching, 22 patients were included for data analysis (11 in the AS group, 11 in the ORIF group). Baseline characteristics were comparable in both treatment groups. Mean age was 34.4 years (SD 12.2 years) and time from trauma to surgery amounted to 3.2 days (SD 4.1 days). Clinical outcomes were analyzed at two time points: at early and final follow-up corresponding to 6.5 months (SD 1.7 months) and 15.3 months (SD 9.7 months), respectively. Patients undergoing AS had a significantly higher Mayo Wrist Score at final follow-up (75.9% vs. 60.5%, mean difference 15.4%, 95% confidence interval [1.8, 29.1], p = 0.028). Wrist range of motion, grip strength, scapholunate angle, lunocapitate angle and complication rate were comparable in both groups throughout both follow-up periods.

Conclusion

AS tends to produce better clinical outcomes in terms of a higher Mayo Wrist score than ORIF in patients with perilunate dislocations at final follow-up. However, high quality prospective comparative studies with long-term follow-up are needed to confirm this claim.

Introduction

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are rare but severe injuries to the wrist, usually resulting from a high-energy trauma occurring in sports injuries, motor vehicle accidents, falls or machine related accidents. Treatment of choice is early reduction with carpal transfixation, fracture fixation and refixation of the injured ligaments. As reports on mid- to long-term outcome are scarce, we aimed to investigate clinical and radiological outcome of open treatment after a minimal follow-up of 2 years.

Methods

Patients treated for PLD and PLFD in our institution were identified in the electronic OR planning system which was available back to 2008. Inclusion criteria were PLD and PLFD of any kind who underwent open surgery, had a minimal follow-up of 2 years and were available for a clinical and radiological follow-up at our hospital. Clinical examination included ROM and grip strength. PRWE, quick DASH, SF-12 and the single assessment numeric evaluation (SANE) score were used as PROMs. Pain was assessed on a 10cm VAS. Dorso-palmar and lateral X-rays of both wrists were done and assessed for carpal height, inter- and radio-carpal angles and degenerative changes.

Results

Of a total of 55 identified patients, 49 had a minimum follow-up of 2 years. Of those, 10 had been treated as tourists or guest workers from abroad and thus, were not available for follow-up. Of the 40 remaining patients, 7 could no longer be located and contacted leaving 32 available for the study. By the date of abstract submission 12 patients after PLFD and 8 after PLD had been followed-up in our clinic. Mean follow-up was 107months (24-170). Mean F/E was 39/0/51 for the affected and 68/0/66 for the healthy wrist, P/S 77/0/72 and 80/0/79, R/U 26/0/40 and 30/0/50. Mean grip strength was 41kp and 47kp. Mean score for PRWE was 7.4, qDASH 7.6%, SF-12 physical score 52.8, mental score 54.6 and SANE 89%. 9 patients showed a DISI>10° and 10 slight to moderate degenerative changes. Carpal height according to the Nattrass Index differed significantly (p<0.008) between affected (1.45) and healthy (1.52) sides.

Discussion

Generally, patients did well 2-14 years after surgery for PLD and PLFD. Although the affected wrists showed reduced ROM and SANE scores, patients were mostly satisfied with the outcome and only exhibited little functional impairment. Open reduction and fixation of PLD and PLFD reliably lead to satisfactory results even in the long-term.

Introduction

Trans-articular intramedullary fixation using cannulated headless screws is an established method for fixation of displaced and and unstable finger fractures. It is stable and allows early postoperative mobilization, reduces the risk of adhesions, and shows a low implant removal rate. Clinical short-term results are very satisfactory, there is however little evidence in literature regarding long-term outcomes.

Patients and Methods

From March 2014 to Mai 2016 we treated 28 patients with proximal phalanx fractures with intramedullary screw fixation. 8 patients with 9 fractures could be recruited for a follow-up visit, the remaining were lost to follow-up.

All the fractures were initially treated with an open or closed reduction and intramedullary headless compression screw fixation, 6 in an antero- and 3 in a retrograde fashion. Patients were revisited 3 years postoperatively. Subjective and objective patient related outcome measures were assessed by means of the Michigan Hand Questionnaire (MHQ), active range of motion (aROM) and grip strength. Additionally a conventional x-ray and tomography was performed to assess consolidation and signs of osteoarthrosis.

Results

Two of the fractures needed revision, one after 6 weeks due to malrotation and the second one after two years due to malrotation and MCP joint contracture. Other than that there were no complications noted and no screws removed.

The average 3-year follow-up MHQ was 83% with a satisfaction score of 86 %. Mean total aROM was 216° (range 95°-285°) compared to 185° at 1-3 months postoperatively. The average extension lag for the MCP-joint was 27.2°, 5.5° for the PIP- and 1.1° for the DIP-joint. Mean Jamar grip strength in the dominant injured hand was 35.5kg (range 30kg-48kg) and 25.4kg (range 19kg-30kg) in the non-dominant injured hand.

Digital tomosynthesis showed a full fracture consolidation in 7 fingers. In one finger the fracture gap was slightly visible and in one case the images were unusable. Incipient athrosis was only found in one case, which was an intra-articular thumb fracture.

Conclusion

Given our results, the use of intramedullary headless screw fixation has shown good clinical long-term outcomes, with satisfactory range of motion and grip strength, as well high rates of patient satisfaction. Furthermore there were no signs of arthrosis due to the trans-articular screw insertion.

Objectives

Intramedullary screw (IMS) fixation has been increasingly used as an alternative treatment option in metacarpal shaft fractures of the hand. Biodegradable implants made from magnesium (Mg) alloys have been developed to obviate the need for implant removal. This makes Mg-based headless compression screws (HCS) ideal for IMS fixation. The present study aims at investigating the stability of Mg-based HCS with respect to torque at failure in a synthetic bone model as well as torque at metacarpal insertion in human cadaver specimens.

Material and Methods

The study products investigated were CE certified Mg-based cannulated HCS (MgYREZr-alloy, MAGNEZIX^® CS 2.7/3.2) that were provided by the manufacturing company Syntellix AG, Hanover, Germany. Torque at failure was measured in a synthetic bone model using a standardized polyurethane foam block with 50 PCF and 62.5 PCF, respectively. In ten cadaveric metacarpal bones, Mg-based HCS were inserted into the medullary canal, while assessing the torque applied every half-turn interval. Quantitative variables were summarized by descriptive statistics. To investigate statistical correlation between non-parametric variables the Mann-Whitney-U test was used.

Results

Median torque at failure for the 2.7 mm and 3.2 mm HCS was 43.2 Ncm (range 39.2 - 45.7 Ncm) and 63.2 Ncm (range 58.6 - 65.4 Ncm), respectively (Mann-Whitney U = 0, n₁ = 12, n₂ = 12, p < 0.001). Median count of half-turn intervals at failure in the two groups was 12 (range 10 - 18) and 17 (range 13 - 26), respectively (Mann-Whitney U = 21.5, n₁ = 12, n₂ = 12, p = 0.004). In the human cadaver model, the distribution curve of torque during metacarpal insertion showed three peaks, which averaged 5.2 Ncm (range 2.6 - 7.9 Ncm), 5.5 Ncm (range 3.2 - 7.7 Ncm), and 22.7 Ncm (range 13.0 - 31.4 Ncm), respectively. The highest insertional torque value of metacarpal insertion reached 53.6 % of the lowest torque at failure measured in the synthetic bone model.

Conclusions

As far as the torsional demand is concerned, Mg-based cannulated HCS are suitable for IMS fixation of metacarpal fractures. The use of biodegradable implants may represent a relevant improvement of this treatment method.

Key words

Intramedullary screw fixation; metacarpal fractures; cannulated headless compression screws; biodegradable implants; magnesium screws

The open palm technique for Dupuytren's disease has been described originally by Dupuytren himself but its popularity has decreased along the years because of the risk of intraoperative nerve damage.  Nevertheless, the optimal outcomes of this technique regarding the scars and the relatively low risk of damaging nerves  in patients with mild contractures, makes this technique interesting. We present a series of 22 patients with early Dupuytren's disease treated with this technique.

Matherials and Methods: From January 2019 to June 2021, we treated 22  patients with Dupuytren disease. There were 17 men and 5 women for a total of 23 hands. There were 37 rays operated. Three rays were stage 0  and were next to more severe contracted rays. Twentyone rays were stage 1 disease, 9 rays stage 2 and 2 rays stage 3. All patients were operated under regional anaesthesia with a transverse incision at the palm along the distal palmar crease and one or two more transverse incision at the digital transverse crease, accordingly to the severity of the disease. A selective fasciotomy was then performed in order to remove al visible disease, leaving the transverse fibers intact. All patients were treated posteoperatively with a humid dressing with double fat gauzes that was changed by the Hand Therapist once a week. All patients started immediate immobilization after surgery. A night splint in extension was used for patients with stage 2 and 3 disease. We recorded early and late complications. At the last follow up at 16 months (range 11-25) we measured the range of motion, strength and  any visible recurrence. We also asked for patient satisfaction.

Results: All patients eventually healed. We observed no early complications  as nerve damage or infections. At the last follow up all patients had a complete correction of the Dupuytren's contracture, except in one patient that developed a painful scar and a consequent new smal contracture. At the last follow up the range of motion and the strength were recovered. No recurrence was observed. All patient but one were satisfied with the results and highly satisfied with the scar.

Discussion: The open palm technique seems to be safe and useful in treating early and mild Dupuytren's disease, with excellent scars. The paradigm of operating only patient with Dupuytren's disease stage 2 or higher, might come under discussion.

Background: To date, there are no clear guidelines available, how patients with residual symptoms after thumb carpometacarpal (CMC) resection arthroplasty should be treated further. Therefore, the FaiTh (Failed Thumb carpometacarpal resection arthroplasty) study was launched to develop such guidelines. One part of this project consisted of a Delphi study to determine current world-wide trends in the treatment of failed thumb CMC resection arthroplasty.

Methods: The project is directed by the FaiTh steering committee consisting of nine experienced hand surgeons from Europe, America and Asia and one methodologist. In a first Delphi-round, an electronic survey was sent to 181 hand surgeons from all over the world. Questions included sociodemographic data and the participants’ practice in cases of failed thumb CMC resection arthroplasty.

Results: Delphi participants returned 110 completed surveys (61%) and had a mean experience as hand surgeons of 22 years (SD 7). Seventy-five percent were working in Europe, 14% in North America, 5% in Asia, 4% in South America and 2% in Africa. The main indications for performing thumb CMC revision surgery were reported as "persistent pain" (85%), "remaining scapho-trapezoidal (ST) osteoarthritis" (54%), "instability of the thumb metacarpophalangeal joint" (46%) and "subsidence of the first metacarpal bone" (39%). The participants mentioned 25 different techniques for revision surgery. The most frequently mentioned techniques were the revision of the existing interposition using an autologous tendon (62%), resection of the ST joint (56%), suspension with a Mini TightRope® (29%) and arthrodesis between the first and second metacarpal (18%). Most surgeons (67%) indicated that they would wait at least 1 year until they perform revisions surgery, while 28% would do a revision between 6 and 12 months postoperatively and 5% even earlier.

Conclusion: The treatment strategies for failed thumb CMC resection arthroplasty differ widely among experienced hand surgeons. Based on the results of this first survey, the FaiTh steering committee will launch two additional Delphi surveys to further specify the treatment strategy and develop guidelines for the treatment of failed thumb CMC resection arthroplasty.

Introduction: Arthritis of the basal thumb is a relatively common condition also affecting younger patients. Wilson et al. described a 20° to 30° closing wedge osteotomy of the first metacarpal bone to unload the trapeziometacarpal joint. It was the purpose of this study to analyze the clinical and radiographic outcome of patients who underwent proximal extension osteotomy of the first metacarpal bone using patient-specific planning and instruments (PSI).

Methods: All patients who underwent proximal metacarpal osteotomy for basal thumb arthritis at our tertiary referral center were retrospectively included. The patients underwent preoperative planning using computed tomography and 3D segmentation to build patient-specific guides and instruments for the operative treatment. Stable fixation of the osteotomy was achieved by internal plating. The inclusion criterion was a minimum follow-up of one year with clinical examination, including Michigan Hand Outcomes Questionnaire (MHQ), and computed tomography to validate the correction. Complications and reintervantions were recorded. 

Results: A total of eight Wilson osteotomies in six patients could be included at a mean follow-up duration of 33 months. The postoperative MHQ for general hand function was 77 and the MHQ for satisfaction 77, respectively. The working status was unchanged in 7/8 hands (6/7 patients). Radiographic analysis revealed successful correction in all cases with unchanged Eaton-Littler stage in 7/8 hands.

Conclusion: The combined extending and ulnar adducting osteotomy using patient-specific guides and intrumentation provides a accurate treatment for early-stage thumb arthritis.

Introduction :

La prothèse Motec® est une arthroplastie totale du poignet associant une tige en titane non cimentée radiale et une tige au sein du 3ème métacarpien. Le type de charnière est une articulation métal/métal sphéroïde permettant ainsi des mobilités dans les trois plans de l’espace. Elle est indiquée dans les arthroses pancarpienne pour lesquelles la seule option reste une arthrodèse pan carpienne. Nous relatons nos 3 premières années d’expérience avec cet implant.

Méthodes :

Il s’agit d’une série prospective monocentrique continue. Nous avons relevé les indications opératoires, l’analyse fonctionnelle et radiologique, les complications post opératoires.

Résultats :

La série comporte 18 cas avec un recul moyen de 24 mois. Il s’agissait de 6 femmes et 12 hommes. Tous les cas opérés présentaient une arthrose pan carpienne. Il s’agissait de 5 cas de polyarthrite rhumatoïde avancée, 4 reprises d’arthroplastie partielle type RCPi® ou Amandys®, 4 SLAC wrist stade 4, 3 reprises d’arthrodèse médio carpienne, 1 reprise de résection de première rangée des os du carpe, 1 cas de résection tumorale du carpe. L’analyse radiologique a montré une tendance à la distalisation du carpe, avec une translation radiale et dorsale du carpe. Un implant s’est décelée en métacarpien, nécessitant une reprise chirurgicale pour changement de pièce métacarpienne. Un patient a présenté une ténosynovite des fléchisseurs sur un conflit marginal antérieur du radius, nécessitant également une reprise chirurgicale pour résection osseuse.

Conclusion :

La prothèse Motec® semble être une solution acceptable par rapport à une arthrodèse pan carpienne. En revanche, la modification des centres de rotation du poignet nécessite plus ample investigation pour connaitre son impact fonctionnel.

Introduction

Due to various problems as implant dislocation, silicon synovitis, and continuous carpal collapse, prosthetic lunate replacement has not become a standard procedure so far. We hypothesize that using a patient-specific implant in combination with a reconstruction of the scapho-lunate (SL), luno-triquetral (LT) and long radio-lunate (LRL) ligaments will allow a close to normal restoration of carpal kinematics in the cadaver wrist.

Methods

Five thawed cadaver wrists were used. 3D-reconstructions of the wrists were obtained based on standard CT-scans. The prosthesis was planned as a replica of the original lunate and manufactured in titanium. Two types of ligament reconstructions using a distally based FCR-stripe in combination with FiberTape^R were tested. 1) Anatomical front and back (ANAFAB) technique for SL- and LRL-ligaments combined with an LT- and dorsal intercarpal ligament (DICL) reconstruction through a y-shaped channel in the lunate (2 wrists). 2) SL-/LT-reconstruction through an oblique channel and isolated LRL-reconstruction with an isolated anchoring on the palmar aspect of the prosthesis (3 wrists).

4D-CT scans were obtained for extension/flexion (E/F) and radial-/ulnar-abduction (R/U) with the original lunate and after implantation of the prosthesis. Translation and rotation of the carpals were qualitatively and quantitatively analyzed in a 3D-coordinate system.

This study was supported by Medartis AG and Arthrex (anchors & FiberTape^R).

Results

The prostheses fitted perfectly after removal of the original lunate. In type 1 ligament reconstruction, the whole carpus almost acted as one block with restricted intercarpal and midcarpal motion. While the lunate qualitatively showed a close to normal rotation pattern, the amount of rotation and translational motion was increased in all dimensions. The scaphoid showed close to normal rotation but increased translation too. This improved substantially in type 2 reconstructions. 

Discussion

The production of an anatomically shaped and sufficiently polished prosthesis using conventional milling and polishing techniques nowadays is feasible. We believe that carpal kinematics is mainly influenced by the type and tensioning of the ligament reconstructions. Including DICL reconstruction led to midcarpal stiffness and should not be done. Future investigations should focus on further refinements of ligament reconstruction with special emphasis on intraoperative control of ligament tension.