Wissenschaftliches Programm: Freitag, 24. November

Introduction

Skier`s thumb injuries are frequent sports injuries. Rarely, so-called two-level injuries have been described in the literature, where an osseous lesion and a Stener lesion without attachment of the ulnar collateral ligament (UCL) to the bone fragment occur simultaneously. We report a rare case of an acute two-level skier’s thumb injury, intraoperative findings, treatment with anatomic reduction and follow-up results.

Material and methods

A 46-year-old patient presented to our emergency department with pain of the right thumb after a skiing accident. Clinical examination revealed significant ulnar instability. The X-ray showed a dislocated and 90 degrees rotated avulsion fracture of the proximal phalanx base as well as a conspicuous saucer-type small ulnar-sided fragment at the level of the distal first metacarpal bone. In the ultrasound of the first metacarpophalangeal joint we saw an irregularity of the UCL and rupture of the adductor aponeurosis, which was suspicious for a Stener lesion. Because of these findings we indicated surgery. Intraoperatively the UCL was found flipped back at the ruptured aponeurosis with a small bone fragment attached. Incision of the aponeurosis and the capsule, revealed the dislocated and rotated fragment of the proximal phalanx. Refixation of the avulsion fragment and the distal ligament with one bone anchor was performed. The intraoperative X-ray showed an anatomical reduction.

Results

After 4 weeks of immobilization the fracture was mostly consolidated, the joint was stable and the patient pain free. After three months the patient had an equivalent range of motion in both thumbs.

Discussion and conclusion

Compared to other skier`s thumb injuries, here it was important to recognize the rotation of the big fracture fragment and to recognize the second smaller fragment in the X-ray. Also the case is a good example that even if ultrasound was not performed perfectly, it led to additional information - the suspicion of a Stener lesion. To recognize these deviations from other skier`s thumb injuries, was important to make the decision to perform surgery. The assumption that the big bone fragment presents the location of the distal part of the ulnar collateral ligament can lead to false treatment decisions. Particularly in frequent cases it`s important to stick to an established diagnostic algorithm, be alert of deviations from the typical injury and to be flexible in treatment options according to intraoperative findings.

Introduction

Soft-tissue tumors of the hand are common and most often benign. Rare entities should be considered as they can affect surgery and aftercare. We report of a schwannoma of the digital nerve as one reason for soft-tissue swelling in the finger.

Material and Method

A 46-year-old woman presented with a slowly growing mass over the last 3 months at the ulnopalmar side of her ring finger. The mass was painful and progressively compromising the flexion of the finger. There was neither an impairment of capillary refill or sensibility nor a Tinel sign. We palpated a firm, elastic mass, which was mobile to surrounding tissue. Ultrasound showed an 11x4x6mm well defined, rounded, hypoechoic mass in proximity to the ulnopalmar digital artery without any Doppler flow. The ulnopalmar digital nerve was not clearly identifiable.

Result

During Surgery, we identified the ulnopalmar neuro-vascular bundle. The tumor presented as an elliptic, beige mass, incorporated in the digital nerve's sheath and was bluntly separated from the nerve fascicles. Histologic results confirmed the diagnosis of a schwannoma. After 4 weeks, the patient was pain-free with a good range of motion. There was a painless Tinel sign over the digital nerve with normal sensibility.

Discussion

A schwannoma is a benign tumor growing from Schwann cells and with about 90% the most common peripheral nerve tumor (Pertea2022). Usually growing slowly and eccentrically in the peripheral nerve sheath it can remain asymptomatic until it causes functional deficit or pain. To define the relationship to adjacent structures diagnostic imaging is helpful. MRI can differ between a malignant and benign lesion but cannot distinguish a schwannoma from a neurofibroma. Ultrasound shows a well-defined, fusiform, hypoechoic mass with loss of fascicular patterns. Final diagnosis can only be made histologically. Only few cases of occurrence in the hand were reported so far. Still, it should be considered as a differential diagnosis of neoplasms such as ganglion cyst, giant cell tumor, lipoma or neurofibroma. If symptomatic, surgical excision is advised.

Introduction: Chronic luxation of a finger joint, either the metacarpophalangeal (MCP) or proximal interphalangeal phalanx (PIP) joint, can be challenging to treat. After open reduction and arthrolysis, reluxation or impaired range of motion (ROM) are often observed. We think the key of success lies in postoperative immediate guided, controlled passive motion of the involved joint. With the use of the MiniFlo™ (Citieffe, Bologna, Italy), an external distraction device, successful management may be achieved.

Method: We report two cases of chronic MCP V respectively PIP II joint luxation. In both cases, initial reduction through a dorsal and palmar (MCP) respectively palmar incision (PIP) was unsuccessful, with reluxation and impaired ROM after surgery. In a second attempt six months, respectively four months later, an arthrolysis and reposition of the chronically dislocated joints in combination with installation of the external fixateur MiniFlo, to start with immediate postoperative controlled passive motion for 4-8 weeks, was performed. Because of reluxation, pain and joint stiffness, the only alternative would have been an arthrodesis.

Results: On average, a joint motion from 0° pre-operatively to about 90° ROM could be documented about two to three months after dismantling the MiniFlo. During the follow up time, eight to twelve months after the second surgery, no reluxation or subluxation in either case was observed and ROM could be maintained. So far, no “third” surgery for arthroplasty because of joint-pain was necessary.

Conclusion: An early controlled, passive joint motion, managed with the “MiniFlo”, instead of a postoperative immobilization phase, is a promising therapy extension in chronic finger joint luxation. Especially if arthrodesis would be the only other option to treat rigid, painful, degenerative joint arthritis. Pre-requisite is a motivated and compliant patient.

Objective:

To analyse our short term clinical and radiographic results for double mobility prostheses for trapeziometacarpal arthritis using two different implant systems and hence also focusing on possible differences between the two systems.

Methods:

Patients treated with a double mobility implant for trapeziometacarpal arthritis were prospectively included in a registry since February 2021. The implant type used was either MAÏA™, or TOUCH^®, depended on the location where the operation was performed (our clinic performs operations equally at two locations). We recorded data preoperatively, at 6 weeks, 3 months and 1 year. Patient reported outcome was assessed using the bMHQ. Pain was rated at rest and during daily activities. Key pinch strength and thumb mobility using the Kapandji score was measured. In the radiographic assessment we focused on cup position (i.e. eccentricity – defined as the cup breaching or touching the cortex of the trapezium) and in the short term on signs of cup loosening. Further, we recorded complications and revisions.

Results:

Until submission of the abstract, we have 47 implants in our registry, of whom 25 were operated on 1 year ago or earlier and were therefore considered in this analysis. No revisions had to be performed so far, resulting in a survival rate of 100%. As the sole complication, we encountered one case of De Quervain’s tenosynovitis. This case was treated with additional surgery. At one year, 19 patients were available for follow-up (8 MAÏA™, 11 TOUCH^®). Overall, the bMHQ score increased from mean 45.9 (CI: 42.2-49.5) preoperatively to 85 (CI: 82.4-89.4). Pain at rest/ during daily activities decreased from 8 (CI: 7.7-8.3)/ 8 (CI: 7.7-8.3) to 0.15 (CI: 0.01-0.29)/ 0.4 (CI: 0.2-1.11). Key pinch strength increased from 4.2kg (CI: 3.6-4.8) to 5kg (CI: 4.6-5.4). Thumb mobility showed a slight improvement. No significant difference in the respective results between the two implants could be detected. Radiological analysis showed no case of cup loosening until final follow up. Eccentric cup position occurred in four cases (equally allotted between the two implants) but without detectable implications on clinical outcome.

Conclusions:

Our results, despite a small patient number, using two double mobility implants for treating trapeziometacarpal arthritis are very promising and comparable to the current literature. No detectable difference in the clinical or radiological analysis between the two implants could be documented.

Abstract

Giant cell tumors of tendon sheath (GCTTS), also known as pigmented villonodular tenosynovitis, are the second most common soft tissue tumors after ganglion cysts. They can be divided into masses with localized or diffuse growth pattern. We herein report a case of a GCTTS recurrence in a 54-year-old male patient.

The patient suffered from a left middle finger GCTTS recurrence. Radiographs and magnetic resonance (MR) imaging revealed involvement of the ulnar neurovascular bundle, the flexor and extensor tendons as well as a destruction of the distal interphalangeal (DIP) joint. The patient was an active sportsman and wished for digital preservation. Hence, radical excision with en-bloc resection of the DIP joint was performed, resulting in a sub-circumferential 4x3 cm defect. The joint was fused using a cannulated compression screw and the soft tissue defect was reconstructed with a retrograde-arterialized free venous flap from the ipsilateral forearm. One arterialized inflow vein and two outflow veins (1 dorsal and 1 palmar) were included in the flap. The further clinical course was uneventful with no radiographic or MR signs of recurrence at 6-months. Histopathology revealed a GCTTS without signs of malignant transformation. At 4 months after surgery, the patient was able to return to all previous recreational activities.

Recurrent and infiltrative GCTTS in fingers are a challenging clinical problem. In our case, the patient opted for digital preservation with microvascular tissue transfer. Free venous flaps are an excellent reconstructive option for extensive digital defects because they can be tailored to almost any defect geometry. Furthermore, depending on the forearm anatomy, they can also serve for concomitant digital nerve reconstruction using terminal branches of the lateral or medial antebrachial cutaneous nerves. However, amputation should always be discussed with patients suffering from massive GCTTS recurrence. Compared with potentially complicated microvascular reconstruction, digital amputation offers a faster treatment with a lower risk for long-term complications.

Taken together, massive distal digital defects associated with GCTTS recurrence are a reconstructive challenge. Free venous flaps are an excellent option for digital salvage in these cases.

Introduction
Most Nocardia infections have been identified after inhalation in immunocompromised hosts, including patients with HIV infection, persons taking immunosuppression after transplantation, or those receiving chemotherapy for malignancy. In rare cases, immunocompetent patients can develop a cutaneous form of Nocardia infection after a traumatic percutaneous inoculum. In disseminated disease, the lungs, brain, and skin are most commonly affected.

Case
We describe a 64 –year-old immunocompromised man undergoing chemotherapy for hepatic and pulmonary metastatic adenocarcinoma, who presented with an atraumatic, infectious forearm lesion, which was surgically debrided. Co-amoxicillin was empirically started. The microbiological report detect Nocardia paucivorans, so that the imaging diagnostics with PET CT and skull MRI were completed. They could describe the primary pleural focus, as well as the presence of a cerebral nocardial abscess. After identification of the cerebral and pulmonary lesions, we started an intravenously antibiotic therapy with Ceftriaxon and Amikacin immediately. The control - MRI of the skull showed a complete regression after 6 weeks, so that the antibiotic therapy could be switched to peroral Minocyclin and Moxifloxacin.

Discussion
Due to its rarity and the unspecific clinical picture, nocardiosis is often misdiagnosed and has a high mortality rate especially in immunosuppressed patients. On the other hand, these bacteria are very difficult to identify in culture, which delays the diagnosis. In some cases, it require 2-4 weeks until the colonies appear. In our case, the germ was identified only nine days after the patient presented in our hospital.

To our knowledge, no disseminated Nocardia infection, presenting with subcutaneous lesion as a single sign of this disseminated disease has been until now reported. During the clinical examination on the emergency department, there was no suspicion of either pulmonary or cerebral involvement.

When patients present with unfamiliar, atraumatic skin lesions, it is important to think of Nocardia infection as possible pathogens, especially among risk groups such as immunocompromised patients.

Introduction

Synovial chondromatosis is a rare benign disorder. It is characterized by the metaplasia and proliferation of synovial tissue, resulting in the formation of loose cartilaginous or osteocartilaginous bodies within the synovial membrane of joints. It predominantly affects large joints, while its occurrence in small joints, such as finger joints, is uncommon. The malignant degeneration into chondrosarcoma has been described but is rare. The typical radiographic presentation of synovial chondromatosis is characterized by multiple calcified cartilaginous loose bodies. In advanced stages, it may progress to the formation of a giant solitary synovial chondromatosis through the fusion of the loose cartilaginous bodies. This case report presents an interesting case of synovial chondromatosis, highlighting the clinical manifestations with significant functional impairments and the successful treatment outcome.

Material & Methods

A comprehensive work-up of the patient's medical records, including history, examination findings, radiographic imaging, and surgical intervention, was performed.

Results

The case report describes a 40-year-old male cook who presented with a progressive swelling of the distal interphalangeal joint of the small finger, persisting for 15 years. The swelling was indolent but hindered the patient's ability to grip knives properly due to restricted mobility. The patient's inability to use the non-functional finger in daily activities led to a strong desire for amputation. Although joint disarticulation was considered as a therapeutic option, the patient ultimately underwent tumor resection, which included extensor and flexor tendon tenolysis. Remarkably, the patient achieved a full restoration of range of motion and became completely symptom-free.

Conclusion

By presenting this exceptional case report, it serves as a reminder to hand surgeons about the potential involvement of smaller joints, such as the distal interphalangeal joint, in synovial chondromatosis.

Einleitung: 

Die Behandlung intraartikulärer Trümmerfrakturen der Metakarpale-I-Basis ist anspruchsvoll und zeigt nach konventioneller Frakturversorgung häufig unbefriedigende Ergebnisse bei nicht anatomisch wiederherstellbarer Gelenkfläche mit Ausbildung einer sekundären Arthrose. 

Im Bereich der elektiven Behandlung der Osteoarthritis des Daumensattelgelenks zeigt die CMC-1 Prothese zuverlässige, sehr gute mittel- und inzwischen auch langfristige Ergebnisse. Die Verwendung derselben als Frakturprothese bietet sich als Rückzugsmöglichkeit in komplexen Fällen an. Hierzu finden sich in der Literatur bis dato keine Fallberichte.

Wir präsentieren den ersten Fall einer CMC-1-Prothesenimplantation bei intraartikulärer, dislozierter, mehrfragmentärer Metakarpale-I-Basisfraktur als alternative Frakturversorgung bei einer rüstigen, betagten Patientin. 

Ergebnisse: 

Im postoperativen follow up kann eine vollständige Schmerzfreiheit bei vollständig freier Beweglichkeit des linken Daumens mit Wiederherstellung der Selbständigkeit im Alltag erreicht werden.

Zusammenfassung: 

Die primäre Implantation einer Daumensattelgelenksprothese bei nicht anatomisch rekonstruierbaren Trümmer- oder Defektfrakturen der Metakarpale-I-Basis ist eine technisch einfach umsetzbare Rückzugsmöglichkeit und kann als Alternative zur herkömmlichen Frakturversorgung dienen. Postoperativer Verlauf und Outcome unterscheiden sich nicht von der Implantation bei Rhizarthrose.

Zur Evaluation der indizierten Frakturtypen, dem geeigneten Patientenalter sowie dem langfristigen Outcome ist eine randomisierte, prospektive Studie in unserem Haus geplant.

Introduction: The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment.
Methods: A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retro- spectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. 

Results: Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large.

Conclusion: The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought.

Introduction:

High intensity focused ultrasound (HIFU) is a potential non-ionizing and non-invasive application for benign and malign disease. Ultrasonic waves are concentrated in a specific manner to achieve high level of energy in specific area of tissue. This leads to an increase of temperature and to necrosis due to coagulation resulting in irreversible damage of the tissue. We will describe one pediatric case where HIFU was successful in the treatment of an osteoidosteoma.

Material and Methods:

A seven-year-old boy presented in our department for hand surgery due to notable indolent swelling of the distal phalanx of the right ring finger. Neither recent trauma, nor any history of rheumatological disease in family history was memorable. Clinical examination showed significant enlargement of the distal phalanx with minimal pain on palpation and unlimited mobility. Conventional radiography showed discrete fuzzy sclerosis of the metaphyseal part of the growth plate. MRI was not conclusive, but suspicious for chronic osteomyelitis. Bone biopsy showed reactive change with no signs for acute inflammatory event. Periodic checks were performed, with no change in clinical and radiographic aspect. Nine months after the first appointment, the patient presented with pain after minor trauma and increase of the swelling. Radiography showed a visible light spot, so called nidus, in the distal phalanx leading to a suspected diagnosis of an osteoidosteoma. In a synopsis of the present findings, MRI-guided HIFU (MR-HIFU) was recommended.

Results:

One year after the first appointment, MR-HIFU was performed to destroy the nidus of the osteoidosteoma and to prevent further hypertrophic growth. Six months after the intervention the patient presented with no further exponential growth and the difference to the other phalanges was minimized. Furthermore, radiography showed no retention of the nidus with a plane distal phalanx.

Discussion:

MR-HIFU is a promising approach in the non-invasive treatment of tumorous neoplasm. Because of its non-ionizing ultrasonic waves, there is no upper limit in dosing. The deposition of heat is in general limited by the surrounding tissue, which should not be exposed to overheating. The main factors preventing MR-HIFU treatment are thick bone around the nidus, a superficial position with risk for skin burn and the vicinity to neural structures. Osteoidosteomas are generally rather small and therefore well suited for MR-HIFU.

About a quarter of the world's population is latent infected with Mycobacterium tuberculosis. In Switzerland, the incidence remains very low, especially in the native population. Digital localization is uncommon, representing 4-8% of cases of osteoarticular tuberculosis.

Method

We report the case of a 49-year-old bricklayer of southwestern European origin, who showed a painful atraumatic swelling of the IP joint of his right thumb for several weeks, without improvement after an empirical antibiotic treatment and an incision for drainage of a suspicious panaritium. Synovial hypertrophy but no frank effusion was found sonographyically, an osteopenia and narrowing of the IP joint space on conventional radiographs. The appearance of a dorsal fistula about one month after the initial presentation raised the suspicion of chronic septic arthritis. A debridement with sampling for microbiological and histopathological analysis was performed. Conventional microbiological analysis revealed no bacterial growth, but the histopathology severe chronic granulomatous synovitis and partially necrotic osteomyelitis. The diagnosis of Mycobacterium tuberculosis osteoarthritis was confirmed by subsequent PCR analysis. Systemic evaluation revealed associated pulmonary tuberculosis, and antibiotic treatment was initiated. After an initial positive postoperative period, the IP joint remained symptomatic at three months, with localized pain, decreased range of motion, and progressive destruction on conventional radiograph. A second debridement with sampling was performed and the joint was fused with Kirschner wires. No bacterial growth, residual granulomatous inflammation, or giant cells were identified in the intraoperative samples. The local pain decreased rapidly. At the last follow-up before abstract submission (11 weeks), the arthrodesis was not completely healed, and immobilisation with a splint was continued.

Conclusion

Even if it remains very rare in developed countries, tuberculosis should be considered as a differential diagnosis in cases with atypical presentation of digital osteoarthritis. Although the literature on tuberculous interphalangeal osteoarthritis is sparse, its treatment appears to be primarily medicamentous. Surgery is initially needed as diagnostic tool and sometimes to treat symptomatic sequelae in the later course of the disease. As treatment for symptomatic destruction of the interphalangeal joint of the thumb, arthrodesis appears to be a valuable option.

Objective: The aim was to compare the 2-year outcomes after proximal interphalangeal (PIP) joint surface replacement in joints with more than 15° preoperative deviation to the longitudinal finger axis versus joints without any preoperative deviation.

Methods: Patients who received a primary single surface replacing PIP arthroplasty (CapFlex PIP, KLS Martin, Germany) were included. Longitudinal finger axis deviation at the PIP joint level was measured and classified as: no deviation (<5° deviation to the longitudinal finger axis), moderate deviation (5°-15°) or severe deviation (>15°). Active range of motion (ROM) of the PIP joint was measured. Patients completed the brief Michigan Hand Questionnaire (MHQ) and rated their pain during daily activities on a Numeric Rating Scale (0-10). Baseline and 2-year outcomes between patients with and without deviations were compared with the Mann-Whitney U test.

Results: Out of 216 fingers initially operated, there were 7 (3.2%) that required revision surgery. Four fingers had severe axis deviation before surgery and 3 were classified with moderate deviation. The reasons for revision were stiffness (n=4), suspected metal intolerance (n=1), late low-grade infection (n=1), and luxation of the implant components (n=1).

Before surgery, 47 patients had a severe axis deviation and 39 had no deviation. At the 2-year follow-up, only 4 of the 47 patients still had a severe axis deviation; all remaining fingers could be corrected to a deviation of less than 15°. At 2 years, patients with severe and without deviation had a mean ROM of 63° (95% Confidence Interval [CI]: 58-68) and 59° (CI: 52-65) (p=0.4), respectively. In addition, the respective mean pain scores were 2.1 (CI: 1.4-2.8) and 1.7 (CI: 1.2-2.2) (p=0.8), and the brief MHQ scores were 72 (CI: 66-79) and 75 (CI: 71-80) (p=0.7).  

Conclusion: Clinical and patient-reported outcomes at 2 years were similar between patients with severe and without preoperative axis deviation, and the joint axis could be corrected in most cases. The incidence of PIP joint revision surgeries was higher with a preoperative longitudinal joint axis deviation, yet the reasons for revision cannot be directly related to this factor. Stiffness may be related to axis deviation, as these joints were immobilized longer after surgery than straight fingers. We recommend a surface replacing implant to correct severe axis deviations, but the risk of revision surgery needs to be considered.  

Aim: The aim was to provide a comprehensive assessment of complications and revision surgeries up to 5 years after thumb carpometacarpal (CMC) dual-mobility implant arthroplasty.

Methods: All patients with osteoarthritis of the thumb CMC joint who underwent primary implant arthroplasty (Touch®, KeriMedical) between June 2018 and April 2023 were prospectively documented in a registry and included in this analysis. Intra- and postoperative complications and its treatment strategies were documented. Clinical (key pinch, grip strength) and patient-reported outcomes (pain, brief Michigan Hand Outcomes Questionnaire) before surgery and at 2-year follow-up were compared between patients with and without complications using an independent t-test. Implant survival up to 5 years was estimated using the Kaplan-Meier method.

Results: A total of 281 patients with a mean age of 64 (±9) years were included. Thirty-three complications (12%) occurred and 8 implants (2.8%) required revision, resulting in an estimated 5-year survival rate of 96% (95% confidence interval: 92%-98%). Reasons for revision were symptomatic implant loosening, dislocation, or migration. In 4 cases the components were changed and in the other 4 cases a resection arthroplasty was performed. The most frequent other complications were de Quervain tenosynovitis (n=12) and trigger thumb (n=6), which were treated with either steroid injections or soft tissue surgery. There were also 3 cases of intraoperative trapezium fractures that were successfully fixed with a suture cerclage. There were no differences in the 2-year outcomes between patients with and without complications (p>1).

Conclusion: Thumb CMC dual-mobility implant arthroplasty shows high implant survival and soft-tissue complications can usually be resolved with an injection or minor surgery. The reasons for revision were mainly iatrogenic, i.e. implant placement was not optimal in our first cases or we tried to implant a prosthesis despite a small or insufficient trapezium. Therefore, we recommend good training of the surgeon and careful indication.

Introduction

Combined extending and ulnar adduction osteotomy using patient-specific guides and instrumentation showed good results in early-stage thumb arthritis. The aim was to investigate the subjective and clinical results of ten early to advanced stage trapeziometacarpal osteoarthritis and to compare the joint loading area before and after surgery.

Method

Between November 2020 and December 2021, we included nine patients with early to advanced trapeziometacarpal osteoarthritis in a prospective observational study who underwent Wilson extension osteotomy using preoperative 3D planning and patient-specific guides at our institution. Preoperative and one-year postoperative subjective assessment was based on a visual analogue scale (VAS) for pain and MHQ score. Range of motion (ROM) and grip strength data were investigated. Postoperative computed tomography with the corresponding 3D models was used for comparison with the preoperative plan. For the measurement of the minimum joint space between the trapezium and the first metacarpal bone, the bone-to-bone distance maps were calculated with the CASPA

Result

Pain and patient satisfaction improved significantly at the one-year follow-up. The mean ROM of the metacarpophalangeal and interphalangeal joints was similar to the preoperative ROM. The minimum joint space distance remained approximately unchanged from preoperative to postoperative, with a mean distance of 0.1 mm (SD 0.2 mm) preoperatively to 0.2 mm (SD 0.3 mm) postoperatively. The peak load zone of the trapezium articular surface shifted postoperatively by an average of 0.4 mm (SD 1.4 mm) (p=0.110) to radial and 0.1 mm (SD 1.2 mm) (p=0.515) to volar.

Conclusion

Extension and ulnar adduction osteotomy were found to result in satisfactory patient condition not only in Eaton stage I but also in II and III osteoarthritis, possibly leading to a change in the loading pattern of the joint surfaces. However, computed tomography-based three-dimensional analyses could not show a significant displacement of the peak load zone in dorsal-radial direction, as the values obtained are considered too small. Nevertheless, trends emerged suggesting that flatter pressure distribution and a dorsal displacement of the peak load zone could contribute to an improvement in pain and patient satisfaction.

Introduction

One of the most challenging problems of hand surgery is the treatment (and prevention) of proximal interphalangeal (PIP) joint stiffness. At present, functional outcome measures are mostly based on range-of-motion in the finger joints. We propose a method for the quantitative assessment of PIP joint stiffness and applied it in patients after PIP joint replacement surgery.

Methods

Seven patients with a minimum follow-up period of 1 year since PIP implant arthroplasty (Swanson or CapFlex) in context of osteoarthritis (OA) were included. PIP joint stiffness of all long fingers in both hands was measured, using a newly developed finger stiffness measurement device (FSMD) and assigned to the following categories: healthy, Swanson, CapFlex, and symptomatic OA. The FSMD passively moves the tested finger and registers the exerted torque during a preset angle sequence (safety threshold of ±0.2Nm). The slopes of the recorded torque-angle curves represent joint stiffness.

Results

Among a total number of 56 PIP joints, 12 were healthy, 3 replaced with a Swanson prosthesis, 19 CapFlex prosthesis and 8 symptomatic OA.

Over all measured joints, PIP joint stiffness was lower in intermediate flexion positions and increased towards end positions of the joint (figure 1); e.g. median stiffness was 1.5Nmm/° [range 0.6-5.6], 1.7Nmm/° [0.5-18.9] and 3.3Nmm/° [1.0-15.7] at 50°, 30° and 90° PIP flexion, respectively. Within the set torque threshold, two fingers with a CapFlex prosthesis were not able to reach flexion angles ≤30°, while all three Swanson PIP did not reach flexion angles ≥90°.

Discussion and Conclusion

Measurement with the FSMD provides torque-angle data, which enables calculation of joint stiffness throughout the ROM of a finger`s PIP joint. We present the results in a small number of patients, offering preliminary data for the chosen, specific subgroup after PIP joint replacement surgery.

PIP joints with a Swanson prosthesis tend to be less stiff in more extended positions and become considerably stiffer at finger flexion angles >60°.

PIP joints with a CapFlex prosthesis tend to be particularly stiffer in more extended positions. Furthermore, this group showed a large variance for stiffness in the extended positions, i.e. while some could not even reach flexion angles of <30°, others delivered values equal to healthy joints.

In a future perspective, measurement and a systematic analysis in a larger number of patients is required for the introduction of this novel method to assess and quantify finger joint stiffness.

Aims: The primary objective was to examine whether thumb carpometacarpal (CMC) implant arthroplasty can correct hyperextension in the thumb metacarpophalangeal (MCP) joint. As a secondary outcome, clinical outcomes one-year post-surgery were compared between patients with and without MCP hyperextension.

Methods: Patients treated with a thumb CMC implant arthroplasty (Touch®, KeriMedical, Switzerland) who were prospectively documented in a registry and had complete baseline and 1-year follow-up data were included. Hand function was assessed with the brief Michigan Hand Outcomes Questionnaire (brief MHQ, score 0-100). Key pinch strength was assessed with a pinch gauge and range of motion of the MCP joint with a goniometer. Differences between baseline and follow-up were analysed with the Wilcoxon signed-rank test. The outcomes of patients with a preoperative MCP extension of > 20° (hyperextension group) were compared to the outcomes of patients with ≤ 20° using the Wilcoxon rank-sum test.

Results: We included 172 patients of whom 41 had a preoperative MCP hyperextension of > 20° and 131 patients had no hyperextension. In the hyperextension group, MCP extension was corrected from preoperative mean 33° (95% confidence interval CI: 31-35) to 10° (CI: 6-13) at 1 year (p≤ 0.001). Patients in the control group had a preoperative MCP extension of 10° (CI: 9-12) which was reduced to 5° (CI: 4-7) at 1 year (p≤ 0.001). Patients with preoperative MCP hyperextension had lower key pinch strength at 1 year compared to the control group (5.9 kg (CI: 5.3-6.6) vs. 7.0 kg (CI: 6.7-7.5), p≤ 0.01). The brief MHQ did not differ between the groups (85 (CI: 82-88) vs. 87 (CI: 82-92), p=0.7). Complications appeared in 29 patients of whom 7 had preoperative MCP hyperextension. No significant association between hyperextension and complications was observed (p=1.0).
In our registry, there are 8 patients who dropped out of the data collection, because they underwent revision surgery. Only one of them had a preoperative MCP hyperextension, indicating that there is no association between preoperative MCP hyperextension and revision surgery.

Conclusion: Thumb CMC implant arthroplasty can correct preoperative MCP hyperextension, and preoperative MCP hyperextension does not appear to increase complications. Therefore, we recommend using implant arthroplasty also in patients with hyperextension of the MCP joint, provided the joint is stably otherwise.

Purpose

The aim of this project is to define the necessary axes (anatomical, mechanical and adjacent joint axis) of the first metacarpal bone in order to calculate a first metacarpal tilt angle and to determine a correction angle to be used in a Wilson osteotomy.

Material and Methods

CT-scans of twenty healthy and six symptomatic patients were used to find a method to define the required axes. Once the axes were defined, the first metacarpal tilt angle could be determined. This value was compared between healthy and symptomatic data. The angle of the closing wedge in a Wilson osteotomy was the calculated and explained with the defined axes and the determined angles. The effect of a Wilson osteotomy was described based on these data.

Results

We defined and reproduced the anatomical, mechanical and a proximal joint axis. The angle between the anatomical and mechanical axis showed an average of 6.1° (SD 1.2°). An angle of 85.4 ° (SD 2.8°) between the proximal joint axis and the mechanical axis (metacarpal tilt angle mechanically) and 79.4° (SD 3.1°) for the anatomical axis (metacarpal tilt angle anatomically) was calculated. The proximal joint axis is angulated 9.6° (SD 4.6°) to the middle plane of the metacarpal one. There was no statistically difference between healthy and symptomatic preoperative MC I angles and axes.

A mean angle of 28.7° (SD 5.2°) of correction was found in 6 symptomatic patients. Based on these data an angle of 22.6° (SD 2.5°) 1 cm and 26.7° (SD 2.5°) 1.5 cm above the proximal joint axis has been identified as optimal average correction angle for a Wilsons-osteotomy.

A comparison between the mean values calculated based on 2D and 3D data showed no significant differences.

Conclusion

The correction angle of 20°-30° determined by Wilson could be reproduced with the calculations and explained with the axes of the bone. However, the angle of correction is variable depending on the osteotomy height, bone thickness and angle between the axes. This newly developed method for calculating the angle of correction when performing a Wilson osteotomy can be used to improve the surgical technique and outcome.

If the axes are defined with small adjustments on a lateral 2D X-ray, similar values can be calculated and a 3D data set is not necessarily required, which is more suitable for a daily clinical routine.

Osteoarthritis of the trapeziometacarpal joint (TMC) can effectively be treated surgically with Wilson osteotomy (WO), trapeziectomy with ligament reconstruction/tendon interposition (LRTI) and implant arthroplasty (TP). The aim of the study was to record the thumb motion during basic motion and 3 activities of daily living (ADL) in patients following WO, LRTI or TP using infrared cameras. Twenty-nine patients (max. 60 y/o) who had been treated with WO(n=10), TP(n=10) and LRTI(n=9) were recorded with a motion capture system during isolated abduction-adduction, flexion-extension (F/E), opposition and circumduction and three ADLs: opening a jar, bottle and key. Mean follow-up was 23 months (12-66). The patients subjective hand function was assessed with the MHQ. TMC range of motion (ROM) was calculated for each movement trial. Forces during each ADL were measured using a torque force device. Results are reported as median (range) and compared with a Kruskal-Wallis test (α=0.05). MHQ was similar in all groups with WO 78, TP 88, LRTI 84. During thumb opposition, TMC F/E ROM was significantly larger after WO (44°, 28-54°) compared to TP (28°,18-64°,p=0.038) and LRTI (30°,15-41°,p=0.026). During circumduction, TMC adduction-abduction ROM was significantly larger after TP (27°,13-46°) compared to LRTI (15°,12-28°;p=0.021), but not compared to WO (21°, 8-44°). In contrast, during isolated movements in the standard anatomical planes, no statistically significant difference was present. When opening a glass, patients after WO reached 125% of force compared to the contralateral side, after TP 100% and 85% after LRTI. For turning a key TP reached the highest forces.Total MHQ score was indicative of good to very good function, 3 patients indicated a fair function. Patients after LRTI had lower function in pinch force and ROM in basic movements compared with the other two groups. When comparing kinematics of patients after WO and TP during circumduction and opposition, WO allows more TMC movement in the F/E plane whereas motion in the radial-ulnar plane was larger after TP. These differences were not found during isolated movements in the anatomical planes. Force recordings during ADL compared to the contralateral side was highest in the WO group when opening/closing a jar,TP group reached highest forces in turning a key. For the kinetic parameters, patients after LRTI had the poorest outcome, while WO and TP showed advantages depending on the considered outcome.

HYPOTHESIS

In children with symbrachydactyly, we hypothesized that the highest Pediatric Quality-of-Life Inventory (PedsQL) scores would be found in patients with the most severe forms. Further, we posited that non-significant differences would be observed in assessments of patients' Health-Related Quality-of-Life (HRQoL), appearance, and perceived function compared to their parents.

METHODS

In this single-center, observational study, all symbrachydactyly patients treated from 2000 to 2018 were invited to participate. Patients (≥3y) and their parents were asked to complete questionnaires on HRQoL (PedsQL), appearance (ZASH, Zurich Appearance Score for Hands), and function (CHEQ, Children's Hand-use Experience Questionnaire). Patients were assigned to groups based on their ability to grasp. Group A: good grip (unrestricted/slightly impaired grip), Group B: pinch only, Group C: no grip/pinch capability.

RESULTS

We included 58 patients/parents (male 60%; median age 8.5 years [range 3-26]). All symbrachydactyly types were represented and categorized (Group A [n=18; 31%], Group B [n=15; 26%], Group C [n=25; 43%]).

Overall PedsQL scores were high (median 89.1) and similar between genders (M 90.2; F 89.1). Compared to the reference sample, no significant difference between overall scores was detected (95% CI, -0.9 to 4.4; p=.23). For the PedsQL sub-scales, patients consistently rated their perceived function as highest (median 93.8) and emotional sub-scale as lowest (median 87.5). When grouped by hand function, PedsQL scores were lower in Group B (median 85.2) compared to Group A (median 91.3) and Group C (median 92.4).

When comparing patient/parent assessments, parents assessed the emotional sub-scale significantly lower (95% CI, -10 to -2.5; p=0.01).

ZASH scores were higher in patients (median 59.5) compared to parents (median 54.0), whereas CHEQ scores were concordant. ZASH scores did not correlate with either the CHEQ or PedsQL, while the CHEQ moderately correlated with PedsQL scores (r=0.53-0.68), but only in the parent sample.

CONCLUSIONS

Overall, patients with symbrachydactyly and their parents reported consistently high HRQoL scores. Patients without grip capability had the highest PedsQL scores.

The differences in PedsQL scores between parents and patients were similar to those in the reference group. ZASH and CHEQ scores were similar between patients and parents.

Neither hand function nor appearance were found to have appreciable correlations with the PedsQL.

Background: Trapeziometacarpal (TMC) joint osteoarthritis is a frequent degenerative pathology encountered in hand surgery. Arthroplasty through a dorsal approach is a routine surgical procedure with satisfactory results, including significant pain reduction and improvement of functional thumb range of motion. However, some patients report persisting post-operative pain on the thenar eminence over the trapezium. It can be explained by an overseen palmar osteophyte of the trapezium, which could not be identified on preoperative plain radiographs nor during the surgical procedure but can only be assessed on a CT scan. To the best of the authors’ knowledge, limited studies have evaluated the degenerative aspect of trapezium, and particularly the osteophytic development on the palmar side. Overlapping of carpal bones on plain radiographs does not allow a proper analysis of trapezium osteophytes on its palmar side, resulting sometimes in incomplete surgical treatment. Indeed, this osteophyte can be responsible for persisting pain despite the adequate management of TMC osteoarthritis. 

Methods: Starting from 2021, we systematically looked for palmar tenderness over the trapezium during our routine clinical examination of patients suffering from TMC osteoarthritis. If the clinical exam was positive, a complimentary CT was realized to assess the aforementioned osteophyte. When present, we added to our usual surgical procedure for arthroplasty a palmar approach to excise the osteophyte, sometimes using 3D printing of the trapezium for preoperative planning.

Results: Our study involves 12 patients suffering from TMC osteoarthritis with an additional symptomatic palmar osteophyte, clinically suspected and detected on CT scan. The excision of this osteophyte through a palmar approach led to a resolution of the specific palmar pain.

Conclusion: The knowledge of this possible symptomatic palmar osteophyte changed our therapeutic procedure. The standard surgical dorsal approach of the TMC does not allow visualization of the palmar side of the trapezium and consequently the presence of a palmar osteophyte, whose persistence precludes satisfactory postoperative pain evolution. This allowed us to develop a new algorithm for the treatment of TMC joint osteoarthritis. We now systematically include a CT-scan when palmar tenderness is present over the trapezium of a patient suffering from TMC osteoarthritis, allowing the proper treatment to a poorly known source of persisting pain.

Introduction

Since the withdrawal of the market authorisation of Collagenase clostridium histolyticum (CCH) in Europe in March 2020, the value of this treatment option in Dupuytren’s disease became more evident. The aim of this study was to compare outcomes of patients receiving CCH injection with patients undergoing limited fasciectomy (LF) with focus on the early postoperative soft tissue conditions and individual burden measured by the frequency of surgeon and hand therapy visits.

Materials and methods

All consecutive patients undergoing either CCH injection or LF as a first line treatment in a 15 year period (2006-2021) at the University Hospital of Bern, Switzerland were assessed for eligibility. Propensity score matching involving confounding factors (age, gender, diabetes, family history, disease severity and number of rays involved) was performed to minimize selection bias. Primary outcome analysis was focused on the early postoperative soft tissue condition of the hand using a local wound score with points given for hyperaemia, tenderness and scar mobility. Secondary outcomes included the number of medical and hand therapy visits.

Results

In the mentioned timeframe, 195 patients were treated for Dupuytren’s disease at the University hospital of Bern. After exclusion and propensity score matching, two treatment groups of 32 patients each were formed. Mean age was 69.7 years (range 42-85 years) in the CCH group and 70.4 years (range 40-91 years) in the LF group. There were no significant differences in baseline characteristics between treatment groups. Correction of extension deficit was comparable in both treatment groups. Local wound score was significantly worse in the LF group than in the CCH group (mean 0.47 vs. 0.09 points, MD 0.38, 95% CI [0.15, 0.60], p = 0.002). The number of surgeon and hand therapy visits was significantly higher in the LF group (mean 4.7 vs. 1.9 visits, MD 2.8, 95% CI [1.8, 3.8], p < 0.001 and mean 14.6 vs. 4.4 visits, MD 10.2, 95% CI [4.2, 16.1], p = 0.004, respectively).

Conclusion

Evidence of the present study suggests that patients undergoing CCH injection have a significantly less complicated wound healing with softer scar conditions requiring less intensive surgical and hand therapy aftercare. In our opinion, CCH treatment is an important tool in the armamentarium for the treatment of Dupuytren's disease and the reintroduction or approval of a generic drug worthy of being supported.