Wissenschaftliches Programm: Donnerstag, 24. November

Einleitung. Die qualitativ hochstehende Versorgung von Patient:innen in der Handchirurgie ist alltägliches Bestreben. Doch wie steht es um die Lebensqualität der Handchirurg:innen, die diese hohe Qualität tagtäglich gewährleisten. Ziel dieser Arbeit ist es, die Lebensqualität und die Arbeitsbedingungen von Schweizer Handchirurg:innen zu evaluieren.

Methodik. Wir etablierten eine nationale Befragung. Die Umfrage wurde durch die Schweizerische Gesellschaft für Handchirurgie und die Vereinigung der Jungen Handchirurg:innen via E-Mail versendet. Via Zugangslink konnte online der standardisierte Fragebogen anonym ausgefüllt werden. Kernthematik waren Arbeitsumstände, Lebensqualität und die Zufriedenheit mit dem Beruf sowie Aspekte des Privatlebens. Die Daten wurden als uni- und multivariable Modelle ausgewertet.

Resultate. Es konnten ca. 250 Handchirurg:innen angeschrieben werden. Mit 110 vollständig ausgefüllten Fragebögen ergab sich eine Rücklaufquote von 44%. Die Befragten sind überwiegend männlich (58%). 93% aller Befragten sind in einer Partnerschaft, 71% haben Kinder und 9% sind Raucher:innen. 43% geben an, dass sie 4-7 Tage pro Monat Bereitschaftsdienst haben. Demgegenüber stehen 9%, die nie Bereitschaftsdienst haben. Die wöchentlichen Arbeitsstunden und Dienste haben einen negativen Einfluss auf die Lebensqualität. Mehr als 50% der Befragten fühlen sich auch während den Ferien/Freizeit durch den Beruf gestresst. 88% fühlen sich durch das Umfeld verstanden und unterstützt. 85% haben das Gefühl, dass die Arbeit private Beziehungen beeinflusst. 83% würden erneut die Fachrichtung Handchirurgie wählen.

Schlussfolgerung. Die Lebensqualität von Schweizer Handchirurg:innen ist im Allgemeinen überwiegend sehr gut. Dennoch ist der Beruf Handchirurg:in in der Schweiz stressig und beeinträchtigt die Lebensqualität. Die Rate an chronischer Erschöpfung, Burnout und Depression ist ähnlich hoch wie in der Literatur für andere chirurgische Fächer angegeben. Die Mehrheit der Befragten gibt an, dass eine Stelle an einem Akutspital für Handchirurgie durch weniger Dienste und/oder eine bessere Entschädigung der Arbeitszeit und der Dienste für sie attraktiver würde.

Background: Despite the recognition of the importance of routine measurement of clinical outcomes in healthcare, the implementation remains a challenge. This article describes the framework by which the authors have created and implemented multiple registers for the routine measurement of patient outcomes in hand surgery. In addition, we discuss how this highly automated data collection infrastructure promotes a high coverage rate and provides an essential foundation for meaningful scientific data analyses and publications.  

Methods: In the registries, baseline data as well as clinical and patient-reported outcomes are documented at 6 weeks, 3 months, 1, 2, 5, and 10 years postoperatively. For this purpose, the secure and web-based application REDCap (Research Electronic Data Capture) is used, supported by a database for the routine monitoring created on Filemaker Pro Advanced, which is automatically and periodically updated with new data from the clinic information system. Data collection and completeness of data is dealt with by the study assistant, while the research assistant is responsible for data management. In addition, the participation of the surgeons as well as the secretaries is essential. Both the setup of the registers as well as the data analysis are approved by the Cantonal Ethics Committee. All patients with an arthroplasty of the proximal interphalangeal (PIP), the metacarpophalangeal (MCP) or thumb carpometacarpal (CMC I) joint and patients with an individual patient-specific implant (IPS) for corrective osteotomy are recorded in separate scientific registries.

Results: The coverage rate of all our registries is 100%, meaning that no patient was missed. Our biggest and oldest registry covering PIP joint arthroplasties includes 743 patients. We may report a follow-up rate two and five years postoperatively of 96% and 95%, respectively. The registry containing 236 CMC I prostheses also shows a follow-up rate of 96% one year and 93% two years postoperatively. Furthermore, this collection of scientific data has led to the publication of more than 15 peer-reviewed articles in international journals since the start of the registries.

Conclusion: Although the maintenance of registries requires resources and manpower, the recording of essential clinical data in registries serves as a strong foundation for scientific publications, for the improvement of the quality of patient care as well as to tackle various scientific questions.  

Introduction: While video consultation is widely accepted and integrated in the service of many health care providers, no studies have yet been conducted regarding patient satisfaction with video consultation in hand surgery. The aim of this project was to evaluate patient satisfaction with video consultations in elective hand surgery using a self-developed patient questionnaire.

Methods: All patients attending video consultation by a hand surgery consultant since March 2022 were included in this study. Patients were offered video consultation either for the initial assessment of unspecific hand complaints or as a postoperative follow-up in case the patients were free of any complications. After the video consultation, patients received a survey in which they noted sociodemographic data and rated their experience and satisfaction with the video consultation.

Results: Until May 2022, 37 patients with a mean age of 53 years (range 17-81) were included. Patients had different education levels ranging from vocational training to doctoral degrees. Eighteen patients had a first consultation and 19 a postoperative follow-up. The most frequent reasons for attending video consultation were recommendation of the surgeon (n=16), travel time savings (n=10) or reduced waiting time until the first appointment (n=10). Most frequent diagnoses of the postoperative consultations were total joint replacement arthroplasties (n=4), carpal tunnel release (n=3) and joint arthrodeses (n=3). Of all patients 95% (n=35) were satisfied or very satisfied with the video consultation in general. While 31 patients would consider a video consultation again, 4 patients would prefer an in-clinic appointment. Two patients were dissatisfied, one because the symptoms could not be clarified completely, the other criticized the video and sound quality. Furthermore, both had a foreign language as their mother tongue.

Discussion: Video consultation in hand surgery seems to be a valuable additional offer to in-clinic appointments, given that the internet speed and the video and audio quality are sufficient. The service is appreciated by patients for time savings and less waiting time. Patients were satisfied with this procedure regardless of their age or education. However, for patients who are not native speakers, a video consultation might not be optimal. The project is on-going, and data of more patients will be presented.  

INTRODUCTION

It is well known that pronation and supination of the forearm leads to a physiological dorso-palmar shift in the distal radioulnar joint (DRUJ). However, little is known about the translational movement in the proximal radioulnar joint (PRUJ) during pronation and supination.

Therefore, the primary objectives of this study are to demonstrate the existence of an anterior-posterior translation in the PRUJ, its degree, and directionality during forearm rotation based on an in vivo motion analysis.

METHODS

This study recruited 15 healthy adult volunteers with no reported history of pathology that might affect the rotational movement of the forearm. Each participant underwent an ultra-low dose computed tomography (ULD-CT) of both forearms in neutral position, pronation, and supination. Bilateral 3-dimensional surface models of the radius and ulna were generated from the ULD-CT slides by segmentation of the bones in the image data. The models were then superimposed on each other, the axis of rotation was determined, and the degree of dorso-palmar translation of the radial head center was measured.

RESULTS

Fifteen volunteers (7 females, 8 males) with a mean age of 34 years (Range: 26-55 years old) were included in the study. Study participants were right-handed in 73% (11/15) and left-handed in 27% (4/15). In all participants, an anterior translation of the radius in the PRUJ during supination was found and posterior translation during pronation was observed. The mean anterior-posterior shift was 2.5 mm (Range: 0.4 mm – 4.4 mm) on the right side and 2.6 mm (Range: 0.9 mm – 5.5 mm) on the left side.

DISCUSSION & CONCLUSION

Overall, our results indicate that an anterior-posterior translation during forearm rotation exists in the proximal radioulnar joint (PRUJ) with a posterior shift of the radial head in pronation and an anterior shift in supination.

These in vivo analyzed findings contradict the previous studies describing translational motion in the PRUJ. This finding re-defines specific aspects of the complex spatial relationship between the radius and ulna during forearm rotation.

Background: Despite the many clinical registries in healthcare, only a fraction of the data is effectively being used to improve clinical processes and outcomes in many cases. We describe the framework by which registries can be further used to support decision-making or patient-doctor communication during consultations.

Methods: Patient-reported data is collected using the secure and web-based application REDCap (Research Electronic Data Capture) with which questionnaires can automatically be distributed to patients. Patient-reported and clinical outcomes are documented preoperatively, on the day of surgery, and 6 weeks, 3 months and 1, 2, 5, and 10 years postoperatively.

REDCap data along with demographic and clinical data from the clinic information system is forwarded to a data warehouse, which serves as a rich data source for various research activities or clinimetrics. Moreover, the data is integrated into the workflow of health professionals via a visualization platform built on Microsoft PowerBI, allowing clinicians to have direct access to individual patient outcomes during consultations.

Results: Over 12 years, 4 registries of the hand surgery departments have been regularly managed at our clinic. Approximately 3000 questionnaires have been filled out by patients for over 1'000 surgeries. Last year, the coverage rate of all registries was 100%, meaning that no patient that should have been recorded was missed across all our registries.

Currently, for patients with implant arthroplasty at the first carpometacarpal joint, our hand surgeons have the possibility to visualize individual patient data in relation to the patient's cohort (Figure 1). Besides expanding this functionality to all registries, we are currently working on implementing decision-support tools such as e.g., goal-setting instruments, prediction models or clinical alert systems into the same platform.

Conclusion: By visualizing individual outcome data relative to other patients, both the patient and the clinician are provided with a reference to discuss treatments and their outcomes. Future developments intend to further improve clinical care and aid doctors in their decision-making.

Introduction

Proximal phalangeal fractures (P1) account for approximately 10% of all fractures. Displaced and unstable fractures require a surgical treatment. During the healing period, adhesions between the fractured bone and the adjacent soft tissue contribute for limited total active range of motion (TAM). Hand therapy is important after operative treatment of fractures to counteract stiffness of the joints. We compare the clinical results of plate osteosynthesis versus intramedullary screw osteosynthesis applying a rehabilitation protocol.

Materials and methods

Between February 2017 and March 2020, 29 patients with 31 comparable fractures of the proximal phalanx that were treated either with a plate (14) or with minimal invasive cannulated compression screw (17). The mean age of the patients was 46 years (16-82).  All the patients received a rehabilitation-protocol with initial splinting, followed by early active mobilization. The number of sessions were documented. Total active range of motion (TAM), work disability, Pain, strength, and QuickDASH score were assessed. Level of significance was set at p<0.05. A power analysis was performed with power target of 0.8.

Results

All patients attended hand therapy postoperatively. The screw group attended an average of 10 sessions compared to the plate group with 21 sessions (p=0.02, power 0.94). The TAM was 41° worse in the plate group prior to the plate removal compared to screw group with a TAM of 205° versus 246° (p=0.02, power 0.99). After plate removal the TAM in the plate group was 227° with a difference of 22° (205°) not reaching statistical significance (p=0.32, power 0.38). The extension lag difference of 13° between both groups prior to plate removal and 12° after plate removal was statistically significant (p=0.01/p=0.03, power 0.99).

In the screw group, sick leave was 5.6 weeks compared to 9.9 weeks in the plate group (p=0.05, power 0.97). There were no statistically significant differences in pain, strength and QuickDASH score.

Conclusion

Hand therapy is important after surgery of proximal phalangeal fractures. The chosen method of fixation, plays a significant role in the outcome of the TAM and the amount of needed hand therapy sessions.

Purpose: This study aimed to describe the joint movements during rock climbing using an optoelectronic motion capture system and to investigate the practicability of this method.

Methods: One higher elite, eight elite and two advanced level rock climbers performed climbing moves on handholds instrumented with self-developed load cells collecting kinetic data, that were used to determine the holding phase. An optoelectronic motion capture system (VICON®) simultaneously recorded the movements of the finger joints and wrists. Measurements were performed for three common grip positions in rock climbing (crimp, half-crimp and open-hand grip). Kinematic data was analysed using Matlab®.

Results: Marker visibility was best for the open-hand grip and for the more proximal joints. During the holding phase, mean left ring finger proximal and distal interphalangeal (PIP, DIP) joint angles were 86° (SD 2.3°) and -16° (SD 1.9°) for the crimp grip, 66° (SD 2.1°) and -7° (SD 1.8°) for the half-crimp grip and 27° (SD 3.8°) and 19° (SD 3.3°) for the open-hand grip, respectively. The wrist joint was extended between -37° (crimp) and -10° (open hand). During the holding phase, joints moved within a range of maximally 14° for the crimp and the open-hand grip and 12° for the half-crimp grip task. Two different open-hand grip methods could be observed, with the ring finger PIP joint angle either below 15° or above, ranging from 20 to 78°.

Conclusion: Despite challenging marker visibility in some task, the optoelectronic motion capture system proofed to be a practicable tool for 3D motion analysis of the hands during rock climbing. The obtained joint angles were in line with general descriptions in previous studies. Joint angles did not vary considerably during the holding phase but remained stable. This allows direct force transmission on the wall when pulling on a handhold. Eccentric finger joint motion during high loads, notably a risk factor for finger flexor pulley injuries, was not observed. It presumably only occurs unintentionally during an unexpected load rise on the hand. The two open-hand grip methods most likely differed in whether the little finger was used or not, leading to more flexed or extended middle and ring fingers. As loads on pulleys are lower with less flexed PIP joints, instruction not to use the little finger for the open-hand grip might be important after pulley rupture.

Objective: The aim was to analyse the outcomes 2 years after thumb carpometacarpal (CMC I) implant arthroplasty with the focus on revisions and complications.

Methods: Patients treated with an implant arthroplasty (Touch®, KeriMedical, Switzerland) who were prospectively documented in a registry were included. Revisions up to 2 years postoperatively and complications were recorded. Before surgery and 2 years thereafter, all patients had their hand function assessed with the brief MHQ (score 0-100) and rated their pain during daily activities on a Numeric Rating Scale (NRS; 0-10). Key pinch strength was measured with a pinch gauge. Two-year implant survival was estimated using the Kaplan–Meier method. We used a two-sided t-test to analyse for differences between baseline and 2 years.

Results: Currently, we have 232 CMC I implants in our registry, 67 of whom were operated on 2 years ago or earlier and were therefore suitable for this analysis. Three out of these 67 implants had to be revised 14-24 months after implantation, leading to an estimated 2-years survival rate of 95% (95% Confidence interval [CI]: 84% to 98%). The reason for revision was cup loosening in one case, mispositioning of the cup in another case and impingement due to suboptimal cup positioning and a too short head/neck component in the third case. Further complications that required additional conservative therapy and/or steroid injection and/or soft-tissue surgery include tendovaginitis de Quervain (n=2), tendovaginitis stenosans at the operated thumb (n=2), connective tissue nodule at the EPL tendon (n=1), intraoperative trapezium fracture (n=1) and thumb stiffness (n=1).

At two years, 54 patients were available for follow-up. The brief MHQ score increased from mean 46 (CI:42-51) at baseline to 87 (CI:83-92) at 2 years (p≤0.001) and pain during activities decreased from 7.2 (CI:6.8-7.7) to 1.4 (CI:0.8-1.9) at 2 years (p≤0.001). Key pinch strength was 4.8kg before surgery and 7.2kg at final follow-up (p≤0.001).

Conclusions: The 2-year survival rate of 95% of the Touch® implant is acceptable and better than for other CMC I implants reported in the literature. A careful surgical technique, especially in the placement of the cup in the trapezium, is needed and the learning curve of the surgeon has to be considered.

Objective: The aim was to investigate if patients treated with a thumb carpometacarpal (CMC I) implant arthroplasty recover significantly faster than patients after resection-suspension-interposition (RSI) arthroplasty, regarding the number of days they went back to work.

Methods: This study comprised two cohorts: (1) Patients treated with an implant arthroplasty (Touch®, KeriMedical, Switzerland) who were prospectively documented in a registry and (2) RSI patients from a previous clinical trial. Before surgery, 3 months and 1 year thereafter, all patients noted the number of days until they returned to work post-surgery. Hand function was assessed with the brief MHQ (score 0-100) and pain during daily activities was measured on a Numeric Rating Scale (NRS; 0-10). Key pinch strength was measured with a pinch gauge.

Results: In the implant group, 125 patients with a mean age of 63 (±8) years were available and their 1-year outcomes were compared to 127 RSI patients with a mean age of 65 years (±9). In the implant group, 70 patients were employed and 39 in the RSI group. After implant arthroplasty, patients returned to work after a mean time of 44 days (95% confidence interval [CI]:27-61), which was significantly faster than the mean time of 68 days (CI:41-96) for the RSI group (p≤0.05). Moreover, patients with an implant had a significantly better 3-month postoperative brief MHQ score (83, CI:80-86) than those after RSI (69, CI:65-72) (p≤0.001, figure 1). Pain at 3 months was also significantly lower in the implant than RSI group (1.9 (CI:1.6-2.3) versus 3.2 (CI:2.9-3.6), p≤0.001). Key pinch at three months was significantly higher in the implant than RSI group (6.9kg (CI:6.3-7.6) versus 3.1kg (CI:2.8-3.4), p≤0.001). At one year, patients in both groups had similar outcomes, except for key pinch, that was still significantly higher in the implant group.

Conclusion: Patients after CMC I implant arthroplasty return almost twice as fast to work and also show significantly faster recovery of hand function than patients after RSI. One year after the surgery, there is only a difference between both groups in strength but not in the other outcomes.

Introduction

Despite the satisfactory outcomes of RSI-Arthroplasty, the Touch prosthesis has become an excellent alternative in recent years. Due to their double mobility concept, the third generation prostheses show significantly better 5-year results than the second generation prostheses. The aim of this study was to retrospectively analyse not our results but our complications in order to assess our learning curve and its consequences in a hand surgery teaching unit.

Methods

We are using Touch prosthesis since 2019. To date (May 2022), 80 patients have been operated on by two surgeons. We have recorded our complications in a retrospective analysis. On the basis of clinician and patient reported outcomes, postoperative X-rays and the prosthesis components used, we have tried to identify technical challenges and to draw learning effects from them. We used the spherical cup in 76 % of cases.

Results

We analysed 80 Touch prosthesis in 76 patients. Mean age was 62 years, 16 men and 60 women. A total of 6 complications (4.8%) were detected in 6 different patients: 2 cup dislocations, 2 instabilities of the metacarpo-phalangeal (MCP) joint, 1 ossification and 1 de Quervain’s tenosynovitis. All 6 patients had to be reoperated: 2 re-positionings of the cup, 2 MCP fusions, 1 resection of the ossification and change to a bigger size of the neck and finally 1 synovectomy in the first extensor compartment.

Conclusion

Five out of 6 complications (83%) were among the first 19 patients (24%). The 2 cup dislocations were due to incorrect cup placement and/or insufficient resection of trapezium osteophytes. Periarticular ossification in 1 thumb caused stiffening of the prosthesis and was probably caused by insufficient resection of trapezial and metacarpal osteophytes. Persistent MCP joint instability after any procedure at the osteoarthritic trapeziometacarpal joint is a common problem in literature. It’s debatable if this entity should be called “complication”. In literature, de Quervain’s tenosynovitis following Touch prosthesis is well described. In our series it was only once a real problem, so we don’t see the need to address first extensor compartment routinely.

In conclusion, our lessons learned are:

- complete resection of hemicircular capsule and complete release of metacarpal base to get enough mobility for cup positioning

- proper resection of osteophytes

- invest enough time for optimal cup positioning

- use of machine drill for conical cup if possible

Objective: The aim was to compare the 5-year outcomes between surface-replacing implants at the proximal interphalangeal (PIP) joint of the index finger versus the same implants at the PIP joints of the other fingers. Our primary hypothesis was that patients with an index finger PIP implant would not have a higher revision rate 5 years after surgery compared to patients with PIP implants at the other fingers.

Methods: Based on our prospective registry, patients who received a single PIP surface replacing arthroplasty (CapFlex-PIP) and had a 5-year follow up were included in this analysis. Revisions and complications were recorded. Active range of motion (ROM) of the PIP joint and deviations from the longitudinal finger axis were measured. Before surgery and at follow-up, patients completed the brief Michigan Hand Questionnaire (MHQ) and rated their pain during daily activities on a Numeric Rating Scale (0-10). Between-group differences in revision rates were calculated with a Fisher's exact test and differences in the other outcomes using the Mann-Whitney U test.

Results: Forty-four patients with an arthroplasty of the index finger and 37 patients with an arthroplasty at the other PIP joints were evaluated. The 5-year revision rate did not differ significantly between groups and was 6.5% for the index finger and 2% for the other fingers (p=0.38). Preserved PIP joint range of motion (ROM) after 5 years was 46° (SD 25) for the index finger and 54° (SD 25) for the other fingers (p=0.18). The brief MHQ score at 5 years was 68 (±16) for the index finger group and 76 (±16) for the other fingers (p≤0.05). However, this difference is not clinically meaningful, as it is below the minimal important difference. There was no significant difference in pain after 5 years between groups. Longitudinal axis deviations were more frequent the index finger group before surgery, but this proportion was similar to the other finger group after 5 years.

Conclusion: Five years after surface replacing arthroplasty, patients with an index finger arthroplasty show similar outcomes to patients with arthroplasties of the other PIP joints. Therefore, we recommend PIP joint arthroplasty at the index finger, but a surface replacing implant with its increased intrinsic stability should be used.

Introduction

Despite the satisfactory outcomes of proximal interphalangeal (PIP) joint surface replacing implants, we know too little about the correct positioning of the individual implant components and their effect on the surgical outcome. Furthermore, there are no standardized radiological assesments available to quantify the implant position. The aims of this study were to define radiological measurements to quantify the position of the CapFlex-PIP implant, to test the reliability of these measurements and to explore, if the implant position influences the outcomes one year after surgery.

Methods

We used data from our prospective CapFlex registry and selected two groups of patients: Group 1 included patients with the best total active range of motion (ROM) of the PIP joint 1 year after surgery and group 2 included patients with the worst ROM after one year. Two independent raters took 7 different measures to quantify the position of the proximal and distal components in relation to the proximal and middle phalanges on radiographs. Interrater reliability of these measures was calculated with the intraclass correlation coefficient (ICC). Correlation between the radiographic measures and ROM, the brief Michigan Hand Outcomes Questionnaire (MHQ) and pain were determined using Spearman's correlation coefficient.

Results

We analysed the radiographs of 63 fingers. Interrater reliability of the 7 different measures was poor to moderate indicated by ICC values between 0.34 and 0.69. The radiographic measures did not correlate with ROM, brief MHQ or pain, shown by correlation coefficients between 0.00 and 0.29. There was no difference in the radiographic measures between patients with the best and worst ROM, except for the deviation of the axis of the proximal component. Patients with the best ROM at 1 year showed an angle of mean 67° (SD 13) and patients with the worst ROM showed an angle of 71° (SD 18) (p≤0.05). However, the difference of 4° does not seem to be relevant and could be attributed to measurement error.

Conclusion

A correlation between the implant position and the 1-year outcomes could not be detected, which might be either due to the inaccurate radiological measures, unstandardized X-rays or because there is actually no correlation between the implant positioning and functional outcomes. Despite the lack of evidence for a correlation, we still recommend a precise intraoperative component positioning, because at least it has no negative influence on the outcome.

Objective: To evaluate the one-year postoperative clinical and patient-reported outcomes in patients who had a 3D-planned corrective osteotomy because of malunion of distal radius and forearm shaft using a printed anatomical patient-tailored titanium plate and to determine the feasibility and effectiveness of this methodology.

Methods: Simulation in computer-assisted preoperative planning of corrective osteotomy results in three-dimensional printed surgical guides, surgical models, and in this series additional anatomically customized printed plates for application at the distal radius and forearm. Patients with malunions of the distal radius or forearm who underwent fixation with such custom-made plates were documented in our registry. Grip strength and range of motion assessments were made preoperatively (baseline) as well as at 6 weeks, 3 and 12 months. Additionally, patients rated their wrist-related pain and disability using the Patient-Rated Wrist Evaluation (PRWE).

Results: Fourteen patients with a median age of 56 years underwent corrective osteotomy and had a 1-year follow-up. All osteotomies showed osseous consolidation and no severe adverse events were reported.  The median baseline PRWE score improved from 47 to 7 after one year. Baseline flexion-extension arc of motion of the wrist increased from 90° to 130° at one year and pronation-supination arc of motion of the wrist increased from 135° to 160°. Differences in radiological measurements for palmar and radial inclination as well as for ulnar variance between the affected and contralateral wrists were reduced with the osteotomy. In one case of a young patient, the plate was removed around 11 months after the osteotomy.

Conclusions: Today 3D-simulation and printed individual guides for correction of forearm malunions is a well proofed method and different systems are available. Printed patient-tailored and anatomically customized plates for stable fixation in each patient is a new option and described only in case reports. The advantage compared to standard implants lies in the more accurate placement of printed plates on the deformed bone, especially in the diaphyseal forearm and in correction of intraarticular deformities, where anatomical landmarks for the correct placement of the implant are technically difficult to determine.

PEROPERATIVE MORBIDITIES IN DISTAL RADIUS FRACTURES TREATED BY LOCKINGPLATE IN THE SUPER ELDERLY POPULATION: A RETROSPECTIVE STUDY

Purpose

Nowadays there is no consensus concerning distal radius fracture treatment in the super elderly population. The aim of this study was to evaluate the operative morbidities and requirement of rehabilitation care after a distal radius fracture treated by locking plate among patients 85 years old and above.

Methods

A retrospective study of all patients 85 years old and above who underwent open treatment by locking plate for a distal radius fracture from January 2013 to December 2018 in a level 1 trauma center was conducted. The occurrence of minor complications (tendinopathy, neuropathy, carpal tunnel syndrome and infections), major complications (Complex Regional Pain Syndrome (CRPS), pseudarthrosis, loss of reduction, intra-articular screw and displacement of the osteosynthesis material) and need for any revision surgeries were recorded. The need and timing for rehabilitation care were also observed. A nested case control study was performed to evaluate predictive factors associated with the need for rehabilitation care.

Results

The mean global complication rate among the 185 patients included was 17 % (n=26) with 7.6 % (n=12) showing minor complications and 8.9% (n=14) showing major complications.

In-patient rehabilitation care was required for one third of the patients (n=59) and 7% (n=11) were definitely placed in nursing home. The place of residence before the fracture, the ASA score and the type of anesthesia were associated with rehabilitation need.

Conclusions

Overall, age does not put patient at higher risk for post-operative complication as comparative literature find the same complications rate for younger patients. Nevertheless, given the frequent requirement for rehabilitation, further consideration must be given.

Level of evidence: IV

Introduction

Nerve gap reconstruction remains a challenge in modern peripheral surgery. Many different techniques have been proposed in the past, any of them as effective as autologous nerve grafts, especially on in defects longer than 20mm. Silk fibroin has been already used in the past to manufacture nerve conduits showing promising features: cell attachment and guidance, slow resorption, limited inflammatory reaction. However, many problems remained with an unfavourable balance between mechanical stability and biological properties.

SilkBridge^®, a novel hybrid three-layered tube based on silk fibroin (obtained from the silk of the Bombyx mori) was developed with optimized characteristics for peripheral nerve regeneration. The device has two nanofibers electrospun layers (inner and outer), and an intermediate textile one. The preclinical studies demonstrated a high mechanical stability and the capability to sustain neurite growth and improve length and myelinization. The aim of this pilot study is to assess efficacy and safety in a first-in-human trial.

Patients and methods

Following the requests of Swissmedic, finger nerve defects up to 26mm in four patients were repaired with the new device and followed up for twelve months. After surgery the patients were controlled regularly with clinical tests (MHQ, pain VAS, 2-point discrimination) and ultrasound examination.

Results

Four patients were included, with a finger nerve defects 12-26mm long. At 12 months follow-up all patients showed a very good sensation recovery with a static 2-point discrimination of 7-12mm, moving 2-PD of 5-10mm, MHQ 98 points, patient satisfaction (PGIC scale) of 6-7/7. The ultrasound morphology of the device was conserved in three patients, while in one case, a patient  treated for a painful neuroma, an initial swelling over the implant was observed without any clinical correlation. The same patient reported some residual pain under load, not preventing him to return to a manual work. All other patients were completely pain free. No further local or general complications were recorded.

Discussion

The device performed very well in vivo, allowing for a complete functional recovery in all patients without complications. In one case, after an initial swelling, the healing was uneventful.

In conclusion the new hybrid, multi-layered silk fibroin device SilkBridge^® is safe and effective in the reconstruction of peripheral nerve defects. The study will continue with the inclusion of more patients.

Introduction

Despite better knowledge of the pathophysiological processes activated after nerve injury, timing of nerve transfers remains difficult. After 12-18 months, the Wallerian degeneration results in irreversible muscle atrophy and fibrosis and the axon tubes will be stenotic, and consequently, poor outcome of nerve transfer can be expected. As primary nerve reconstruction is the standard initial treatment for peripheral nerve injuries in most cases, a dilemma arises between waiting for nerve regeneration and performing a nerve transfer. In tetrahand surgery, we face lesions of the upper (UMN) and lower motor neuron (LMN) at the level of the spinal cord injury. Lesions of the LMN cause the same type of  pathophysiologic changes as injuries of peripheral motor nerves. The timing of a nerve transfer in these patients is crucial to provide a good outcome.

Methods

We retrospectively analyzed 32 tetraplegic persons treated with nerve transfer of supinator motor branches to interosseus posterior nerve. Damage of the LMN was preoperatively assessed by motor point mapping examination of Extensor digitorum communis (EDC) at week 2,4, and 8 after spinal cord injury. Muscle strength of EDC was graded according to MRC (Medical Research Council Scale) at 6, 12 and 24 months postoperatively.

Results

16 patients showed preoperatively damaged LMN, 16 had an intact LMN. Surgery was performed 13 months (range 8-24) post injury. Among patients with damaged LMN of EDC, 8 were operated later than 6 months post injury (range 10.0 - 16.7 months). These patients achieved significant lower strength grades of EDC than those operated within 6 months post injury (MRC ≥ 3 12.5% and MRC ≥ 3 50% respectively, p-value = 0.016).

Conclusion

Our data confirm inferior results after nerve transfer in patients with LMN damage when operated more than 6 months post injury. Thus, respecting the window of opportunity is critical for success of nerve transfer surgery. The duration of axonal outgrowth to reach the target muscle should also be included in this calculation. Patients with peripheral motor nerve injuries with missing signs of reinnervation after first treatment or expected poor outcome may benefit from early nerve transfer.

Background: Subchondral bone and the marrow adipose tissue (BMAT) contained therein, undergo elevated turnover and remodelling during progression of osteoarthritis (OA). Previously regarded as inert filler cells, marrow adipocytes have recently been identified as crucial regulators of bone homeostasis and energy metabolism. In this study, we sought to characterize BMAT tissue morphology in thumb carpometacarpal (CMC1) OA.

Methods: Resection specimens were harvested from 14 consecutive patients (median age: 62, range 26-71, 9 female) undergoing total joint arthroplasty or trapezectomy for thumb CMC1 OA (Eaton Litter stage 1 (N=1); stage 2 (N=1), stage 3 (10), stage 4 (2). Neutral lipids (triglycerides) and cell nuclei were visualized in 1mm thick tissue sections using whole mount staining with Oil red O and Hoechst.  Specimens were evaluated by fluorescence stereomicroscopy.

Results: Ten out of fourteen tissue samples displayed moderate to severe articular cartilage degeneration along osteosclerosis of the subjacent subchondral cortical and trabecular bone. Four specimens with mild articular degeneration showed a homogeneous distribution of marrow adipocyte size and neutral lipid staining patterns. Nuclear staining revealed a relatively low cell abundance both in between adipocytes and at the subchondral trabecular bone surface (Fig 1a). In contrast, specimens with osteochondral pathology displayed striking differences in BMAT morphology. Adipocyte size distribution was heterogeneous and zones of high bone turnover and formation contained fewer and smaller adipocytes. Oil red O staining indicated a relative reduction of neutral lipid content in adipocytes, suggesting altered lipid metabolism. High cell abundance was observed around adipocytes as well as at trabecular bone surface, indicating elevated remodelling of both bone and marrow adipose tissues (Figure 1b).   

Conclusion: These findings demonstrate that BMAT changes associate with pathological bone formation in thumb CMC1 OA. We hypothesize that bone marrow adipocyte dysfunction is a factor that alter the energy metabolism in bone and finally leads to the typically changes in OA. It isn’t merely a consequence of it. These changes may be induced by obesity, thereby providing a novel mechanism for explaining the association between obesity and hand OA.

HYPOTHESIS

The use of multiple measurements and ratios of the circumferential surface area (CSA) of the median nerve by Ultrasonography (US) along its course through the carpal tunnel improves diagnostic power for carpal tunnel syndrome (CTS) compared to single values.

METHODS

Prospective study on 50 patients and 51 controls. All participants were interviewed and examined by the same hand surgeon and completed DASH Scores and Boston Carpal Tunnel Questionnaire. Ultrasound was performed by 2 independent examiners with measurement of the median nerve at the forearm, inlet, tunnel and outlet of the carpal tunnel. All patients (not controls) had nerve conduction studies. Statistical analysis was performed using chi-squared and Student's t-tests for patient characteristics, linear regression for measurements, logistic regression for diagnostic accuracy and Receiver operating characteristic curves for diagnostic performance. Inter-observer reliability was computed by Bland-Altman plots and Intra-class correlation coefficients (ICC).

RESULTS

Mean age was 59 years for patients and 57.5 for controls. Boston and DASH-Scores were significantly worse in CTS patients (p<0.0001). All four CSA values as well as the two ratios of Inlet/Tunnel and Outlet/Tunnel differed significantly between controls and patients (p<0.0001). The latter two ratios showed the highest adjusted odds ratios for predicting CTS of all measurements. Of the four single values, the CSAinlet had the best performance (AUC 0.79) with an optimized cut-off of 11.75mm2 (Sensitivity 0.78, Specificity 0.70). The inlet and outlet ratios performed even better (AUC 0.93 and 0.90). The optimized cut-offs were 1.25 (Sensitivity 0.80, Specificity 0.92) for the Inlet and 1.45 (Sensitivity 0.80, Specificity 0.85) for the Outlet ratio. Inter-obsserver reliability showed limits of correlation of about 5mm2 for the CSA at forearm, inlet, tunnel and about 8mm2 at the outlet, whereas examiner 2 measured slightly higher values. ICC (95%CI) was generally high, with better values for single CSA than for ratios.

SUMMARY

The use of ratios instead of a single value of circumferential surface area measurement improves diagnostic power of US and we thus recommend their clinical use for the diagnosis of carpal tunnel syndrome. The optimized cut-offs were 1.25 for the Inlet ratio and 1.45 for the Outlet ratio. If using a single measurement, the inlet CSA had the best performance with the cut-off of 11.75mm2.

Introduction

Percutaneous sonographically guided carpal tunnel release is a new procedure with promising advantages over classic open or endoscopic release. Thanks to the sonography control the procedure should be safer and percutaneous modality should have the benefits of limited post-operative pain and shorter recovery time.

The aim of the present study is to assess clinical short term results of this surgical technique.

Materials and Methods

Medical data from patients with carpal tunnel syndrome, confirmed by electromyography, operated by the same surgeon using the percutaneous sonography method between July 2017 an April 2021 were retrospectively reviewed. Follow–up appointments were set at 14 days, 1 month, 3 months, 6 months and 9 months at which measurement of grip and pinch strength were systematically performed. Additionally, the presence of Tinel, Phalen and Durkan signs as well as pillar pain were systematically assessed. Odds ratios were calculated with x² test, while continuous variables means were compared with one-way ANOVA.

Results

A total of 278 patients were included in this study with a mean age of 56.5 y.o. All surgeries were performed under local anesthesia. The mean duration of each procedure was 13 minutes (range 4-32minutes). No major complication like nerve, artery nor tendon iatrogenic lesion, and no post-operative infection were observed. A hundred and seventy patients were operated unilaterally while 67 patients were treated on both sides with the same method. At 14 days a significant decrease (p<0.001) in the grip (mean= 44.49%) and pinch strengths (mean= 35.9%) were recorded. Both values returned to their prior to surgery levels at 6 months (mean reduction G-0.7%; P-6.9%) and increased at 9 months post-surgery for the grip strength (mean reduction G-10.4%; P-0.8%). Tinel, Phalen and Durkan signs disappeared within the first three months post-operatively. Pillar pain appeared immediately post-surgery in 65.7% of patients and was persisting in 21.4% of patient at 6 months.

Discussion and conclusions

Percutaneous sonographically guided carpal tunnel release is a safe and effective procedure. Even if the procedure is minimally invasive, post operative functional limitations like decreased grip and pinch strength and pillar pain are observed in a significant proportion of patients. Prospective randomized comparative studies should be performed to better assess the functional advantages of this technique over the classical open procedure.

Objective: Stroke is nowadays a leading cause of disability with devastating sequelae. Upper limb spasticity is one of them. Nevertheless, not all the muscles are equally affected, as some may turn spastic or paretic and other remain intact. This unique pathophysiological mosaic dictates a precise therapeutic plan. Existing spasticity treatment has significant drawbacks due to its unspecific targeting and short duration. A causal, life-lasting treatment, precisely adapted to every single patient's needs and to disease pattern, is currently missing. Hyperselective muscle denervation and subsequent cognitive reinnervation with appropriate unaffected donor nerves may break the pathological spastic circuit and provide volitional muscle control. We performed cognitive nerve transfers to spastic muscles of stroke patients and prospectively investigated their effects on clinical and functional level.

Methods: To provide volitional muscle control of finger flexors and wrist/fingers extensors we transferred the branch to brachialis muscle to the anterior interosseous nerve and the branch to the lateral head of triceps to the deep branch of radial nerve in a total of five hemiplegic patients. As spastic forearm pronation was always present, we additionally cognitively reinnervated the pronator teres muscle with a branch to the pectoralis major muscle using a nerve graft. Supplementary surgical steps as tendon lengthening and hyperselective neurotomies were performed as needed. Nerve donors had been always carefully selected, provided they could be volitionally recruited and de-recruited and had a minimum M4 strength. Clinical and functional outcomes are evaluated 6 and 12 months after surgery.

Results: At 6-month follow-up, all patients had improved DASH and CAHAI scores and modified Ashworth scale revealed no abnormality in muscle tone and resistance to passive stretch. Muscle activity of the newly reinnervated muscles could be observed only electrophysiologically with surface electromyography. The 12-month follow-up is still ongoing.

Conclusion: A novel concept for treatment of upper limb spasticity after stroke that allows patients to regain volitional muscle control has been now established. Cognitive muscle reinnervation through selective nerve transfers reduces spasticity and offers the possibility for permanent biological restoration of hand function.

Objective:

Posttraumatic stiffness of the proximal interphalangeal (PIP) joint is very common and can severely affect hand function. Despite its potentially high impact, joint stiffness is usually not assessed quantitatively in clinical settings. The aim of this study was to measure joint stiffness in patients after treatment of intra-articular PIP fractures and to assess the relationship between joint stiffness and daily function.

Methods

Ten patients with intra-articular PIP joint fractures and a minimum follow-up time of 2 years were included. The stiffness of the PIP joint of the affected digit was measured using a newly developed finger stiffness measurement device (FSMD). It measures the torque required for a predefined movement sequence, while the finger is fixed in the device and passively moved by an actuator.

In addition, 3D motion analysis was used to record kinematics of all finger joints during maximal flexion-extension movements and when grasping four different objects: 1.5l bottle (empty and full) and dumbbell (1kg and 3kg). Maximum range of motion (ROM) and joint stiffness were compared between affected and healthy side using paired t-tests.

Results:

Average stiffness of the PIP joint was 0.0028Nm and 0.0024Nm for the affected finger and the healthy contralateral PIP joint (p=0.01). One patient with swan-neck deformity had to be excluded as the finger could not be positioned correctly in the FSMD.

Mean ROM in the affected PIP joints (77°) was significantly reduced (p=0.0005) compared to the ROM of the healthy PIP (108°). In the functional tasks, PIP ROM for gripping bottles and dumbbells ranged from 23-36° and 52-71°, respectively. ROM of the affected PIP was significantly reduced when gripping a full/empty bottle (p<0.03) and a 3kg dumbbell (p=0.03).

Conclusion
The application of the new FSMD was shown to be successful in most cases. The applied force of the FSMD was easily tolerated by all patients without causing pain or discomfort. Patients after intra-articular fractures showed a reduced maximal ROM as well as an increased joint stiffness in the affected PIP. Despite not requiring the full ROM of the joint in the functional tasks, there was still reduced PIP motion compared to the healthy side.

Measurements of joint stiffness complements standard clinical outcome assessment. The influence of increased stiffness on hand function with regards to intra- and inter-digital coordination and different treatment modalities will be further investigated.