Showing papers in "Hand surgery and rehabilitation in 2020"

COVID-19: Initial experience of an international group of hand surgeons.

Abstract: The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Anatomy of the median nerve and its clinical applications.

Abstract: The median nerve is a mixed sensory and motor nerve. It is classically described as the nerve of pronation, of thumb, index finger, middle finger and wrist flexion, of thumb antepulsion and opposition, as well as the nerve of sensation for the palmar aspect of the first three fingers. It takes its name from its middle position at the end of the brachial plexus and the forearm. During its course from its origin at the brachial plexus to its terminal branches, it runs through various narrow passages where it could be compressed, such as the carpal tunnel or the pronator teres. The objective of this review is to summarize the current knowledge on the median nerve's anatomy: anatomical variations (branches, median-ulnar communicating branches), fascicular microanatomy, vascularization, anatomy of compression sites, embryology, ultrasonographic anatomy. The links between its anatomy and clinical, surgical or diagnostic applications are emphasized throughout this review.

Functionalized nerve conduits for peripheral nerve regeneration: A literature review.

Abstract: Functionalized neurotube are a third-generation of conduits with chemical or architectural bioactivity developed for axonal proliferation. The goal of this review is to provide a synopsis of the functionalized nerve conduits described in the literature according to their chemical and architectural properties and answer two questions: what are their mechanisms of action? Has their efficacy been proven compared to the autologous nerve graft? Our literature review relates all kind of conduits corresponding to functionalized neurotubes in peripheral nerve regeneration found in Medline and PubMed Central. Studies developing nerve gaps, chemotactic or structural features promoting each conduit, results, efficiency were selected. Fifty-five studies were selected and classified in: (a) intraluminal neurotrophic factors; (b) cell-based therapy (combined-in-vein muscles, amniotic membrane, Schwann cells, stem cells); (c) extracellular matrix proteins; (d) tissue engineering; (e) bioimplants. Functionalized neurotubes showed significantly better functional results than after end-to-end nerve suture. No studies can be able to show that neurotube results were better than autologous nerve graft results. We included all studies regardless of effectives to evaluate quality of reinnervation with modern tubulization. Functionalized neurotubes promote basic conduits for peripheral nerve regeneration. Thanks to bioengineering and microsurgery improvement, further neurotubes could promote best level of regeneration and functional recovery to successfully bridge a critical nerve gap.

Internal fixation of metacarpal fractures using wide awake local anesthesia and no tourniquet

Abstract: We sought to report on the use of wide-awake local anesthesia and no tourniquet (WALANT) for internal fixation of metacarpal fractures. We retrospectively examined 10 patients with metacarpal fractures that required either closed reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF). WALANT was administered 20minutes before the surgery outside the operating room. Once the area was numb, an open or closed reduction was made followed by internal fixation of the fracture using plating, intramedullary screws or Kirshner wires (K-wires). We used intraoperative X-ray to confirm anatomic reduction and correct internal fixation. After proper reduction and fixation, the active range of motion (AROM) was assessed while the patient was awake. Patients were discharged the next day after evaluating their neurovascular status and establishing pain control. Follow-up evaluations were carried out at 2, 6 and 12 weeks postoperatively. All individuals underwent uneventful operations. No significant pain or bleeding was recorded during the operation. Nine out of ten patients regained full AROM at the 12-week follow-up visit in the outpatient clinic. One patient still had slight reduction of range of motion (ROM) of the 5th metacarpophalangeal joint. No neurovascular damage or surgical site morbidity was recorded. CRIF and ORIF of simple metacarpal fractures can be executed successfully using WALANT with good functional results without increased morbidity compared to monitored anesthesia care.

Arthroscopic-assisted 6U approach for foveal reattachment of triangular fibrocartilage complex with an anchor: Clinical and radiographic outcomes at 4 years' mean follow-up.

Abstract: The main objective of this study was to evaluate the long-term clinical and radiological outcomes of arthroscopic-assisted foveal repair of proximal triangular fibrocartilage complex (TFCC) tears with an anchor. The secondary objective was to look for ligament damage associated with TFCC tears. Twenty-four patients who underwent foveal repair of the TFCC were evaluated retrospectively: 16 stage 2 and 8 stage 3 in the Atzei-EWAS classification. The TFCC was repaired with an anchor using an expanded 6U approach. Systematic testing of intrinsic and extrinsic ligaments was performed. The assessment criteria were pain on a visual analog scale (VAS), wrist joint range of motion, grip strength and pronation-supination strength, and the QuickDASH and PRWE outcome scores. X-rays were also taken to assess anchor position and to look for distal radioulnar (DRU) joint damage. The average follow-up was 44 months. After the surgical repair, pain was reduced (7.36±1.3 preoperatively vs. 0.69±1.3 postoperatively; P<0.001), the QuickDASH score improved (52.1±16 vs. 21.7±7; P<0.001), the PRWE score improved (83.7±35 vs. 9.3±12; P<0.001) as did strength (35 vs. 43kg; P<0.001). The DRU joint stability was also significantly improved. The time away from work was 2.6 months. During the arthroscopy exploration, 25% of patients had an ulnotriquetral ligament lesion and 8% had an ulnolunar ligament lesion in combination with their TFCC tear. Fifteen anchors were positioned in the anatomical fovea (62%). No DRU joint damage was noted. Six patients had neurapraxia of the dorsal branch of the ulnar nerve, although it recovered spontaneously. One patient still had hypoesthesia of the ulnar side of the fifth finger at 48 months. Arthroscopic-assisted foveal repair of the TFCC yields good results in terms of pain, strength and DRU joint stability. In one-quarter of cases, TFCC foveal tears are associated with lesions of the ulnotriquetral ligament. There is no long-term degeneration of the DRU joint.

Partial wrist denervation versus total wrist denervation: A systematic review of the literature.

Abstract: The aim of this systematic review was to understand which procedure-total or partial wrist denervation-provides better results in terms of pain relief and function. This review was registered on PROSPERO (CRD42018088856). We searched the Medline (PubMed), Web of Science and Scopus databases. Twenty-one studies were included in this review. We assessed the quality of the studies using the Coleman Methodological Score. Data on demographics, surgical indications, diagnostic methods, follow-up periods, type and rates of complications, survivorship of the procedure, return to work, and outcome measures were recorded. A total of 1065 patients were included in this review; the mean quality of the studies included was considered poor. The outcomes could not be analyzed because none of the studies had reliable outcome data reported, but both procedures were effective in terms of pain relief and range of motion. Partial wrist denervation has an average subsequent procedure rate of 19%. Total wrist denervation had an average subsequent procedure rate of 4.7%. No complications were reported in any patient who underwent partial wrist denervation versus 20 patients who underwent total wrist denervation. Both partial and total wrist denervation are safe and reliable procedures that can provide good pain relief and preserve wrist range of motion. Total wrist denervation offers better long-term outcomes in term of pain relief, with fewer subsequent procedures being needed compared to partial denervation, and with a low complication rate. LEVEL OF EVIDENCE: Level III, Systematic review, Therapeutic.

Scaphocapitate fusion for the treatment of Lichtman stage III Kienböck's disease. Results of a single center study with literature review.

Abstract: The purpose of this study was to report the outcomes of scaphocapitate fusion without lunate excision for the treatment of stage III Kienbock's disease and to compare these results with historical results of limited wrist arthrodesis and proximal row carpectomy. Clinical and radiographic evaluations were performed preoperatively and at a mean of 5.8-years’ follow-up (range 1.5 to 10.5 years) on 17 patients with advanced Kienbock's disease (Lichtman stages: IIIA n = 4 and IIIB n = 13) treated by scaphocapitate fusion without lunate excision between January 2000 and July 2015. The average DASH score was 19 points (range 2 to 61) and the PRWE score was 23 points (range 0 to 77). The average preoperative VAS for pain of 8 was significantly reduced to an average of 4 with activity (P = 0.002) and 1 at rest (P = 0.001). The flexion/extension arc was 91° and grip strength was 76% of the contralateral side. The preoperative mean modified carpal height ratio decreased significantly to an average of 1.14 at the latest follow-up (P = 0.02). The average carpal-ulnar distance ratio was not altered (P = 0.89). The radioscaphoid and scapholunate angles were restored to their normal range. Four scaphocapitate joints failed to fuse. No re-operations were performed. Scaphocapitate fusion for advanced Kienbock's disease maintains wrist motion and significantly relieves pain. Lunate excision is not necessary. Based on a literature review, our results were comparable to those of scaphotrapeziotrapezoid fusion. Proximal row carpectomy is still an option when the radius and capitate articular surfaces are free of significant chondral lesions.

Trapeziometacarpal prosthesis: an updated systematic review

Abstract: The trapeziometacarpal prosthesis is mostly used in Europe to treat osteoarthritis of the basal joint of the thumb. Its supposed benefits are that it restores the length of the thumb, improves strength, function and mobility while reducing recovery time compared to other surgical treatments. However, previous reviews of the literature could not confirm these assumptions. This article provides an updated systematic review to help answer to these questions through a methodical statistical analysis and to quantify the two main complications, namely failure and deep infection. To achieve these aims, a selection of articles including implant case series was done in the Medline database based on specific criteria. Data about pain, function, strength, infection, and failure were compiled and a statistical analysis was performed. Results show a fast recovery in terms of pain and function but the positive effect on strength seems limited. The failure rate represented by the revision rate is high and the deep infection rate is fairly low. Randomized controlled studies are needed to obtain reliable data to compare the prosthesis to other surgical treatments.

Pyrocardan® implant arthroplasty for trapeziometacarpal osteoarthritis with a minimum follow-up of 5 years.

Abstract: Many surgical procedures are available for treating trapeziometacarpal (TMC) osteoarthritis (OA). The aim of this study was to analyze the mid- to long-term outcomes of 103 pyrocarbon interposition arthroplasties in the TMC joint with Pyrocardan® implant performed prospectively in a single center to treat painful early stage OA. There were 96 patients with a median age of 59 years. Twenty-eight percent of patients were manual workers and 39% had a fixed dislocation of the first metacarpal. Fifteen percent of patients were 50 years old or more. After a minimum follow-up of 5 years, there was a marked improvement in the pain level (0.6/10), QuickDASH (9/100) and PRWHE (4/100) scores and strength (key pinch 8 kg, grip strength 27 kg). There were no differences in strength or range of motion compared to the opposite side. Four patients underwent revision surgeries. Two of them were converted to trapeziectomy. The 5-year implant survival rate was 96.2%. Dislocation of the first metacarpal was completely corrected in 80% of cases. Younger patients (≤50 years old) had slightly better outcomes than older ones. Overall satisfaction rate was 96%. Pyrocardan® interposition implant arthroplasty is a reliable alternative to trapeziectomy, total arthroplasty or fusion of the TMC joint especially for young, active patients.

Management of forearm bone loss with induced membrane technique.

Abstract: There are very few published studies describing the treatment of segmental bone defects of the forearm using the induced membrane technique. The objectives of this study were to evaluate the time to bone union, the function of the joints above and below the treated bone segment and the patients' quality of life over the long-term. We performed a retrospective study in all patients treated by the induced membrane for a forearm bone defect over at 13-year period. Demographics, bone union, complications, functional outcomes and occupational status were collected. Six patients were included: 2 posttraumatic injuries, 1 osteomyelitis, 1 septic arthritis, 1 aseptic nonunion, 1 tumor. The average defect length was 64mm (48-110). All defects were treated with internal fixation. Bone graft was harvested from the iliac crest in two patients, the femur (using the Reamer Irrigator Aspirator technique) in three patients and the radius in one patient. Five patients achieved bone union after a mean of 4months (3-6). Three complications were observed: 1 radioulnar instability, 1 infection of the fixation device, 1 abscess. At an average 8½ years' follow-up, the pain level on the VAS was 0.6 (0-3), the Mayo Elbow Performance Score was 98 (90-100), the Herzberg score was 108 (85.6-140) and the QuickDASH was 14.9 (2.7-35). All patients returned to work. Using the induced membrane technique avoids the complications associated with vascularized autograft and yields good functional outcome and quality of life.

Finger joint denervation in hand osteoarthritis: Indications, surgical techniques and outcomes. A systematic review of published cases.

Abstract: In cases of osteoarthritis with preserved motion, joint denervation can be an effective alternative to arthroplasty or arthrodesis to reduce joint-related pain. Although denervation is a standardized procedure for wrist osteoarthritis, it is used sparingly for finger joints. We conducted a systematic review to summarize reported cases of finger joint denervation in hand osteoarthritis with a specific focus on surgical procedures and postoperative outcomes. PubMed, Cochrane and Science Direct databases were searched from 1998 to 2019 and 13 relevant articles were selected. Three hundred and twenty-five denervations were conducted on 291 patients. Distal interphalangeal (DIP) joint denervation was performed through a dorsal approach; 83% of patients were satisfied with the surgery and complications occurred in 58%. Proximal interphalangeal (PIP) joint denervation was performed through a palmar approach; 90% of patients were satisfied with the surgery; complications were observed in 14%. Good results were observed in 95% of patients who underwent metacarpophalangeal (MCP) joint denervation; complications were observed in 26%; denervation was carried out with dorsal and palmar approaches in all cases. Denervation of the trapeziometacarpal (TMC) joint was achieved through the Wagner approach (61%), multiple incisions (26%), or dorsal approach (13%); satisfaction rate was 91%, with a 6% complication rate. Finger joint denervation in hand osteoarthritis is a simple and effective procedure, providing satisfactory pain relief. Good results are reported in all studies, especially for PIP and TMC joint denervation. Further investigations should be conducted on DIP and MCP joint denervation.

Microvascular anastomosis using loupes and smartphone magnification: Experimental study for application to limited-resource environments.

Abstract: Finger revascularization has been performed without a microscope in limited-resource environments only when absolutely necessary. This experimental study sought to assess the feasibility of microvascular anastomosis in rats performed using loupes or smartphone magnification. Thirty rats were divided into three groups of 10 individuals according to the magnification method used: operating microscope (control group M), surgical loupes (group L) and smartphone (group S). The infrarenal aorta was dissected under a microscope, then anastomosed by interrupted sutures using the group-specific magnifying device. The main analytical criteria were vessel diameter, anastomosis duration, immediate flow patency (T0), patency after one hour (T1) and anastomosis quality. Anastomosis duration was comparable between groups M and L, but was twice as long in group S. The number of leaks at clamp removal was higher in group S. Patency rates at T0 and T1 were 100% in groups M and L, but were significantly lower in group S. The anastomosis quality was low in group L and poor in group S. Anastomosis of digital arteries using loupes is possible, but the resulting quality is lower than with a microscope. Current smartphones are not adequate for performslt ing microvascular repairs in a living model.

Predictors of return to work in patients with occupational hand injury

Abstract: Work-related hand injuries are the primary cause of disability and prolonged time away from work. This prospective cohort study was conducted to determine the predictors of return to work (RTW) after traumatic work-related hand injuries. Our study included 280 patients who were referred to the Plastic and Reconstructive Center for treatment of their occupational hand injuries from July 2017 to February 2018. Several functional questionnaires were completed, and they were followed up at 1, 3 and 8 weeks. Telephone interviews were done 3 months later. Approximately half the subjects had returned to work during the first 3 months after a median time away of 57 days. No relationship was found between age, gender, marital status, hand dominance and RTW time. Nevertheless, there was correlation between RTW time with cigarette smoking, injury severity and disability. Our study findings suggest that injury severity and higher work disability scores are prognostic factors for RTW. Also, smoking was associated with later RTW, which could be the result of poor circulation and delayed healing. Employers should implement injury prevention programs with appropriate rehabilitation that takes into consideration the severity of the hand injury, and health strategies to improve unhealthy lifestyle factors such as smoking.

Effects of early manual therapy on functional outcomes after volar plating of distal radius fractures: A randomized controlled trial.

Abstract: We sought to investigate the effects of early manual therapy on functional outcomes in patients treated with volar plating of a distal radius fracture (DRF). This was a prospective, single-blinded, randomized controlled trial. Patients treated with volar plating of a DRF were randomly assigned to either Early Manual Therapy Group (EMTG, n=19) or Standard Physiotherapy Group (SPG, n=20). While SPG received standard physiotherapy, EMTG received standard physiotherapy plus Mulligan's Mobilization with Movement technique two sessions a week, through 12 weeks. Function, pain intensity, range of motion, grip strength and the level of disability were assessed using the Patient Rated Wrist Evaluation (PRWE), Visual Analog Scale (VAS), goniometer, hand dynamometer and Disabilities of Arm, Shoulder and Hand (DASH) Questionnaire, respectively. Measurements were made at 3, 6, and 12 weeks postoperatively. Of the 54-screened patients, 39 met the inclusion criteria and were randomized. In total, 32 patients (EMTG, n=15; SPG, n=17) were analyzed. EMTG had significantly better DASH score and wrist flexion at 12 weeks, less pain and better PRWE total score, wrist extension, ulnar/radial deviation, supination and grip strength at all time points. Moreover, wrist flexion increased more with the addition of early manual therapy than standard physiotherapy alone (26.50±13.19 versus 16.21±16.06). The addition of early manual therapy to standard physiotherapy may contribute to better functional outcomes and be more effective in increasing wrist flexion in patients treated with volar plating of a DRF.

Hand injuries treated at a hand emergency center during the COVID-19 lockdown.

Abstract: The recent coronavirus outbreak has tested the adaptability, cooperation and organizational capabilities of our healthcare systems. Restrictions were implemented in several countries to reduce virus transmission whilst emergency departments (ED) were overwhelmed and there was shortage of healthcare providers. Given this situation and the consequences of hand injuries, we studied the epidemiology of hand injuries in an accredited FESSH emergency center during the lockdown in France (March 17 to May 10, 2020) due to the coronavirus outbreak. During this period, 1947 patients consulted for a hand injury. We found high percentages of men (63%), open wounds (70%), domestic accidents (88%) and surgical treatment being required (76%). There was a significant decrease in admissions and consultations relative to the same period in 2019. This reference data can help healthcare systems prepare for future outbreaks and similar restrictions.

Clinical and radiological outcomes of 40 cases of SLAC and SNAC wrist treated by four-corner arthrodesis with locking plate.

Abstract: The treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist varies. No clear consensus exists on surgical indications. Scaphoid excision and four-corner arthrodesis with locking plate is one of preferred treatments for these lesions. The purpose of this study was to assess the clinical and radiological outcomes of locking plates for treating SNAC and SLAC wrist after a mean follow-up of 5 years and to compare these outcomes with the results reported in the literature. A retrospective study was conducted in two hospitals, involving 40 patients who underwent scaphoid excision and four-corner arthrodesis with locking plate between January 2006 and September 2016. All patients were reviewed as outpatients with clinical and radiographic measurements. At the last follow-up, the mean pain level on visual analog scale (VAS) was 2.5/10 [0-7] (SD: 1.7). Patients had a mean flexion of 46% and a mean extension of 46% compared to the contralateral side. An 18% gain was observed in grip strength. The mean postoperative QuickDASH score was 30 [0-57] (SD: 15.3). Seventy percent of patients were satisfied with the operation. Complete (all four joint interfaces) joint space fusion was achieved in 55% of patients. Only one patient (2.5%) had no joint fusion. The joint between the lunate and the capitate was fused in 38 patients (95%). Nine patients suffered complications; eight of them required surgical revision (20%). Four-corner arthrodesis with locking plate is a valuable surgical technique for treating SLAC and SNAC wrist because it preserve satisfactory range of motion and grip strength (64% compared to the non-operated side), maintains the height of the carpus and prevents the premature appearance of radiocarpal osteoarthritis, as long as the technical challenges of this procedure are mastered.

Flexor tendon complications in distal radius fractures treated with volar rim locking plates.

Abstract: Volar locking plates used for treating distal radius fractures can damage the flexor tendon. Fractures distal to the watershed line can be fixed using volar rim locking plates. The aim of our study was to report the incidence of flexor tendon lesions when using these plates. Our case series included 15 patients (7 women, 8 men), aged 59 years on average (23-88) who underwent distal radius fixation using a volar rim plate (Extradistale®, Newclip Technics™, Haute Goulaine, France). Eight patients had complications: seven cases of synovitis treated by synovectomy with a satisfactory final outcome, 10 cases of partial tendon ruptures treated by synovectomy and tendon repair in two cases, and five cases of complete rupture that were not repaired at the patient's requests. Our working hypothesis was not verified as we found flexor tendon complications in half our patients. When the fracture is distal to the watershed line, we recommend removing the plate after bone healing, never after the 3rd month postoperative.

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Clinical results of a new technique using an endoscopic carpal tunnel release device.

Abstract: Exertional compartment syndrome of the forearm is a rare pathology, occurring almost exclusively in motorcycle racers. The results of endoscopic techniques are similar to those of open fasciotomies, but they are less invasive and leave smaller scars. The aim of our study was to present a new endoscopic technique for superficial fasciotomy using the Agee® system and to describe the results. This was a single-center, retrospective descriptive study of 21 patients (36 forearms) operated on between 2006 and 2016. All patients but one were competitive motorcycle racers. The mean operating time was 38.2 min (standard deviation (SD), 10.5 min). The QuickDASH score was 23.3 ± 10.2% preoperatively versus 1 ± 2% postoperatively (mean ± SD). Among the 18 patients who came back for a follow-up visit after 4.9 ± 2.7 years, 17 (94%) were satisfied or very satisfied. The mean time before returning to sport was 4.3 weeks (SD, 1.8 weeks), 9 patients (50%) at the same level as before surgery, 8 (44%) at a higher level, and one at a lower level. There were a few minor complications (superficial vascular lesions, hematoma, transitory hypoesthesia) and symptoms recurred in two patients. Our technique yields outcomes similar to those of other published endoscopic procedures and allows early return to sport. It has the advantage of being based on the Agee endoscope, which is commonly used to treat carpal tunnel syndrome, making the procedure easy to master.

The effect of mirror therapy after carpal tunnel syndrome surgery: A randomised controlled study

Abstract: The aim of this randomised controlled study was to investigate the effectiveness of mirror therapy (MT) on carpal tunnel syndrome (CTS) patients' symptoms and hand function after surgery. The patients' hand function was evaluated using the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) and the Nine Hole Peg Test. Their pain was evaluated using a visual analog scale, and their sensitivity was evaluated using the Semmes-Weinstein monofilament test before surgery, and at 3 and 6 weeks post-surgery. Thirty-five patients between the ages of 25 and 60 years were included in the study. In the control group (CTG) (n=17), the conventional physiotherapy program was applied for 4 weeks after 2 weeks of immobilisation. In addition to conventional physiotherapy, the MT group (MTG) (n=18) did MT during the immobilisation period. There were no statistically significant differences between the groups' demographic and clinical characteristics before treatment (P˃0.05). After treatment, all parameters improved in both groups. MTG had statistically lower pain at rest (P=0.004) and night-time pain (P=0.037) in the 3rd week, but there were no statistically significant differences between the other parameters and scores between the groups (P˃0.05). The study indicates improvement in the parameters due to the early introduction of MT after CTS surgery, but once conventional methods were started after immobilisation, there were no significant differences between groups. However, the MT had reduced pain and improved sensation and function. Both groups experienced positive effects of the surgical treatment and the physiotherapy in the 6th postoperative week.

Functional evaluation following emergency arthroplasty of the proximal interphalangeal joint for complex fractures with silicone implant.

Abstract: The proximal interphalangeal (PIP) joint is particularly vulnerable to trauma. In comminuted fractures, arthroplasty with a silicone implant is a treatment option that may be controversial in an emergency setting. This joint destruction is usually accompanied by soft tissue injuries (skin and tendon damage, devascularization) making the reconstruction all the more complex. The aim of our work was to evaluate emergency finger silicone implants for complex and comminuted fractures of the PIP joint as well as clinical and radiological complications. In this single-center, retrospective study, 13 patients operated between January 2007 and January 2019 on an emergency basis with a Neuflex® PIP arthroplasty were reviewed. This PIP joint reconstruction was associated with the soft tissue repair at the same time (skin cover, tendons, nerves) in all patients. The average age was 57.7 years with a male predominance (92%). The injuries were caused by a domestic accident in 61% of cases. The average follow-up was 4.7 years. The average total active motion arc was 183.8°. The average QuickDASH score was 24. There was one case of broken implant with no functional consequence. No infection or instability was reported. Silicone implant arthroplasty is a simple, reliable, fast, and durable solution for complex PIP fractures when conservative treatment is impossible. This solution is an alternative to arthrodesis or even finger amputation.

Reconstruction strategies after rupture of the extensor pollicis longus tendon: A systematic review

Abstract: Ruptures of the extensor pollicis longus (EPL) tendon result in a major loss of function. The most practiced reconstruction surgery appears to be extensor indicis proprius (EIP) transfer, which is contraindicated in certain cases. The objective of this review was to present the various reconstruction methods for the EPL tendon. A systematic review was conducted of the literature from 2010 to 2020 on strategies for reconstructing the EPL tendon. A search of the PubMed database was done using the following keywords: 'extensor', 'pollicis', 'longus', and 'thumb'. Data analyzed were the type of study, the number of patients, surgery, follow-up, and results. Of the 142 articles selected from PubMed, only 18 (12.7%) were included in the analysis. Follow-up ranged from 6 months to 6 years, with an average of 28 months, and the total number of patients was 515. Numerous strategies exist for reconstruction following rupture of the EPL tendon. The preferred modality seems to be a transfer of the EIP tendon with intraoperative testing of applied tension with the interphalangeal joint in extension, hand flat, forearm in pronation, and neutral wrist position. When the EIP is not available, other transfers should be considered if the patient has significant tendon attrition, or a graft should be considered if an isolated defect is present.

Long-term results after semiconstrained distal radioulnar joint arthroplasty: A focus on complications.

Abstract: Arthroplasty of the distal radioulnar joint (DRUJ) using a semiconstrained DRUJ implant yields good outcomes according to the literature. The aim of this study was to investigate the subjective, clinical and radiographic outcomes with a special focus on complications in nine patients with a mean follow-up of 6years and to compare them with our previously published 3-year follow-up results. No subjective or objective changes were seen between the 3-year and the 6-year follow-up. In the previous study, one implant loosening and two irritations of the superficial branch of the radial nerve occurred. We saw three complications that needed surgery in addition to the three complications already found 3years after surgery. One patient with a large ulna had loosening of the cemented ulnar stem and therefore the prosthesis was explanted. One patient had an allergic reaction to the metal alloy of the prosthesis, which also led to removal. One patient had an ulnar impaction syndrome caused by too-distal placement of the implant that needed revision. Prior studies reported low complication rates. In our study, six complications occurred in four out of nine patients, requiring reoperation including two revisions and two implant removals. A precise surgical technique is mandatory to avoid the otherwise frequent complications and potential implant failures. LEVEL OF EVIDENCE: IV.

Lateral stability in healthy proximal interphalangeal joints versus surface replacement and silicone arthroplasty: Results of a three-dimensional motion analysis study.

Abstract: The objective of this study was to quantify the lateral stability of healthy proximal interphalangeal (PIP) joints using a three-dimensional motion capture system and compare it to affected joints after surface replacement or silicone arthroplasty. Three study groups comprised healthy participants, patients with PIP joint osteoarthritis treated with a surface replacing implant (CapFlex-PIP) and those with a silicone arthroplasty. All participants were matched on gender and finger, and the two patient groups were also matched on length of follow-up. An optical tracking system was used to measure lateral stability. Radial and ulnar stability of the PIP joint was measured as the maximal lateral deviation angle of the middle phalanx under loads of 40 g, 90 g and 170g at 0°, 20° and 45° PIP joint flexion. Measurement reliability was evaluated with a test-retest trial [intraclass correlation coefficient (ICC)]. A total of 30 joints were assessed with 5 index and 5 middle fingers per test group. Lateral deviation increased proportionally with applied weight. Silicone arthroplasty joints had a higher median lateral deviation angle of 5.1° (range 0.7-7.9) than healthy [3.0° (0.5-11.0)] and surface replacement joints [3.3° (0.3-7.4)] at 45° flexion and under 170g load. Test-retest reliability was high with an ICC of 0.93. Lateral PIP joint stability is highly variable in both healthy participants and patients after PIP joint arthroplasty. PIP joint surface replacement arthroplasty tends to achieve better anatomical stability compared to flexible silicone implants.

Ten-year radiological and clinical outcomes of capitolunate arthrodesis with scaphoid and triquetrum excision for advanced degenerative arthritis in the wrist: Single-center, retrospective case series with 10 patients

Abstract: The aim of this study was to evaluate the long-term outcomes of capitolunate arthrodesis for treating advanced wrist osteoarthritis. The arthrodesis procedures were performed in three women and seven men having a mean age of 59years (range, 20-70). Eight of the patients were manual laborers. The dominant hand was operated on in seven patients. The osteoarthritis was attributed to scapholunate dissociation (SLAC) in six patients and scaphoid nonunion (SNAC) in four patients. The arthrodesis site was stabilized with two vertical compression screws. Patients were reviewed after an average follow-up of 122months (80-172). The clinical and radiological outcomes consisted of measuring pain on a visual analog scale (VAS), determining the QuickDASH and PRWE scores, the patients' satisfaction, the radiolunate and capitolunate angles, carpal height, radiolunate joint condition, and fusion of the arthrodesis site. The mean pain level was reduced from 5 to 1 (P<0.05). The range of motion improved by 20° in flexion-extension and 10° in radioulnar deviation, while strength improved by 8kg relative to the preoperative measurements (P<0.05). The QuickDASH was 15points (±12) and the PRWE was 20 (±32). Relative to the preoperative values, the radiolunate angle was reduced by 4.5° and the capitolunate angle by 6.5°. Carpal height was 6.5mm less on average (P<0.05). None of the patients had a nonunion or deterioration of the radiolunate joint. One patient developed Type II complex regional pain syndrome. The nine other patients were able to return to work. Capitolunate arthrodesis provided pain relief and good function in 9 of the 10patients in our case series. The results was maintained over time, both in terms of mobility and pain relief, which were clearly improved after the surgical treatment. We found no signs of deterioration of the radiolunate joint over 10years. There are very few published studies describing the long-term outcomes of this procedure. Our findings are consistent with those in the literature, which makes capitolunate arthrodesis with scaphoid and triquetrum excision a highly satisfactory and reliable technique in the long term for the treatment of advanced osteoarthritis in the wrist. LEVEL OF EVIDENCE: IV.

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types

Abstract: The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P

The use of the RegJoint™ implant for base of thumb osteoarthritis: Results with a minimum follow-up of 2 years.

Abstract: The RegJoint™ (Scaffdex Oy, Finland) implant is a bio-absorbable poly-L/D-lactide implant which acts as a temporary support in resected joint spaces. It can be used in base of thumb surgery as a spacer to prevent first metacarpal subsidence. However, high rates of adverse tissue reactions and bone osteolysis have been reported recently by one group. The objective of this study was to investigate the outcome of patients treated in our institution with this implant. Patients underwent a postoperative clinical and radiological assessment. The QuickDASH questionnaire, Patient Evaluation Measure (PEM) and a visual analogue scale for pain assessment were used. Grip strength, key pinch, pinch strength, thumb palmar and radial abduction and opposition were measured. Trapeziometacarpal height was used to evaluate thumb shortening compared with the preoperative value. Periprosthetic bone-erosion of the trapezium and metacarpal were measured. Subluxation of the joint was evaluated by measuring the step-off between the radial edge of the trapezium and the base of the first metacarpal bone. Twenty-two patients from 2013-2016 were included. There were no postoperative wound complications. There was no significant difference in grip strength, key pinch or pinch between the operated and the contralateral hand. There was no significant difference in the trapeziometacarpal height, trapezial height or the degree of subluxation pre-or post-operatively. Contrary to recent reports, we did not find any adverse soft tissue reactions or significant bone erosion. There was no significant change in hand function. We consider the RegJoint™ a useful adjunct in the management of a select cohort of patients with base of thumb arthritis.

Fingertip reconstruction by palmar bipedicular island flap in long fingers (modified neurovascular Tranquilli-Leali flap): A dual-center study.

Abstract: When bone is exposed, fingertip defects may require a flap procedure. Many types are available, with little consensus about which one is best. But each one has its own disadvantages: esthetic (claw nail deformity), neurological (sensory disorders) or functional (stiffness). The purpose of this study was to evaluate a palmar bipedicular island flap (our modification of the Tranquilli-Leali flap) for fingertip reconstruction. We retrospectively analyzed the prospective data of 42 patients with a mean follow up of 16.4 months (6–30 months) operated in two hospital facilities. Thirty-three patients were men. Mean age was 39.5 years (12–83 years) and 24 (57.1%) were smokers. In 23 cases (54.8%), the trauma was work-related. A crush mechanism was identified in 29 patients (69%). According to Allen's classification of fingertip injuries, there were 26 cases of stage II, 14 cases of stage III and 2 cases of stage IV. All procedures were performed on an emergency basis, within 24 hours of the trauma. No claw nail deformity was observed. The mean discrimination in the Weber test was 3.8 mm (2–6 mm). The mean Total Active Motion (TAM) was 268.3 ° (255–275 °). The patient satisfaction was graded at 8.7 on a 10-point scale. Results were considered as excellent in 15 cases and good in 23 cases. The modified palmar bipedicular island flap makes the old Tranquilli–Leali flap – which has a poor reputation in the hand surgeon community—simpler and safer to use. This flap restores proper balance between skin, bone and nail in Allen stage II and III fingertip amputations.

Measurement properties of the German Unité Rhumatologique des Affections de la Main (URAM) scale in patients treated for Dupuytren's disease

Abstract: We sought to investigate the reliability, validity, responsiveness, and interpretability of the German version of the Unite Rhumatologique des Affections de la Main (URAM) scale in patients with Dupuytren's disease. Patients with Dupuytren's disease were evaluated before receiving an injection of collagenase Clostridium histolyticum or undergoing surgical treatment and again 1 year later. Patients completed the URAM, the brief Michigan Hand Outcomes Questionnaire (brief MHQ), and the 5-level EuroQol version (EQ-5D-5L). Flexion contracture was measured. Internal consistency (Cronbach's alpha), construct validity (Spearman's correlation coefficient, r), responsiveness (effect size), and the minimally important change (MIC) and minimally important difference (MID) were determined. Confirmatory factor analysis was used to test the structural validity of the questionnaire. We included 231 patients (273 cases) with a mean age of 67 (SD, 9) years. Cronbach's alpha was 0.91. Correlations between the URAM and the brief MHQ, EQ-5D-5L and flexion contracture were r=-0.76, r=-0.46 and r=0.53, respectively. The URAM effect size was 0.96 and the MIC and MID were 6 and 7 points, respectively. The factor analysis revealed unidimensionality but indicated that one item (pick up small objects) could be removed. The German URAM has high reliability, good construct validity and excellent responsiveness. However, the questionnaire could be shortened by one item to increase its structural validity. We recommend using the URAM as a specific tool for evaluating the treatment effect in patients with Dupuytren's disease in daily practice and for research purposes.

Volar locking plate fixation of distal radius fractures: Isokinetic assessment of the influence of an ulnar styloid process fracture on pronation-supination strength.

Abstract: Although distal radius fractures (DRF) are frequent, the management of associated ulnar styloid process (USP) lesions is still controversial. According to recent studies, a fracture of the USP does not appear to affect functional outcomes after treatment of a DRF with plate fixation. We sought to compare the impact of a USP fracture on pronation and supination strength in isometric and isokinetic tests. We included patients with a DRF who underwent volar locking plate fixation. We divided our population into three groups: one group consisted of patients who had a fracture of the USP base, one group composed of patients without USP fracture or with a distal ulnar fracture only, and a control group composed of subjects with normal wrists. Inclusion criteria included an age of 18 to 50 years and a minimum follow-up of 10 months post-surgery. The main exclusion criteria were complex intraarticular fractures and postoperative complications. The assessment was based on clinical examination and recording of forearm rotation strength during pronation and supination in isokinetic and isometric tests. The ratio between the operated and contralateral sides was compared for each patient. Thirty-six participants were included (mean age 31.1±4.5 years). The mean postoperative follow-up was 17.9±6.9 months. Participants with a USP fracture differed from other participants in their peak torque on the isokinetic test at 45°/s for pronation and supination, but not on isokinetic tests at 120°/s or in isometric tests. Isokinetic tests revealed a decrease in pronation-supination strength during sustained effort for patients with associated basal USP fractures. These findings may have clinical implications for management of the USP but need to be specified with further study. LEVEL OF EVIDENCE: prognostic study level III.