E-Posters

Browse e-poster abstracts below.
Visit E-poster site to see the e-poster files.

Anatomy (8 abstracts)

Samuel George 1,2, Bismark Adjei 1, Paul McArthur 1,2

1 Whiston Hospital, Liverpool, UK; 2 Alder Hey Children's Hospital, Liverpool, UK

Introduction: Anatomical variations of the flexor pollicis longus(FPL) muscle are well described, the common two being an accessory head of FPL also known as Gantzer’s muscle described in 1813 and the anomalous tendon slips from the FPL to the flexor digitorum profundus(FDP) of the index and more rarely middle finger described by Linburg and Comstock in 1979. We present an anomaly not previously described in the literature where the FDP to the ring finger was found to originate from the FPL tendon, causing tight flexion contracture of both due to underlying muscle spasticity. Case Report: An 11-year-old boy with Leigh syndrome was under the care of our plastic surgery unit for flexion contractures of his upper limbs. He underwent botulinum toxin injections 4 weeks previously and was undergoing tendon lengthening/release on the right side. Of note, pre-operatively he had a very tight FPL and wrist flexors but also incidentally a severe flexion deformity of his ring little and fingers which resembled a claw hand. During surgical exploration and release of the muscles, an anomalous fusiform muscle was found originating from the tendon of the FPL, heading to the ring finger and flexing the distal interphalangeal joint. The accessory muscle was divided and improved the flexion contracture. Conclusions: Anatomically distinct from the anomalous tendon slips described by Linburg and Comstock, this accessory muscle actually originated from the FPL and inserted in the ring finger. While most anomalous muscles are asymptomatic, ours was causing symptoms particularly due to underlying muscle spasticity. The other clinical relevance of this is that the ring finger FDP usually supplied by the ulnar nerve was in this instance supplied by the median nerve.

Tamer Ali, Andrew Watts

Royal Devon and Exeter Hospital, Exeter, UK

Anomalous or accessory FDS muscles in the palm are rare, but when present they can be painful and interfere significantly with hand function. We present the case of a 28 year old male mechanic who presented with a painful swelling over his right thenar eminence following a road traffic accident. The patient’s right hand was gripping the steering wheel when he was involved in a low velocity head on collision. Shortly afterwards he noticed a swelling in his right palm over the first web space which increased in size with finger flexion. His grip strength was compromised and had reduced abduction of his index finger. Ultrasound and MRI scans were inconclusive. No intrinsic muscle rupture was detected and no mass lesion was detected. Hypertrophy of the index intrinsic muscles was suggested. The swelling increased in size and his overall hand function decreased, so surgical exploration was planned. At operation, the FDP tendon to the index finger and the intrinsic muscles were intact and of normal appearance. However, an accessory muscle was seen attached to the index finger FDS tendon in zone 3. A tendon ran proximally from this accessory muscle belly into the forearm. The accessory muscle was excised from the FDS tendon and the accessory tendon was sutured end to side on the existing FDS tendon. Postoperatively, the patient made a full recovery with reduced pain and significantly improved hand function. Anomalous and accessory muscles in the palm are anatomical curiosities until they become symptomatic. Accessory FDS muscles presenting in the palm are rare and only a few cases have been reported in the literature since they were first described in 1970 by Vichare. However, significant functional problems have been reported in conjunction with these anatomical variations, including pain, compression neuropathy, digital triggering and stiffness. Because of their rarity, their diagnosis is often delayed or initially missed. The authors show clear anatomical photographs of this accessory muscle along with an algorithm for investigating suspected anatomical variations.

Ji Hun Park, Tae Wook Kang, Seul Gi Kim, Young Woo Kwon, Jong Woong Park

College of Medicine, Korea University Anam Hospital, Seoul, South Korea

Background: Two major lunate types have been proposed on the basis of the absence (Type I) or presence (Type II) of medial facets. The first purpose of this study was to examine the reliability and reproducibility of the two methods of determining the lunate type: posteroanterior (PA) radiographic analysis (PA analysis) and capitate-triquetrum distance analysis (CTD analysis). The second purpose was to investigate the compatibility of the radiographic classification of lunate types with MR arthrography (MRA) findings. Methods: Plain radiographs of a total of 150 wrists were reviewed by three observers. The lunate types were independently evaluated twice using both PA analysis (Lunate Types I and II) and CTD analysis (Lunate Types I, CTD≤2mm; II, CTD≥4 mm; Intermediate, Others). The Cohen kappa and Fleiss kappa statistics were used for estimating the intra- and inter-observer reliabilities. The compatibility of the lunate types with the MRA findings, as assessed by each observer, was investigated. Results: The overall intra-observer reliability was 0.517 for the PA analysis and 0.589 for the CTD analysis. The overall inter-observer agreement of the three raters was 0.448 for the PA analysis and 0.581 for the CTD analysis. The PA analysis and MRA findings for the detection of medial facets of the lunate were compatible in 119 of the 150 patients (79.3%). Twenty-eight (90.3%) of a total of 31 incompatible wrists had a medial facet on the lunate on MRA (Type II), which was undetected on the PA analysis (Type I). On the CTD analysis, 76 (50.7%) of the total wrists were classified into the intermediate group; excluding them, 27 of 29 Type II lunates (93.1%) and 39 of 45 Type I lunates (86.7%) were compatible with the MRA findings. Conclusions: Both systems had moderate inter-observer and intra-observer reliabilities. Although the Type II lunates on both radiographic analyses showed a good compatibility with the MRA findings, clinicians should consider undetected medial facets in Type I lunates on PA analysis.

Ronit Wollstein 1,2, Aviv Kramer 3, Frederick Werner 4

1 New York University, NY, USA; 2 University of Pittsburgh, Pittsburgh, PA, USA; 3 Technion, Israel Institute of Technology, Israel; 4 SUNY, Syracuse, NY, USA

Purpose: In the musculoskeletal system, structure dictates function and the development of pathology. Interpreting wrist structure is complicated not only by the existence of multiple joints and ligamentous structures but also by variability in bone shapes and anatomical patterns. A previous study evaluated normal plain radiographs for lunate and capitate shape in the midcarpal joint. This study identified intracarpal measurements related to lunate and wrist type. Assuming that these disparate patterns will transfer forces differently, our purpose was to correlate the forces transferred to the distal radius and ulna with the morphological measurements in cadaver arms. Hypothesis: we will find significant correlations between force transfer and two distinct anatomical patterns. Methods: Radiographs from a database of 49 cadaver wrists previously tested for force transfer between the radius and ulna were examined. The percentage of the compressive force through the distal ulna and radius was determined by mounting load cells to the distal radius and ulna while 22.2 N tensile forces were individually applied to the extensor carpi ulnaris, the extensor carpi radialis and brevis, the flexor carpi radialis and the flexor carpi ulnaris. Each wrist was tested in neutral flexion-extension and radioulnar deviation. Results: There were 35 lunates type 1 with a mean ulnar force of 27.6% and 11 lunates type 2 with a mean ulnar force of 10.4% (3unclassified). There was a significant correlation between lunate type and percent of force transfer through the ulna p=0.0003. Percent force transferred to the ulna was weakly correlated with ulnar variance (p=0.003 R2 =0.17), capitate circumference (p=0.02, R2=0.12), the capitate –lunate contact (0.003, R2=0.18). The percent of capitate circumference contacting the lunate (p=0.06, R2=0.18) was borderline as was the distance between the radial styloid and scaphoid d2/w2 (p=0.08, R2=0.23). Conclusions: 1) In the intact wrist, ulnar variance is not a strong predictor of percent force transfer through the ulna. This has been published in a previous study. 2) While lunate type was significantly associated with percent transfer of force through the ulna, other intracarpal measurements were only weakly correlated. This may support that a type 2 wrist transfers forces differently through the wrist. 3) The reason for the lack of strong correlations between intracarpal structure and percent load transfer through the ulna may be related to variations in soft tissue structures such as the TFCC and radiocarpal ligaments which can participate in load transfer between the radius and ulna but may also vary with lunate type. 4) Further study is warranted to improve our understanding of the relationship between structure and biomechanics in the wrist.

Santiago Salazar Botero 1,2, Sophie Honecker 1,2, Hamdi Jmal 2, Nadia Bahlouli 2, Philippe A Liverneaux 1,2, Sybille Facca 1,2

1 Department of Hand Surgery SOS main CCOM University Hospital of Strasbourg, Illkirch, France; 2 Laboratory ICube CNRS UMR 7357 University of Strasbourg, Strasbourg, France

Objective: Nerve section is often present in patients with hand trauma. Section of the digital collateral nerves needs appropriate repair to regain sensibility to support physiological local forces to allow early motion in case of concomitant flexor tendon section. This study characterizes the mechanical behavior of digital collateral nerve to stablish their healthy mechanical properties. Methods: 44 digital collateral nerves were harvested using Brüner incisions. Digital collateral nerves were preserved in sodium chloride 0.9% at room temperature during the time between harvesting and mechanical tests (3 hours average). Each nerve was carefully glued and sutured to an emery paper frame and then positioned in the Instron® machine. A tensile test at 6mm/min was made for each nerve until rupture. A correlation and independence test were applied to the values to explore the relationships between groups (each finger: thumb, index, middle, ring fingr,little finger) and between density and Young modulus. Results: 44 nerves harvested from 9 cadaveric hands were tested and the mechanical characterization was done. The stress- strain curve and young modulus were shown. The mean values found for the digital collateral nerves were: Ultimate stress 13,14 +/-4,8, ultimate strain 30 +/-9,5 and Young Modulus 76,55 +/- 35,5. Nerves. The scanty number of samples did not allow to stablish a significant difference between fingers, neither was possible to stablish a correlation between density and Young Modulus. A linear regression model for the scatter plot of nerve specific modulus and specific stress showed a tendency to direct correlation between these variables. Conclusions: Digital collateral nerves biomechanics are the first step toward a development of a better nerve repair. Data acquired during the experiment can be used to improve simulations of nerves during training and surgical planning. Further studies should correlate the ex vivo data with non-invasive techniques as in vivo elastography.

Sarah Jiayu Too 1, Duncan Angus McGrouther 2

1 National University of Singapore, Singapore, 2 Singapore General Hospital, Singapore

INTRODUCTION: Allen Buckner Kanavel (1874-1938) was an American surgeon, best remembered for describing the cardinal signs of suppurative flexor tenosynovitis. His book ‘Infections of the Hand’, a milestone in Hand Surgery, was first published in 1912, with six editions following until 1939. This manuscript focuses on Kanavel’s dissections of the flexor tendon sheaths, deep palmar spaces, and his description of their boundaries. With international concern over antibiotic resistance, it is timely to reconsider the role of surgery preceding the availability of antibiotic medication. Therefore, better understanding of the way infections in the hands can spread is of paramount importance in managing our patients. METHODS: To determine the communications between each fascial space, Kanavel injected a solution of radio-opaque dye mixed with diluted Plaster of Paris from different entry points, such as the tendon sheaths, wrists, and deep palmar spaces. The solution was injected at different pressures into a formalin-hardened hand specimen to observe where infections would spread when the spaces ruptured. He then took X-rays (then the novel Roentgen rays) of the injected hand specimens and performed cross-sections to better delineate these spaces. These spaces described will be illustrated by MRI images of current cases. ANALYSIS: Kanavel’s methods were brilliantly innovative– his findings acted as a basis for current clinical practice and were the basis of many anatomy books that followed. He described two main deep spaces of the hand: the middle palmar and thenar spaces. The middle palmar space was bounded by the third metacarpal to the radial border of the fifth metacarpal bone, with a thin fibrous septum separating it from the tendons that lie anteriorly. The thenar space was said to be bounded by the adductor transversus posterolaterally, and the flexor tendons anteriorly. The septa between these two spaces are thick, firm, and essential in preventing spread of infections. We were initially drawn to his initial study as we noticed it was rare to come across infections of the hand that conformed to his boundaries of the deep fascial spaces in actual clinical practice. Many of the patients with palmar abscesses present with their flexor tendons encased within purulent discharge, instead of being separate from Kanavel’s middle palmar space. Similarly, several later papers had varying descriptions of the boundaries of the deep spaces. For example, Grodinsky (1941) performed dissections and injections on 92 hands describing many other spaces with indeterminate septa within. Kaplan (1965) observed that the “very firm septa” separating the thenar and middle palmar spaces were only seen in patients with Dupuytren’s contractures. One possibility for this discrepancy was that cadaveric studies were unable to replicate the erosive and inflammatory processes of an active infection. Another possibility would be inaccurate interpretation of the dissections, as the spaces were mainly illustrated through hand-drawn images by different artists. CONCLUSION: Kanavel’s classical description of infection spreading from one space to another, distally to proximally, gives understanding of where to evaluate. Modern imaging should be performed to delineate relevant spaces that are encountered during infections.

Jidapa Wongcharoenwatana, Panai Laohaprasitiporn, Saichol Wongtrakul, Roongsak Limthongthang, Panupan Songcharoen, Torpon Vathana

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background: Arterio-venous loop (AV-loop) graft and free functional muscle transfer (FFMT) has been reported in brachial plexus injury (BPI) with concomitant subclavian artery injury which compromised donor arterial flow for FFMT. The donor vein for constructing AV-loop graft was small saphenous vein graft. Currently there is no anatomical study about size, length and number of branching of small saphenous vein. Objective: To study anatomy of small saphenous vein, size and number of its branches and its valves as a vascular graft option for use in AV-loop graft in FFMT reconstruction in BPI with concomitant subclavian artery injury. Methods: The anatomy of the small saphenous vein was studied in 30 legs of fresh and soft cadavers. There were 15 females and 15 males with mean age 56.97 years. The total length of small saphenous vein was measured over the complete length of the leg. We measured vessel length and diameters with vernier caliper (6" MITUTOYO vernier calipers .001" 530-312 accuracy +- 0.03 mm). Recorded location, size and number of branches. We used retrograde saline injection to locate valves direction. Statistical analysis was performed by SPSS 18.0 (SPSS Inc, Chicago, Ill) Results: The average length of small saphenous vein taken from distal edge of lateral malleolus to the point where small saphenous vein connect to popliteal vein was 31.34 cm, ranging between 22 and 44.5 cm. The average diameter of proximal and distal end was 0.6 and 0.52 cm, respectively. The average frequency of branches was 10.67, ranging between 7 and 15. The average size of branches was 0.25 cm. The distance from each branch to distal end ranging from 1.57 to 32.0 cm. Valves of small saphenous vein allow bidirectional flow. Conclusions: Knowledge on the anatomical variations and characteristics of the small saphenous vein can be helpful in clinical practice and surgical operations concerning patient with BPI patients who undergone AV-loop graft in FFMT.

Claudia Lamas-Gómez 1, Ariadna Da Ponte-Prieto, Manuel Llusà-Pérez 2, Camila Chanes-Puigros 1, Marta Almenara-Fernández 1, Laura Velasco-González 1

1 Hand Unit and Upper Extremity, Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; 2 Department of Human Anatomy and Embryology, Hospital Clinic. Universitat de Barcelona, Barcelona, Spain

Objetives: The vascularity of the radius and the union in distal radius fractures has been associated with injury of the blood supply with the surgical approach and/or techniques of osteosynthesis. This study aimed to describe the role of the Pronator Quadratus (PQ) muscle and the Anterior Interosseous Artery (AIA) in the vascularity of the distal radius and its relationship with the union in distal radius fractures. Methods: Sixteen adult hands from fresh cadavers were dissected. There were 8 male and 8 female with a mean age 72 years (range, 50-91 years). The specimens were injected through the brachial artery with Ward ́s latex. Dissections were performed using magnifying loupes and vascular anatomy was studied. Hands were processed using soft tissue digestion and bone clearing using Spalteholz technique. Results: The PQ muscle originates from the ulna by a strong aponeurosis. The muscle is attached to the flexor surface of the distal radius and also on its medial triangular area, proximal to the sigmoid fossa. The distal border of the muscle covered the distal radioulnar joint and is on average 14 mm (11-18 mm) from the lower articulating surface of the radius. The AIA is a terminal branch of the common interosseous artery (IA), but it occasionally arises from the ulnar artery. The AIA is accompanied by its venae comitantes and the anterior interosseous nerve, all of which lie on the flexor surface of the interosseous membrane, deep to the PQ muscle. The artery, along its course gives a series of perforating branches at intervals of 15 mm. The distal radius was supplied by three main vascular systems: epiphyseal, metaphyseal and diaphyseal. The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch and anterior branch of the AIA. These vessels entered the bone through the radial styloid process, Lister ́s tubercle and sigmoid notch. Every specimen studied had one o more palmar metaphyseal arch that coursed through the PQ. Its proximal source was either the anterior division of the AIA (95%) or the AIA itseft (5%). In the metaphyseal area we found numerous periosteal branches originating deep in the PQ and the AIA. These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area only the nutrient vessel provided intraosseous vascularity in the distal radius. Conclusions: Numerous metaphyseal branches arise from the deep PQ muscle and the AIA course towards the distal radius. These branches allow the union of the distal radius fractures and they make that the nonunion be an uncommon complication. The main vascular contribution takes place by deep fibers of the PQ, so that the superficial fibers can be surgically approached for a plate with a minimum risk of injury to the vascularity.

Brachial plexus (1 abstracts)

Hari Venkatramani 1, Nicholas G Rabey 2, Praveen Bhardwaj 1, Raja S Sabapathy 1

1 Ganga Hospital, Coimbatore, India; 2 John Radcliffe Hospital, Oxford, UK

Introduction Mutilating injuries to the upper limb pose a significant problem as an increasing number of young adults participate in high-risk activities. There remains a shortage of literature showing what might be achieved with delayed secondary neurotisation following severe extremity trauma. This case shows what may be achieved if challenging trauma is managed within an effective protocol and timely access to expertise. Case Report A 22-year old male sustained a subtotal amputation of his left arm requiring vein graft revascularisation. Other injuries included a divided axillary artery, fractured clavicle and ruptured musculocutaneous nerve with intact posterior cord of the brachial plexus, median nerve and ulnar nerve. Total ischaemia time was less than 4 hours. The patient made a good recovery and was discharged two weeks later. Three months post-injury the patient had full hand function and sensation and elbow extension, although he scored M1 for elbow flexion, M3 for trapezius function and M0 for shoulder abduction. He underwent a nerve transfer of a median nerve motor fascicle to the brachialis muscle and received physiotherapy and electrical neuromuscular stimulation post-operatively. At clinic 12 months following injury the patient scored M4+ elbow flexion and extension but M0 for deltoid. We carried out a nerve transfer of the posterior motor branch of triceps to axillary nerve. He has regained almost full shoulder abduction and returned to his usual pre-morbid employment. Discussion The high volume of severe trauma at our centre has enabled us to develop an effective trauma system which successfully manages candidates for limb salvage. However, when this patient presented there had been little published utilising delayed nerve transfer following mutilating upper limb injuries. As a result, we had to establish our own practice. We consider three months a reasonable time for secondary procedures as the skin should be supple and swelling-free. For proximal upper limb injuries the restoration of elbow function should take precedence, followed by shoulder stability and active abduction and external rotation. However, when we operated on this patient, the tissue scarring had made the nerve branch to biceps unavailable. Therefore, we chose to coapt a fascicle of the median nerve to the brachialis muscle branch within unscarred tissue. In this patient, the outcome resulting from brachialis reinnervation alone was excellent. On returning for review 12 months the patient still needed improvement in shoulder function. As we could not use the spinal accessory nerve transfer to suprascapular nerve, we utilised the nerve branch to triceps to reconstruct the axillary nerve. Physiotherapy and electrostimulation was given post-operatively and after 10 years the patient has regained almost full arm function. Conclusion This case is the first documented case showing an excellent functional outcome in a revascularised limb following nerve transfer at 12 months. We stress the importance of senior expertise and a clearly defined trauma protocol which minimises ischaemia time. Mutilating upper limb injuries present a challenge, but modern neurotisation techniques, even if delayed, can result in success.

Congenitals / Paediatrics (24 abstracts)

Kazuya Tajiri, Shinichi Yagishita, Hiroyuki Nakanishi, Yu Hatuchi, Daiyu Tsuji, Yuki Hagihara

Municipal Tsuruga Hospital, Tsuruga, Japan

Swelling, heat sensation, redness, pain appeared in the right index finger of a 12 year old girl without attraction, in March 2017. At the first visit on the six day after onset, the X - ray was normal. On the same day, MRI findings was osteomyelitis in the middle phalanx. However, the serum inflammatory response was negative. Serum rheumatic response was also negative, but antinuclear antibody was positive at 320 times. Antibiotic treatment started. On the 12th day after onset of disease, the vicinity of the epiphyseal line of the middle phalanx became erosive. At this point, from literature search and pediatric consultation, we got a diagnosis of Microgeodic disease. The antibiotic was discontinued. Pain was relieved 2.5 weeks after onset. At 4 weeks after onset, the middle phalanx fractured and fixed with the splint. Bone fusion was somewhat late. There was no deformation healing, but the epiphyseal line of middle phalanx and distal phalanx closed. At 7 months after onset, the difference in bone length between bilateral middle phalanges was 2 mm. The finger healed without dysfunction. “Microgeodic” is a sort of nodule that is hollow inside. Redness and swelling of fingers and toes like frostbite. It is accompanied by mild pain and itching. Predilection age is elementary school age (6 - 12 years old). It is mainly in the middle phalanx. A bone resorption image is recognized in the X-ray image. The cause is unknown, it is thought to be a transient bone circulation disorder. Prognosis is usually good, it will heal spontaneously in about 6 months. In this case, owing to attaching a diagnosis at a relatively early stage, appropriate treatment could be done. Microgeodic disease was reported 24 papers in PubMed. Since the arterial arch of the hand is predominant on the ulnar side, it seems that this disease is many in the index finger.

Markus Pääkkönen 1, Max Mann 2, Wiebke Hülsemann 2

1 Turku University Hospital and the University of Turku, Turku, Finland; 2 Catholic Children's Hospital Wilhelmstift, Hamburg, Germany

Introduction Several classification schemes exist for congenital anomalies (e.g. Oberg-Manske-Tonkin [OMT]-classification), but none of these describe involvement proximal from the wrist other than radio-ulnar synostosis. One case of longitudinal cleavage of the upper extremity has been described in the literature. Materials and methods An otherwise healthy 8-month-old infant presented with congenital split right forearm. Results Starting from the elbow joint, the forearm is divided into a superior radial forearm with a thumb and an index finger and an inferior ulnar forearm with two fingers. X-rays showed a radius and two metacarpals in the radial forearm and a hypoplastic ulna and a single metacarpal supporting two digits in the shorter ulnar forearm. The elbow joint of the radial part had an active and passive extension lag of 60 and 50 degrees, respectively, and an active and passive flexion of 100 and 120 degrees, respectively. An ulnohumeral synostosis was present and the ulnar forearm showed no motion. Conclusions This is the first reported case of congenital forearm. A possible suggested ethiologic theory would be an error of limb bud specification in the 4th or 5th week of gestation. It has been suggested that the timing of an error in limb bud specification would determine the extent of duplication. An early insult would lead to a more proximal division of the upper limb. We suggest that the case is a forearm cleavage - less severe than a total of upper extremity cleavage, but more severe as a conventional cleft hand. We suggest that a new category – cleft forearm complex – be added to the OMT –classification.

Xuyang Song, Alexandria L. Case, Rory Carrol, Joshua M. Abzug

University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: Emergency room transfers to a higher level of care are a vital component of modern healthcare, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that upper extremity orthopaedic transfers to a higher level of care facility are frequently unnecessary. Furthermore, these transfers have been shown to be higher during “off-hours” and weekends, and frequently involve patients who have unfavorable insurance status. The purpose of this study was to assess the appropriateness of pediatric orthopedic transfers to a tertiary care center and the factors surrounding them. Methods: All pediatric upper extremity orthopaedic transfers to our pediatric emergency department were evaluated over a four year period. A retrospective review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the emergency department. Results: One hundred twenty eight pediatric orthopaedic emergency room transfers were evaluated, of which 98% of them involved an acute fracture. 25% (32/128) of the transfers occurred on the weekend, with over half (67%) of these transfers being initiated between 6PM and 6AM. Approximately half (48%) of the transfers involved patients with Medicaid. 58% (74/128) of cases required a procedure in the operating room and 30% (39/128) had a closed reduction performed in the emergency department. Conscious sedation was provided in the emergency department for 31% (40/128) of patients. Only 9% (12/128) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the emergency department. Conclusions: The majority of pediatric upper extremity orthopaedic transfers are warranted as they require operative intervention, a closed reduction maneuver, or conscious sedation in the emergency department. Pediatric upper extremity orthopaedic transfers do not seem to be influenced by the day of the week. Similar trends to those seen in adult upper extremity orthopaedic transfers are present regarding off hour presentations and high percentages of less desirable insurance statuses.

Charles Blevins 1, Karan Dua 2, Joshua M. Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objective: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping, which can be inefficient and wasteful of materials. The semi-sterile technique has been shown to have no difference in infection or complication rates when utilized for pediatric supracondylar humerus fractures. Therefore, the authors hypothesize the semi-sterile technique can be utilized for CRPP procedures of all pediatric upper extremity fractures. Methods: A retrospective review was conducted over a five-year period to identify all pediatric patients who underwent CRPP of an upper extremity fracture. During this period, there was a gradual transition from utilizing the full preparation and drape technique to the semi-sterile technique. Factors assessed included demographics, fracture type and location, and length of pin fixation. Qualities of intraoperative care were assessed including average length of surgery, room set up time, and room cleaning time. Additionally, parameters of postoperative care were recorded including average length of follow-up and complication rates. Simple statistics and unpaired t-tests were performed. Results: Two hundred twenty four patient records were reviewed including 162 in the semi-sterile group and 62 in the full preparation group. The average length of surgery was 32 minutes (range 11-110) in the full preparation group compared to 26 minutes (range 7-69) in the semi-sterile group (p=.007). The average room setup time in the full preparation group was 20.1 minutes compared to 18.4 minutes in the semi-sterile group. Furthermore, the average operating room cleaning time in the full preparation group was 18.8 minutes compared to 16.8 minutes in the semi-sterile group. When assessing the setup time, procedure time, and clean up times together, the combined average times were 71.1 minutes in the full preparation group and 61.3 minutes in the semi-sterile group, for a difference of 9.8 minutes. Two complications occurred in the full preparation group including one pin tract infection and one physeal arrest. Conclusions: The semi-sterile technique is a safe and cost effective alternative that should be used when performing CRPP of all pediatric upper extremity fractures. The full preparation technique increases operating room time and medical waste, and therefore should not be utilized when performing CRPP procedures.

Stefanie Zaner 1, Karan Dua 2, Nathan N O'Hara 1, Alexandria L Case 1, Joshua M Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objective: Phalangeal neck fractures are a common orthopedic injury seen predominantly in the pediatric population. The indications for operative treatment are currently evolving. The purpose of this study was to determine the variation among orthopedic surgeons in their practice habits when treating phalangeal neck fractures. Methods: Twenty-five pediatric orthopedic surgeons reviewed sets of posteroanterior (PA), oblique, and lateral finger radiographs of children less than 17 years of age. In each clinical vignette, the age and gender of the patient was included. Surgeons were provided with 12 clinical vignettes and were queried if they would; (1) treat the fracture with immobilization or intervention? (2) if operative intervention was chosen, would a CRPP or ORIF be performed? (3) and when the next follow-up visit would be if the fracture was nonoperatively treated. Additionally, surgeons were asked to complete a demographic questionnaire detailing their training and personal background. The analysis was completed using a mixed effect model with the respondent as the random effect. Results: This study found that for each advancing year of age, the surgeons are 13.8% more likely to treat the fracture surgically which was determined to be a linear relationship (P < 0.0001). Additional results showed that females were 38% more likely to be treated surgically (P < 0.0006). There is a trend that indicates female surgeons are more likely to operate than their male counterparts and that surgeons were less likely to operate if they worked in a dedicated children’s hospital. Conclusions: These is no consensus or standardization for treatment of phalangeal neck fractures in the pediatric population. Age and gender are the primary patient characteristics in determining if a phalangeal neck fracture is surgically treated. In order to provide the best outcomes with the least patient morbidity, more standardized treatment algorithms are needed.

Thomas Chang 1, Karan Dua 2, Alexandria L. Case 1, Nathan N O'Hara 1, Joshua M. Abzug 1

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 SUNY Downstate Medical Center, Brooklyn, New York, USA

Objectives: Fifth metacarpal neck fractures are common fractures affecting the pediatric population. However, no true standardization exists regarding their treatment. The purpose of this study was to determine if variation exists amongst orthopedic surgeons in treating pediatric fifth metacarpal neck fractures and determine the factors regarding this variation. Methods: Twenty-five sets of images of pediatric fifth metacarpal neck fractures with posteroanterior (PA), oblique, and lateral views were identified. Fracture angulation measurements were made for the lateral and oblique views, with half of the images unmarked to assess the effect of marked angulation on treatment decision. Five images were duplicated to assess variability of a surgeon’s treatment choice. Each set of images was accompanied by the patient’s sex and age. The images, along with a brief demographic questionnaire, were evaluated by 25 orthopedic surgeons. A mixed effect model with the respondent as the random effect to determine which patient/radiographic factors were most associated with a decision to operate was performed. Results: Age and angulation were the factors found to be significantly associated with a surgeon’s decision to operate. Patient sex, cast status, and whether or not an image was marked had no association with a surgeon’s decision to operate. Greater than 50% of surgeons would choose surgical intervention if the degrees of angulation in the PA and lateral views were ≥55° and ≥47°, respectively. Age alone was also identified as an independent factor for choosing operative intervention, with 42% of surgeon’s operating on patients aged 17 years. Conclusions: Treatment of fifth metacarpal neck fractures in the pediatric population is not standardized. Worsening angulation above approximately 50 degrees and increasing age (adolescence) appear to be the most important factors when deciding to operate. Improved treatment algorithms based on outcomes studies are needed to determine the optimal treatment.

Seok Woo Hong, Jihyeung Kim, Kee Jeong Bae, Hyun Sik Gong, Goo Hyun Baek

Department Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, Korea

Objective: The aim of this study was to verify the remodeling patterns of proximal phalangeal head after conservative and/or surgical intervention in patients with camptodactyly using radiograph. Methods: A total of 45 subjects and 21 patietns (Male 13, Female 8, mean age 15.11 ± 14.22 months) with camptodactyly were selected. The regular stretching exercises were performed in 31 subjects and the others got surgical correction. Flexor digitorum superficialis (FDS) tenotomy and volar plate release were done through surgical procedure. The two radiographic parameters were proposed for confirming the radiographic remodeling of camptodactyly called Beak triangle ratio and Beak angle. Both parameters were measured using finger true lateral radiographs at initial visit. The same procedures for measurement on finger were done two years after intervention. The extent of proximal interphalangeal joint (PIPJ) contracture on passive functioning was evaluated to determine clinical outcomes from conservative and surgical intervention. Results: The mean Beak triangle ratio before intervention was mean 0.327 ± 0.052 and mean 0.367 ± 0.053 after intervention (P < 0.001). Also the mean Beak angle before intervention was mean 56.05 ± 5.19 degree and mean 50.31 ± 6.21 degree after intervention (P < 0.001). The extent of PIPJ contracture also showed significant improvement (P < 0.001). Conclusions: Remodeling of proximal phalangeal head with camptodactyly after conservative and/or surgical intervention were confirmed on radiograph.

Wenhai Sun, Yachao Zhou, Shengbo Zhou, Yongkang Jiang, Bin Wang

Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiaotong University School of Medicine, China

Purpose To evaluate the outcomes and complications in a series of children with clinodactyly treated with our novel opening wedge osteotomy of the abnormal Delta phalanx. Methods We performed a retrospective review of 8 children with clinodactyly treated at our institution with a novel opening wedge osteotomy of the abnormal delta phalanx between 2007 and 2017. This κ shaped osteotomy included resection of the abnormal longitudinal physis and double opening wedge osteotomy. Preoperative and postoperative clinical angle, radiographic angle, digital range of motion, and pain were compared and complications were recorded. Results 10 digits in 8 patients were included in the study. All had greater than 28 degrees of preoperative clinical angulation (mean, 40 degrees). Mean age at time of surgery was 6 years; mean duration of follow-up was 24 months (range, 12-48 mo). All digits had significant improvement (mean, 34 degrees) in clinical and radiographic angles after surgery. This improvement was maintained at final follow-up in all digits. 5 patients had pain preoperatively and no patient had pain postoperatively. One digit had a recurrent deformity at final follow-up and 3 digits developed stiffness at the interphalangeal joint. Conclusions Our novel opening wedge osteotomy is an effective treatment for angulation in children with severe clinodactyly although the risk of interphalangeal joint stiffness still exists.

Shringari Mahadevaiah Venugopal, Bhaskaranand Kumar, Gudaru Jagadesh

B.I.R.R.D. (T) Hospital, T.T.D.,Tirupati, Andhra Pradesh, India

A Descriptive Study on Radial Club Hand Introduction: Radial club hand is a rare congenital anomaly of hand involving preaxial border of hand with incidence of 1 in 30000 to 1 in 100000. It is associated with deformities in forearm, arm and several other systemic anomalies. Its severity ranges from mild hypoplasia of radius to complete absence of radius. In Indian context there were very less studies describing anomalies and this study aims at describing this anomaly. Materials and methods: This study was a descriptive study aimed at describing Radial club hand anomalies and its association with other systemic anomalies during March 2014 to March 2016 collected from outpatient department of Balaji institute of surgery research and rehabilitation for the disabled hospital, Tirupathi, Andhra Pradesh, India. Results: We reported a total of 62 cases of radial club hand among which 24 were bilateral and 38 were unilateral. Male to female ratio was 2.1:1 and no significant history of environmental or familial factors was reported. Type 4 Bayne radial deficiencies were most common and type 5 Blauth hypoplastic thumb was most common finding. All the finger deformities were more pronounced in index finger and were least seen in little finger. Other systemic anomalies recorded were absence of kidney (6.4%) and atrial septal defect (9.7%), Tibial hemimelia, Spina bifida, hemangioma. Conclusion: This study had recorded unilateral involvement of radial club hand to be more prevalent than bilateral. Association of systemic anomalies was less with bilateral radial club hand.

Eva Matoušková, Mária Kučerová, Petr Havránek

Departement of Pediatric Surgery and Traumatology, Thomayer Hospital, Prague, Czech Republic

Objective: Ten years ago in our department miniinvasive percutaneous osteotomy for malunited phalangeal fractures was developed by senior author. Osteotomy in former fracture line is performed by larger injection needle. Presentation of the method and patient cohort is the aim of the study. Method: Altogether 4722 children in period of 9 years (1/2009 – 11/2017) with acute finger fractures were treated in our department, 252 of them operated on and in 17 patients osteotomy was performed. The osteotomy can be performed only if 1.the original fracture line is still visible on x-rays, 2.callus is presented. Under x-ray control the injection needle is inserted into callus which is step-by-step disrupted. Instead of a fine needle a small elevator from 2 – 3 mm incision can be used. After releasing peripheral fragment is reduced and stabilized by percutaneous osteosynthesis from a separate entry. There are several possibilities of stabilization: intramedullar implant, screw or external fixator. Results: From 17 patients with malunited fracture in all the osteotomy by injection needle was performed, in 3 additional use of a smooth elevator was necessary. Supracondylar fractures were recorded in 10 children, unicondylar in 3, diaphyseal in 2 and intraarticular basal injuries in other 2 respectively. Reduced fragments were stabilized by pre-bended K-wire (“ESIN-like method”) in 11, by a mini-screw in 4, by external fixator in 2. Functional and cosmetic effect was very good. Conclusion: A method of miniinvasive osteotomy of malunited phalangeal finger fractures is presented. Especially in delicate pediatric hand skeleton it can be a beneficial method bringing better results than classic orthopedic procedures. Our above mentioned method is due to miniinvasive osteotomy procedure as well as stabilization maximally sparing soft tissues and can promise better cosmetic and functional outcome.

Tetsuro Onishi1, Takanobu Nishizuka1, Shintaro Oyama1, Tomonori Nakano1, Hisao Ishii1, Katsuyuki Iwatsuki1, Shigeru Kurimoto1, Michiro Yamamoto1, Masahiro Tatebe1, Hitoshi Hirata1

1Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction Dysplasia Epiphysealis Hemimelica (DEH) is a rare developmental disorder characterized by hemimelic epiphyseal overgrowth of cartilage involving one or multiple epiphysis. Histological examination shows the picture of a benign osteochondroma. Most cases of this rare condition are reported in the lower limbs, and occurrence of upper limbs is relatively rare. However, when occurring in the hand, even when the lesion is small, the functional impairment, such as the axial deviation and the restriction of range of motion can become severer than other parts due to the intra-articular lesion. We report six cases of osteochondroma at epiphysis (DEH) in the hand who underwent surgical treatment. METHOD In this retrospective study, six patients (five male and one female) with a diagnosis of DEH were evaluated, they underwent surgery from 2009 to 2017 at the author’s institution. Affected sites were three middle phalanx of middle finger, one proximal phalanx of thumb and ring finger and a third metacarpal bone. The average age at surgery was 9.3 years old and ranged from 1 to 23 years old. The average follow-up is 17.8 months, ranged from 6 months to 47 months. We evaluated the site of occurrence, deformity, chief complaint, surgical procedure and outcome. RESULTS Sites of occurrence were the radial aspect of the proximal phalangeal epiphysis of one thumb, the radial aspect of the middle phalangeal epiphysis of one middle finger, the ulnar aspects of the middle phalangeal epiphysis of two middle finger, the ulnar aspects of the proximal phalangeal epiphysis of one ring finger and one proximal part of third metacarpal bone. The angular deformities were localized at the proximal interphalangeal joint of a ring finger, and the distal interphalangeal joint of two middle fingers. (Angulation: 27°, 11°, 22°, respectively) The complaints at diagnosis were a swelling bony mass that was increasing in size (2 cases), restricted range of motion (3 cases), angular deformity (3 cases), and a pain (1 case). At surgery, osteocartilaginous tissue was excised in all patients, and pathological examination showed an osteochondroma covered with cartilage in all cases. At follow-up, restricted range of motion in affected joint improved in all cases. However angular deformity remains in two cases (angulation: 17°, 11°, respectively). And recurrence was seen in the case of third metacarpal bone, so we performed resection surgery again. CONCLUSION We reported 6 cases of DEH occurred in the hand. If DEH occurs in hand, masses cause incongruity of the joint surface, angular deformity and restricted range of motion of the affected joint. It is necessary to perform the sufficient tumor resection after accurate diagnosis at early stage. After excisional surgery, there are reports of arthritic changes and recurrence, so careful follow-up is necessary.

Marta Bertoli 2, Philip Henman 1, Sahan Rannan-Eliya 1, Julie Allen 1, Volker Straub 3, Bríd Crowley 1

1 Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; 2 Northern Genetics Service, Institute of Human Genetics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Central Parkway, Newcastle upon Tyne UK; 3 Institute of Genetic Medicine, MRC Centre for Neuromuscular Disease, Newcastle University, Newcastle upon Tyne, UK

Objective: Arthrogryposis is a descriptive term referring to multiple congenital contractures. More than 400 acquired and genetic diseases are labelled as arthrogryposis. Because of their rarity and complexity coordinated patient management is often lacking. Multidisciplinary clinics are the ideal setting to provide coordinated and comprehensive care to patients with special needs. These clinics are organized to bring together professionals from several disciplines, with the aim to provide patient centered, comprehensive clinical care, and reduce the burden of multiple medical appointments for the families. A team approach to care has been shown to be beneficial in developing a treatment plan maximizing cognitive, physical, and social development for the child. We report a 9 year experience of an interdisciplinary arthrogryposis clinic. Materials and Methods: Our interdisciplinary arthrogryposis clinic involves participation from paediatric orthopaedic surgery, hand/plastic surgery, clinical genetics, physiotherapists and orthotics. Representatives from a patient support group are available. Patients are referred from a variety of specialties, eg foetal medicine, paediatric neurology, orthopaedics, genetics. This clinic provides: diagnostic work-up, treatment of associated anomalies, overall care coordination of paediatric patients with arthrogryposis. Genetic diagnostic technologies have evolved, from single gene analysis, to gene panels for specific disease groups and exome or genome sequencing for more complex cases. These assist accurate clinical evaluation and increase the chance of providing a precise genetic diagnosis and correct genetic counselling. Results: In our cohort of 66 patients, 55% have a recognized diagnosis( half have amyoplasia). Other diagnoses include conditions presenting with arthrogryposis as their main feature (Freeman-Sheldon syndrome; Beals syndrome), cases where congenital contractures are described, but are not a typical sign of the condition ( DiGeorge syndrome; Ohdo syndrome) or can be part of an unexpected diagnosis for a patient referred for contractures of extremities (16p11.2 deletion syndrome). Conclusion: An interdisciplinary approach reduces the number of appointments, provides patients with arthrogryposis with more specific diagnoses, coordinated orthotic and surgical management and informed physiotherapy. Not only is patient care facilitated but a stimulating and collaborative environment is created for all the clinicians to learn from each other and from the patients’ experiences. In time, this helps build the expertise of the group, enabling it to provide more valuable services to the families. The relationships with the families are strengthened, as is adherence to treatment programmes. Families are pleased to attend a single multidisciplinary clinic rather than be followed up at a number of separate, individual clinics, and they are reassured by the combined expertise available.

Alena Schmoranzova 1,2,3, Radek Kebrle 1, Tomas Hellmuth 1, Stepanka Docekalova 3, Eva Leamerova 2

1 Hand and Plastic Institute, Vysoke nad Jizerou, Czech Republic; 2 Department of Plastic Surgery, Faculty of Medicine, Charles University, Prague, Czech Republic; 3 Department of Plastic Surgery, Faculty of Medicine, Charles University, Hradec Kralove, Czech Republic

o Objective: Hypoplasia of the thumb occurs within a spectrum of hypoplasia along the radial side of the entire upper extremity It is a rare congenital deformity affecting 1 in 100,000 live births. Congenital absence of the thumb, resulting in a loss of its prehensile ability, significantly affects hand function. To function correctly, the thumb must be positioned so that it can oppose the adjacent medial fingers and grasp objects securely from an antiposed (abducted, slightly extended, and pronated) position. o Methods: We followed a groupe of patients in the period 2008-2017 29 children , 41 hands ,men 18x , women 11x 12 children have comorbidity radial club hand Most of them have had floating thumb problem o Results: At the age of four, 29 children came back , we rated parent´s satisfaction and child's hand function using simplified Percival score The result is good in general . The results, which were not entirely right, were evaluated and corrected o Conclusions:. Pollicization is complicated procedure that may have some pitfalls. Additional surgery may improve the function of the thumb The work is documented by video showing some results

Abbas Peymani 1,2,3, Anna Rose Johnson 2, Samandar Dowlatshahi 2, Iwan Dobbe 3, Joseph Upton 4, Geert Streekstra 3, Simon Strackee 1

1 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands; 2 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 3 Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands; 4 Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

Objective. Madelung deformity is a congenital wrist condition characterized by volar subluxation of the wrist and caused by premature growth arrest of the distal radius. Partly due to disease rarity, ambiguity remains with respect to criteria for disease classification and optimal treatment strategy. The purpose of this study was to evaluate the current literature concerning Madelung deformity to determine criteria used in clinical examination, surgical treatment options and operative outcomes. Methods. A comprehensive review of published literature from inception to 2017 was performed to identify all studies that described surgical intervention for Madelung deformity patients, adhering to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Studies eligible for inclusion described a corrective surgery for Madelung deformity and reported post-operative outcomes. Studies were evaluated by level of evidence and a novel self-developed quality assessment tool. Results. Twenty-five studies met our criteria for inclusion in this systematic review. All studies assessed pain, range of motion and aesthetic deformity, with eight studies also assessing grip strength. The primary indication for surgery was the presence of wrist pain. Radiologic criteria were used inconsistently and surgical interventions varied. All studies reported post-operative pain reduction in a majority of patients and nearly all studies reported an improved range of motion. The majority of studies reported complications with revision surgeries occurring in 40% of studies. Conclusions. Despite nearly 200 years of experience with Madelung deformity, there remains a paucity of information regarding the surgical decision making process due to a lack of uniformity throughout case series. Generally, various surgical procedures seem to be effective in regards to post-operative pain reduction and increase in range of motion. However, outcomes are reported in a non-uniform manner, prohibiting pooling of studies and comparison of surgical procedures. We propose multiple changes to serve as the basis for new clinical guidelines, increasing the quality of evidence in future studies to compensate for small patient sample sizes.

Karina Liv Hansen, Hans Tromborg

Hand/Orthopaedic Department, Odense, Denmark

Objective: In Madelungs deformity the Distal Radioulnar joint (DRUJ) is often involved in the pain pathogenesis especially in moderately to severely affected patients. The DRUJ is of is of great importance to the function of the (Shaaban 2004). We studied the functional outcome one year after Constraint Distal Radioulnar Joint Replacement in patients with moderate to severely affected DRUJ (ulnar tilt 37 degrees (from 32 to 60) and lunate subsidence 2mm (-2 to 5)). Methods: We included patients (n=9) who had an DRUJ replacement a.m. Aptis in the cohort. Disability of Arm Shoulder and Hand, grip strength, and EQ-5D were compared before and one Year after surgery. Statistics were performed with paired t-test without correction for repeated measurements. Results: Age of patients: 44(18) (Years (SD)). Patients had a relatively high DASH score before surgery of 50(24) this is relatively high compared to normal 10(14); DASH score dropped significantly to 24(8) this is an improvement of 26(12) (p<<0.01). Grip strength of the affected arm improved 13 (11) kg to 26 (10)kg (p<<0.01). EQ-5D was not significantly improved. One patient (included in the results) had a revision after 2 months and a new alloplasty before one year. Conclusions: Aptis DRUJ joint replacement improve Madelung patients upper extremity function (DASH) one year after surgery in a cohort of patients with moderately to severely affected DRUJ.

Sang Eun Park, Seok Jae Park, Myung Sup Go

Daejeon St. Mary's Hospital, Daejeon, South Korea

Objective : To report the usefulness and radiological and clinical outcome of intrafocal pinning for the severely displaced pediatric distal radius fracture. Methods : A retrospective review was performed for the patients treated with Kapandji intrafocal pinning for their distal radius fractures. At the final follow up, radiologic and clinical outcomes were evaluated. Results : This study included 15 pediatric distal radius fractures. The average age was 9 years (range 8-11years). The inclusion criteria included no physeal involvement, open physis and no cortical contact on initial pre-reduction plain X-ray. The average location of distal radius fracture was 3.3cm proximal to joint line (range, 2.5- 3.8cm). 12 of 15 cases had concomitant distal ulnar fractures located slightly proximal to distal radius fracture. In all cases, post-reduction X-ray showed less than 50% of cortical contact. 1 or 2 0.062 or 0.045 inch K-wire was inserted from dorsal to volar direction through fracture site. Radial to ulnar insertion was performed in cases with need to restore radial inclination. No ulnar fixation was made in all cases. Short arm splint was applied for 4 weeks and K-wires were removed at postoperative 5 weeks and protective physiotherapy was initiated. Postoperative X-ray showed more than 90% of cortical contact on average. Average follow-up period was 12.5 months (range, 5 to 27 months). At the final follow up, any type of malunion and physeal arrest occurred. The final range of motion was equal to contralateral side. In 4 cases, superficial pin-related complication occurred but resolved with K-wire removal. Conclusions: Based on our experience, Kapandji intrafocal pinning is a simple and reliable method for the treatment of severely displaced pediatric distal radius fractures. Especially this method is very useful for the fracture at the metaphysio-diaphyseal junction Key words ; Dstal radius fracture, pediatric, Intrafocal pinning

María L Manzanares Retamosa, Pedro Bolado Gutiérrez, Luis Landín Jarillo, Aleksandar Lovic Jazbec

Hospital Universitario La Paz, Madrid, Spain

Objective: An unusual form of congenital hand deformity is described. It consists of radial club hand deformity with associated anomalies in shoulder and scapula (Grade 5 according Goldfarb). First visit as two year old girl with the bizarre “hook like” deformity of the acromiovlavicular complex, shoulder dysplasia with bifid scapula, lack of elbow flexión together with radial club hand grade IV and aplasia of the thumb. When she appeared for the first time she was already operated in another hospital ( centralization Klug&Baine and pollicization Buck Gramcko) with rather fair result ( recurrence of the wrist deviation and stiff retropositioned thumb). Methods: Two mayor surgeries are carried out: - Double osteotomy of the clavicle and spine of scapula to correct the position of the shoulder. Bipolar transposition of the latissimus dorsi muscle to restore elbow flexion - Radialization of the wrist and osteotomy of the first MC. The objective of the second surgery was strongly conditioned by the first surgery. Results and conclusions:The patient had a favorable evolution ( 2002-2017).She is able to bend the elbow 90° and to reach the mouth.The morphology of the shoulder is still deficient although the function and stability is satisfactory. Volume augmentation using free contralateral latissimus with skin island was recommended to improve the symmetry.

Lisa Ng, Susan Stevenson, Brid Crowley

Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Introduction Constriction ring syndrome (CRS) is a congenital condition with an incidence of 1:2000 to 1:15,000 live births. Upper limbs and distal extremities are most frequently affected. It can present with complex deformities ranging from constriction grooves in skin to complete amputation. Patterson classified these deformities into simple ring constrictions, constrictions with distal deformity (with or without lymphoedema), constrictions accompanied by fusion of distal parts and uterine amputation. We report our experience in managing this complex condition. Methods A retrospective review of children with CRS of the upper limbs referred to a specialist centre was performed. Patient demographics, anatomy of constriction, Patterson classification, management and outcome were recorded. Results 23 patients with upper limb CRS were studied. (M:F ratio 11:12). 5 (22%) were born prematurely, 5 (22%) had other congenital anomalies and 9 (39%) had lower limb involvement also. 11 (48%) patients had bilateral hand involvement. Deformities observed ranged from distal lymphedema of the digits, skin constriction (and deeper), acrosyndactyly, amputations at multiple levels to complex combinations of all these. Surgical Intervention:18 / 23 underwent surgery, with 12 requiring multiple/staged procedures. Procedures included digital separation, release of acrosyndactyly, web deepening, stabilisation of distal lymphoedematous digit, excision of constriction rings and debulking of lymphoedema. The mean age at surgery in our cohort was 18.7 months of age. Optimization of skin condition at every stage is advocated. 2 cases specifically required urgent surgical procedures: i) constriction ring excision at mid humerus level, longitudinal fasciotomies and neurolysis of median and ulnar nerves in a premature infant with high ulnar and median nerve palsy; ii) excision of distal lymphoedema of the hand. Conclusion Specific aspects of our treatment approach include optimization of skin condition at each stage of treatment and excision of constriction rings on limbs without z-plasty using longitudinal fasciotomies. Not all patients require surgery but consider urgent surgical intervention if there is evidence of nerve or vascular compromise. The Patterson classification is a helpful guide, but in reality there is often a complex combination of deformities in multiple digits at multiple levels. Appropriately timed staged surgical intervention maximizes function in these complex patients. Functional and aesthetic improvement was observed in most patients.

Lisa Ng, Susan Stevenson, Brid Crowley

Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Introduction Hereditary multiple exostosis (HME) is a rare, autosomal dominant condition characterised by the formation of multiple osteochondromas in children, particularly around areas of active bone formation. The tibia, femur, pelvis and proximal humerus are commonly involved. 0.5%-5% may undergo malignant transformation to chondrosarcoma. Lesions can cause pain, nerve compression, short stature, vascular compromise and limb length discrepancy. Methods Hereditary multiple exostosis has an estimated incidence of 1: 50,000. HME affects the long bones predominantly, with hand involvement reported in 30-79% of patients. Few case series are reported in the literature. Here we report the case of a fifteen-year old patient with known HME who presented with a symptomatic exostosis of right ring finger proximal phalanx, restricting finger flexion and causing painful triggering. Primary resection was performed. Results Histology demonstrated an osteochondroma with no evidence of malignancy. At operation an exostosis was identified, invading the flexor sheath, distorting flexor tendons at the level of Camper's chiasma. Operative photographs display the findings. Follow-up at two and four months post-op demonstrated restoration of normal finger flexion. There was no recurrence at five-year review. Conclusion HME in the hand is rarely reported in the literature but may cause significant functional problems. Excision of lesions may be indicated to relieve symptoms and restore function. Regular follow-up is recommended for detection of early malignancy and recurrent lesions.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

We observed an unusual type of volar Barton fracture in pediatric age and performed open reduction and internal fixation of the fragment, using the buttress plate in consecutive children. We report the radiological and clinical outcomes after follow-up for least 3 years. From March 2008 to September 2014, 9 consecutive children were treated by buttress plating. Their mean age at the time of injury was 14.1 years. All of the fractures were metaphyseal fractures in the coronal plane and typical Salter-Harris II fractures in the sagittal plane. After accurate reduction of the fragment, a cortical screw was inserted in the proximal area until the maximum compressive force against the fragment was obtained. Then, one or two locking screws were added adjacent to the initial cortical screw. No screw was fixed in the fragment. All evaluations were done at least 3 years postoperatively with a mean follow-up of 48.8 months. At final follow-up, the radial inclinations, volar tiltings, and ulnar variances were 23.2 ± 1.78° (98.7% of contralateral side), 9.4 ± 2.12° (98.4% of contralateral side), and –1.56 ± 0.88 mm (93% of contralateral side), respectively. All radiological parameters of the distal radius were not significantly different from the contralateral values. The flexion–extension arc was 140.56 ± 5.27°, the pronation–supination arc was 165.00 ± 8.29°. The grip strength was 26.67 ± 5.56 kg. All clinical outcomes except the flexion–extension arc were similar to those of the normal side, with statistical significance. A volar Barton type injury can occur in pediatric age involving the physis, and the buttress plating that is used in adults is also a useful treatment method. However, there is little information on this injury and it was difficult to compare treatment outcomes to other methods. Because of the rarity of the injury, a larger, multi-center. prospective comparative study is required to further explore appropriate treatment options, long-term outcomes, and complications.

Johannes Rois, Werner Girsch

Trauma Center Vienna Meidling, Vienna, Austria

Fractures of the lateral humeral condyle in children are the second most pediatric elbow fractures. The treatment for displaced fractures is reduction and stabilisation. Nonunion of a pediatric radial humeral condyle fracture can lead to pain, instability and progressive cubitus valgus with ulnar nerve neuropathy. In this case report we present a surgical technique for providing union of a long standing nonunion and correction of valgus deformity. A girl, at the age of 5 years, sustained a fracture of the lateral humeral condyl after a fall from a climbing scaffold. The fracture was treated conservatively. With the age of 15 years she was referred to our institution because of pain and elbow deformity. The clinical examination revealed tenderness over the lateral humeral condyl, normal neurovascular examination and severe valgus deformity. Elbow motion was 0°-130°, supination 80° and pronation 90°. The radiographs showed a nonunion of the lateral humeral condyle fracture with dislocation and deformity of the trochlea and capitellum. We decided to perform a two-stage surgical procedure. In the first step treatment of the nonunion and in the second step correction of the valgus deformity. The patient underwent free vascularized iliac crest bone-grafting (to minimize the risk of necrosis) to the lateral humeral condyle fracture nonunion with microvascular anastomosis and screw fixation of the fragment. After bony union we performed the planned corrective humeral osteotomy and plating for correction of the valgus deformity. The operations did very well, there were no postoperative complications. Together with plate removal 20 months postoperative, anterior transposition of the ulnar nerve was performed. At the last follow up radiographs revealed a healed lateral humeral condyle and lateral column and restored elbow axis. Elbow motion was 15° to 130°, supination 85° and pronation 85°. In this case report we present a successful technique for the treatment of a long-standing pediatric lateral humeral condyle nonunion. Although further effort is required, when faced with the outcome, the decision for a two-stage procedure with the use of a free vascularized bone-graft was the right one.

Sarah Tolerton 1, Belinda Smith 1, David Stewart 1

1 Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, The Children's Hospital at Westmead, University of Sydney, Sydney, Australia

Title: Patient and Parent Reported Outcomes Following Pollicisation Objective: Pollicisation of the index finger is an established procedure for treatment of Type IIIB to V congenital thumb hypoplasia. Comparing results is challenging due to disparate methods, timing and conduct of assessment. While functional performance following pollicisation is well reported in the literature, we aim to provide further insight into the patient and parent satisfaction with functional and aesthetic outcomes of surgery. Methods: Ninety pollicisations in 79 patients were performed by a single surgeon between 1989 and 2012. Questionnaires were distributed to patients and their families including the Patient/Observer Scar Assessment Scale, Abil Hands Kids, Child Occupational Self Assessment (COSA), PedsQL (8-12), Peds QL (13-18), QuickDash and SF36. Results: We report the subjective assessments of functional and aesthetic outcome following pollicisation. The various additional outcome measures and their interpretation in the setting of pollicisation surgery will be discussed. Conclusion: Despite recognised functional limitations following pollicisation surgery, the majority of patients and their parents are satisfied with the aesthetic and functional outcomes. The development of consensus outcome measures including patient and parent satisfaction is necessary for ongoing research in congenital hand surgery.

Hazem Alfeky, Paul McArthur

Plastic Surgery department, Alder Hey Children's Hospital, Liverpool, UK.

Acrocephalosyndactyly or Apert’s hand is a rare syndrome occurring once in every 45000 live births. It has been well described and classified by Upton into 3 types based on the configuration of the first web space with type 3 as the most severe form. The challenge in Acrocephalosyndactyly is often more than a first web space issue. The pattern of the proximal and distal synostosis is one of the key factors that determines the management and outcome. 42 Apert’s hands have been assessed and managed within MDT setting. All hand procedures were performed by a single surgeon over a period of 10 years. A new proposed classification system is presented. Follow up period ranged between 4 and 13 years. Outcomes were assessed by the hand therapy team as well as patient and family satisfaction. The difficulty in operating on Apert’s hand, and consequently the predicted outcomes, relates more to the degree and level of the synostosis, status of MCPs and absence or coalescence of the osseous elements of the hand more than the status of the first web space. A new classification system, based on clinical and the x ray findings, is proposed to help planning and predicting the outcomes of the surgery in Apert’s hand, in particular a realistic prediction of number of digits achievable.

Ahmet Savran 1, Kubilay Erol 2, Levent Kucuk 2, Erhan Coskunol 2

1 Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey; 2 Ege University Medical Faculty Hospital, Izmir, Turkey

Hemophilia is one of the extrinsic causes of Compartment Syndrome. A patient of 6 months of age is administered our hospital with swelling and diminished circulation at left arm, after intra venous blood sampling for history of bruising and ecchymosis at different location of his body. Without any previous diagnosis for diathesis of hemorrhage, hemophilia is granted presenting as Compartment Syndrome. And Emergent fasciotomy is done, replacement of Factor VIII is started immediately. A Hand Surgeon must be alert for Compartment Syndrome in Hemophilia patients, especially in pediatric age group with limited anamnesis and orientation. And Preoperative management of bleeding diathesis must be done Co-operatively with Pediatrician.

Contractures (5 abstracts)

A. F. Klenner 1, K. Klenner 2

1 Clinics St. Barbara, Hamm, Germany 2 Mariannen Hospital, Werl, Germany

Introduction: If severe Dupuytren´s disease is present, complications in operative treatment are increasing in relation to the level of contracture. Other pathological conditions exist, with a similar presentation of contracture of fingers. Preoperative treatment for all those conditions, aiming to minimize extension deficit is desirable. Aim/Method: In this concern, treatment is divided in invasive and non-invasive methods. Invasive treatment can be associated with severe complications and needs good compliance. Only few technical devices and solutions are described in the literature, most of them exist only at one hospital and are not available for the European or global market. Hence there was developed a non-invasive, pneumatic splint (PNEUMANUS), which addresses severe contractures of the fingers and is obtainable for everybody. Conclusion: PNEUMANUS is a new device, available on the market especially for the preop treatment of Dupuytren´s and other similar conditions described, avoiding the disadvantages of invasive solutions. It's simple to use and adaptive to even severe contractures. The acting forces can be fine-tuned at any time and the splint therefore fulfills the need to act smoothly on the tissues at cellular level. It provides patients with a magnitude of comfort and is highly accepted.

Kazuki Sato, Takuji Iwamoto, Noboru Matsumura, Satoshi Oki, Taku Suzuki, Akiko Torii, Tsuyoshi Amemiya, Ruriko Iigaya,Masaya Nakamura, Morio Matsumoto

Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

Introduction: Costal osteochondral grafting is a technique to achieve anatomical and biological repair for articular defects. Although some small series of clinical application of this procedure for finger joint injury or articular cartilage defect with short-term follow-up have been reported, the longer time outcome is still unknown. The purpose of this study is to clarify the mid to long-term clinical outcomes of costal osteochondral autograft for finger joint ankylosis. Technique and Methods: Twenty-three finger joints (3 MCP joints and 20 PIP joints) in 23 patients with bony ankylosis after trauma or infection were treated with costal osteochondral autograft with at least 5-year follow up. There were 19 males and 4 females, ranging in age from 18 to 55 (mean, 33). Ample exposure of the joint was obtained through a dorsal approach. The periosteum was elevated in concurrent with the bilateral collateral ligaments and the volar plate. After resection of the joint the phalanx (metacarpus) were step-cut for the graft floor. Two pieces of the osteochondral graft were harvested from the 5th and 6th ribs through an ipsilateral transverse sub-mammary incision. The harvested grafts were then shaped to form a matching pair of articular surfaces of the MCP or PIP joint with adequate contour. The grafts were step-cut and stabilized using low profile screws. The finger was immobilized with a splint for a week, followed by range of motion exercises. Clinical outcomes including range of finger motion, the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder and Hand questionnaire (DASH-JSSH), donor-site disturbances, and radiographic outcomes were evaluated after a mean follow-up of 75 months (range, 60-138 months). Results: Radiographs demonstrated complete union of the bony part of the graft to the floor in all of the patients by 8 weeks after surgery. Donor-site pain persisted only 3-4 days after surgery, and raised no particular problems even during sporting activity. One patient injured his operated finger while playing rugby football at 2 years after surgery and diagnosed with fracture of the transplanted PIP joint. He needed additional costal osteochondral grafting. Other additional surgeries were collateral ligament reconstruction in 4, corrective osteotomy of the phalanx in 2, and tenolysis in 1. Significant improvement in finger active extension/flexion was seen from a preoperative average of -24°/26° (arc: 2°) to -12°/75° (arc: 63°) at 1 year postoperatively (p < 0.001) and to -13°/73° (arc: 60°) at the time of final follow-up (p < 0.001). Mean preoperative DASH-JSSH score was initially 23.6, improving to 6.6 at 1 year postoperatively, and to 5.2 by final follow-up. Improvements in status at 1 year postoperatively and at the time of final follow-up were significant compared with preoperatively (p < 0.001 respectively). Conclusions: Costal osteochondral autograft for finger joint ankylosis or severe articular cartilage injury demonstrated anatomical and biological reconstruction and provided stable improvement of clinical outcome with a mean follow-up of 75 months.

Jiro Namba, Michio Okamoto, Koji Yamamoto

Toyonaka Municipal Hospital, Toyonaka, Japan

Introduction Generally, PIP flexion contracture associated with finger stenosing tendovaginitis is resolved by incision of A1 pulley which is a major obstruction site. In spite of the favorable result of A1 pulley release, sometimes certain degree of contracture did not go away due to remaining sliding disorder at other sites except A1. We reviewed whether excision of total or half slip of the flexor digitorum superficialis (FDS) tendon was practicable for primary or revision cases with refractory flexion contracture. Methods We identified 12 fingers in 12 patients who underwent FDS resection. The average age was 76 years old (62-91). 2 fingers had one prior A1 pulley release and 1 had 2 previous surgeries. Diabetes were involved in 4. The long finger was affected in 11 and index finger in one. The intraoperative findings on tendons were recorded. Clinical outcome was reviewed including ROM, grip strength, Visual analogue score (VAS). Results The mean preoperative PIP contracture was 28 degrees. The ulnar half slip of the FDS was excised in 4, both slips in 8 fingers. Intraoperative full extension was achieved in 11 cases, and no other soft tissue release like capsule and volar plate was conducted. All FDS tendons had longitudinal internal lesions and enlargement. The postoperative PIP contracture was 7 degrees, full extension was achieved in 7 fingers at a mean of 18 months postoperative. No case of swanneck deformity was recognized. VAS was 14 points, and grip strength was 86% against contralateral side. Total active arc motion was 241 degrees. Between half slip and total resection, total arc was significantly different with 219 / 252 degrees, as opposed to insignificance among the other variables. Conclusion Resection of hemi or total slip of FDS is an effective method for treatment of residual PIP contracture. In consideration of total arc motion in our cases at final follow up, total resection might provide wider space for flexor digitorum profundus to glide than half slip .

Bertil Vinnars

Dept of Orthopedic and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden

Objective To provide good access in contracture release of the elbow by using a skin flap at the volar side of the joint Method Contracture of the elbow joint is common after brain injury second to trauma or stroke. In an observational study by Kwah et al 35 % of patients developed a moderate to severe contracture 6 month after stroke. According to Ada et al the major independent contributors to contracture were spasticity for the first four months after stroke. Spasticity can cause contracture after stroke and will affect the biceps and brachilis muscles with shortening and contractue of muscle fibers. In standard orthopaedic and hand surgical textbooks release of the contracture is performed by dividing lacertus fibrosus, lengthening of the biceps tendon and cutting the aponeurosis of the brachialis muscle. The recommended skin incision is a transverse or lacy S. We have in several cases experienced that after release of the contracture and straightening of the arm the skin deficit will limit the extension of the joint. In a consecutive case of 5 individuals we have used a trasposition flap from the brachioradialis area covering the area of skin defect. Result In all patients skin healing has been uneventfull with good healing. The method provides good access to the area. Straightening of the joint can be performed to full extension with no limitation of skin defect. The flap can be designed as a pure skin flap or a fasciocutaneous flap. Conclusion A transposition flap on the volar side of the elbow joint provides good access to the joint in releasing elbow contracture second to brain injury. Ref: Ada L, O'Dwyer N, O'Neill E., Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: an observational study. Disabil Rehabil. 2006 Jul 15-30;28(13-14):891-7. Li Khim Kwah1, Lisa A Harvey2, Joanna HL Diong1 and Robert D Herbert1; Half of the adults who present to hospital with stroke develop at least one contracture within six months: an observational study; Journal of Physiotherapy 2012 Vol. 58

Xoan Daniel Garcia Fuentes, Maria Angeles Garcia Frasquet, Rodrigo Marcos Rabanillo

Hospital Universitario Virgen Macarena

OBJECTIVE We present a case report of a patient with Saddle Syndrome, adhesion of the intrinsics at the metacarpal head level associated with pain and functional impairment (described by Watson et al and Chicarilli et al.). This is a complex pathology that requires a high index of suspicion due to its difficult diagnosis. A relation between the clinical presentation and main diagnostic tests is established. METHODS Our patient is a 24 year old female that four years ago suffered a crushing by a weight of aproximately 120 kg on the ulnar surface of the palm, fourth and fifth finger of her right hand. She was evaluated by our unit presenting intense pain and permanent ulnar fingers flexum. During clinical exploration elastic retraction of metacarpophalangeal and interphalangeal joints were noted, as well as pain located in fourth intermetacarpal space and base of the phalanges. Positive Bunell test. Ultrasound, EMG/ENG and MRI were all normal. RESULTS After the suspected diagnosis of Saddle Syndrome the patient underwent surgery, permorming a zig-zag palmar approach and exploring the fourth intermetacarpal space. Adhesions were removed between lumbrical and palmar interosseus and dorsal and deep transverse metacarpal ligament, resecting its most proximal half. The symptoms resolved immediately after the surgery. The pain dissapeared and range of motion was recovered. CONCLUSIONS The presumtive diagnosis should be based on careful anamnesis taking the traumatic precedent and compatible clinica exploration into account. MRI should be performed on every patient although it is not often useful. Differential diagnosis of simulated hand pathology is essential. The diagnosis will be confirmed through surgical exploration.

Distal Radius Fractures (29 abstracts)

Ronit Wollstein 1,2, Yotam Shuali Cohen 2, Miri Steier 3, Nariman Hazan 3, Nofar Ben Basat 2, Raviv Allon 2

New York University, Department Of Orthopedic Surgery, USA 2 Technion Israel Institute of Technology School of Medicine, Israel; 3 Lin Medical Center, Israel

Introduction:rnrnFragility fractures, constitute a major health problem and are a major risk factor for a subsequent fracture in osteoporotic patients. Studies have shown that multidisciplinary teams are most effective in prevention of these fractures, especially when the treating orthopedic surgeon is involved postoperatively.rn rnIn a previous evaluation of our medical system, we found that patients were unlikely to receive timely diagnosis of osteoporosis and/or proper evaluation and treatment for secondary prevention of fragility fractures. We have since begun the implementation of a multidisciplinary anti-osteoporotic clinic designed to treat and follow-up patients with prior fragility fractures of the distal radius. The purpose of this pilot study was to evaluate the short-term effect of this clinic on patients sustaining a distal radius fragility fracture (DRFF) in a large health maintenance organization.rnrnMethods: rnThis was a case-control retrospective study. Cases included all participants assigned to a tertiary, multidisciplinary, fracture prevention clinic. Controls were taken out of a series of surgically treated patients in the same health system that did not attend the multidisciplinary clinic. The clinical team consisted of a hand surgeon, an endocrinologist and an occupational therapist. The primary outcome measure was a second fracture during the follow up period.rnrnResults:rnThirty-eight patients were seen by the clinic. All patients went through rehabilitation with an occupational therapist according to their physical ability and healing progression. The average follow-up period was 20.5 months with a longer period for the untreated group. Cases received more pharmacological treatment for osteoporosis than controls. There were no new fractures in the treated group. There was no difference between the treated and untreated groups in fracture occurrence at 1-year follow-up.rn rnConclusions:rnIt is possible that we were underpowered to detect a difference in fracture occurrence rate. It is also possible that short-term follow-up is not enough for a fracture known to occur years before a second fragility fracture. rnrnThe evidence from this study may support the implementation of a multidisciplinary anti-osteoporotic clinic in reducing subsequent fractures and improving treatment rates following a minimal trauma fracture due to bone fragility, however further study is necessary to improve the ability to realize effective prevention of fragility fractures.

Jinrok Oh, Myunggi On, Hanbin Jin

Wonju Severance Christian Hospital, Wonju, Republic of Korea

Among the distal radius fractures (AO classification 23-B, C) involving the wrist joint, plain X-ray and computed tomography (CT) showed that when the main fracture was initiated from the distal part over the watershed line, it makes difficult to have a firm internal fixation using the conventional anatomical volar locking plate only. Also if the metal plate is positioned over the watershed line, it is high risk that friction between the distal portion of the metal plate and the flexor tendon tend to increase, resulting in the tendon rupture. In order to overcome this problem, using the conventional stabilization of the distal radius anatomical volar locking plate with the use of the 2.0 mm distal ulnar hook plate (Depuy-Synthes®) simultaneously, or two 2.0 mm ulnar distal plates, was able to get the satisfactory results in fixation of the fracture. We would like to report the clinical results and techniques for the treatment of distal radius fracture involving the watershed line or fracture starting from distal part of the watershed line.

Karan Dua 1, Nathan N. O’Hara 2, Andrea S. Bauer 3, Roger Cornwall 4, Christine A. Ho 5, Scott H. Kozin 6, Kevin J. Little 7, Scott Oishi 8, Apurva Shah 9, Suzanne E Steinman 10, Theresa O. Wyrick 11, Dan A. Zlotolow 6, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA; 3 Boston Children's Hospital, Boston, Massachusetts, USA; 4 5 Children's Health, Dallas, Texas, USA; 6 Shriners Hospitals for Children, Philadelphia, Pennsylvania, USA; 7 Cincinnati Children's Hospital, Cincinnati, Ohio, USA; 8 Texas Scottish Rite Hospital for Children, Dallas, Texas, USA; 9 Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; 10 Seattle Children's Hospital, Seattle, Washington, USA; 11 University of Arkansas Medical Sciences, Little Rock, Arkansas, USA

Objective: Distal radius fractures are the most common injury in the pediatric population, but radiographic examination and subsequent classification of these fractures are not standardized. A recent study found poor agreement among pediatric orthopaedic surgeons when diagnosing and treating these fractures. The authors hypothesize substantial variation also exists among pediatric hand surgeons when diagnosing and treating pediatric distal radius fractures. Methods: Ten pediatric hand surgeons who commonly treat pediatric distal radius fractures at different institutions reviewed 100 sets of posteroanterior (PA) and lateral pediatric wrist radiographs. The surgeons were asked to complete a questionnaire describing the fractures, the type of treatment they would recommend and the recommended length of immobilization. Additionally, the surgeons were asked when the next follow-up visit would be scheduled for, and whether or not they would obtain new radiographs at the subsequent and final follow-up visits. Kappa statistics were performed to assess the agreement amongst examiners with the chance agreement removed. Strength of agreement was determined based on guidelines outlined by Landis and Koch. Kappa values of <0.00 were considered poor agreement, 0.00 to 0.20 slight agreement, 0.21 to 0.40 fair agreement, 0.41 to 0.60 moderate agreement, 0.61 to 0.80 substantial agreement, and 0.81 to 1.00 almost perfect agreement. Results: Only fair agreement was present when diagnosing and classifying the distal radius fractures (K=0.312). Diagnoses included torus, greenstick, Salter-Harris II, and extra-physeal fractures. There was also only fair agreement regarding the type of treatment that would be recommended (K=0.242) and only slight agreement regarding the length of immobilization (K=.187). Only slight agreement was present regarding when the first follow-up visit should occur (K=.188), there was only fair agreement whether or not new radiographs should be obtained at the first follow-up visit (K=0.396), and if radiographs were necessary at the final follow-up visit (K=.368). Surgeons had slight agreement regarding stability of the fracture (K=0.139). Conclusions: The inter-rater reliability among pediatric hand surgeons of diagnosing pediatric distal radius fractures showed only fair agreement. Both pediatric orthopaedic surgeons and hand surgeons have wide variability in their treatment of pediatric distal radius fractures. Better classification systems of pediatric distal radius fractures are needed that standardize the treatment of these injuries in order to provide the best health outcomes with the least patient morbidity.

Chun-Jui Weng, Chun-Ying Cheng, Shih-Sheng Chang, Chih-hao Chiu, Alvin Chao-yu Chen, Kuo-Yao Hsu, Yi-Sheng Chan

Chang Gung Memorial Hospital, Taoyuan, Taiwan

Object: Nonunion of distal radius fracture is rare due to metaphyseal position, bony impaction when injury, cancellous bone content and less soft tissue disruption. No consensus about treatment to distal radius fracture nonunion. The aim of our study is to evaluate contributing factor, treatment and outcome to distal radius fracture nonunion. Methods: We retrospective review patients with distal radius fracture. Thirteen patients received surgery due to distal radius fracture nonunion or delayed union. We reviewed preoperative and postoperative radiograph and range of motion. Fracture type, grip strength compared to contralateral hand and functional score were also recorded. Surgical procedure included debridement, realignment, bone grafting and stable fixation. ORIF of ulna or Darrach procedure was performed for associating ulna fracture. Results: According to Frykman classification, three of them were class II, six were class IV, two were class V, and one for class I and VIII respectively. Initial treatment was splinting in 7 patients and surgery in 6 patients. Six patients received plate fixation and bone grafting, two received additional Darrach procedure, six received ORIF with Acumed locking plate, one received shortening of radius and ulna. Postoperative wrist range of motion increased compared to preoperative range of motion. Eleven out of thirteen patients had concomitant distal ulna fracture. No complication occurred except one developed delayed union of ulna. One patient had excellent grade in functional score, eight with good and four with fair. Conclusion: Nonunion of distal radius fracture is rare and difficult to treat. Associated distal ulna fracture may be risk factor for nonunion or delayed union. Surgical treatment leads to high union rate, low complication rate and fair to excellent function outcome.

Hiromichi Yasuoka

Tamana Central Hospital, Tamana-shi, Kumamoto, Japan

[ Hypothesis ] Surgical procedure ‘without pronator quadratus (PQ) detaching’ is superior to ‘with PQ detaching’, when comparing post-operative clinical outcomes after open reduction and internal plate fixation for distal radius fractures. [ Materials & Methods ]  Comparing the surgical procedures and post-operative clinical outcomes of 30 patients with extension type fractures of the distal radius.  Intra-articular fractures having displacement of articular surface and fractures having comminution of volar cortex were excluded from the study.  The cases were randomly separated into two groups.  One group received surgery ‘without PQ detaching’ (16 patients).  The second group received surgery ‘with PQ detaching’ (14 patients).  Post-operative outcomes were assessed at approximately 6 months after surgery using The DASH Outcome Measure, modified Mayo wrist score, range of motion of the wrist and grip strength.  Radiographic assessments were performed immediately after each operations and the last follow up appointment of the patients. [ Results ]  The DASH score were significantly better in the ‘without PQ detaching’ group than ‘with PQ detaching’ group.  DASH score: ‘without PQ detaching’ group average 3.03, range 0~15.91 vs ‘with PQ detaching’ group average 9.31, range 2.5~32.5 (P=0.01).  There were no significant differences between the two groups in the other assessed parameters. [ Summary points ]  No statistical difference was observed in the modified Mayo wrist score, range of motion of the wrist, grip strength, operation time and radiographic assessments between the two groups of patients.  In the demonstrated cases of extension type fracture of the distal radius, the procedure ‘without PQ detaching’ in open reduction and internal plate fixation presented significantly better subjective recovery results than the procedure ‘with PQ detaching’, when comparing patient-rated evaluation. [ Discussion ] When operating the distal radius fractures through a volar approach, the PQ is generally once detached from the surface of the distal radius. In order to preserve physiological function of PQ, some authors recommend not detaching it in operation. In the anatomical and functional literatures, it is stated that PQ has two distinct heads and the superficial head is the prime mover in forearm pronation, and the deep head is a dynamic stabilizer of the distal radioulnar joint. Therefore this study was planned to confirm the influence of PQ detaching to post-operative outcomes in practical clinical scene. Intra-articular fractures having displacement of articular surface and fractures having comminution of volar cortex were excluded from the study because there was a risk of insufficient reduction when the PQ muscle was preserved in operation. Although the number of recruited case was small because of strict criterion for enrollment, there was significant difference in the patient-rated evaluation. Superior patient satisfaction, resulting from surgical procedure which is spared pronator quadratus detaching, could be observed. It was supposed that the damage to the PQ muscle caused by detaching procedure resulted in impairment of the physiological PQ function which contributed to pronation strength in forearm rotation and dynamic stabilization of the distal radioulnar joint.

Michael Jakubietz, Rafael Jakubietz, Laura Mages, Rainer Meffert

University of Wuerzburg, Department for Trauma, Hand, Plastic and Reconstructive Surgery, Wuerzburg, Germany

Background Intraarticular fractures of the distal radius present a challenging problem for surgeons. While preoperative CT scans are considered helpful to understand the type of fracture and to choose an adequate approach, the role of postoperative CT scans is not yet clearly defined. The aim of this study was to analyze indications for postoperative CT scans and to evaluate its potential therapeutic consequence in regard to detection of complications and its influence on revision rates in intraarticular fractures. These findings were used to establish an algorithm to help identifying patients that benefit from a postoperative CT scan. Patients and Methods: 92 patients with intraarticular fractures were included. AO type C fractures were seen in about 90% of patients, with type C3 being present in 55% of the patients. According to Frykman´s classification type 7 and 8 fractures were found in 93%. Data was analyzed in regard to radiographic results, complications and indication for a postoperative CT scan. Results: Six patients underwent revision surgery. When analyzing data in regard to correlation of radiographs and CT Scans a statistically significant correlation was found. Conclusions A high correlation between both imaging techniques can be shown. In inconclusive radiographs, CT scans are recommended to rule out intraarticular screw placement or step offs. Due to the number of patients and the retrospective design, further studies are needed.

Hyun Il Lee 1, Min Jong Park 2

1 Department of Orthopaedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, South Korea; 2 Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea

Introduction: Malunion after distal radius fracture is common complication especially in elderly patients with osteoporosis. Although the relationship between functional outcome and radiologic parameter was well known in younger patients, it is still controversial whether patient-perceived outcome and disability in elderly patients are influenced by a radiologic outcome. We evaluated the actual complaint of the patient and their perceived outcome according to radiologic parameters in elderly patients who underwent conservative treatment. Patients and methods: We reviewed 167 elderly patients over 55 years old with unilateral distal radius fracture to investigate the effect of radiologic deformity on functional outcome and patient’s satisfaction. All fractures were treated with closed reduction and cast immobilization, and followed-up for mean 7.1 years. Their wrist pain was evaluated using the visual analog scale (VAS) and the functional subjective outcome was measured with the disability of the arm, shoulder, and hand (DASH) questionnaire via telephone survey. Overall satisfaction and concern over wrist appearance were part of the subjective assessment. Radiologic evaluations including dorsal tilt, radial inclination, radial length and ulnar variance were performed. Malunion was defined when radiologic parameters showed volar tilt < -10° or > 20°, radial length < 0 mm, or radial inclination <5°. Results: According to radiographic criteria, 51 patients (30%) showed malunion. Mal-united patients are slightly older than patients with acceptable alignment (62.9 versus 69.6 years old, P < 0.001 by Mann-Whitney test). Fracture patterns including AO classification and the incidence of ulnar side fracture were similar between two groups. Mean pain VAS was 0.4 for mal-united patients versus 0.8 for patients with good alignment and it was not statistically significant (P = 0.347 by Mann-Whitney test). Mean DASH score showed inferior score in the mal-united group (14.9 versus 11.1, P < 0.001 by Mann-Whitney test). However, this difference (value of 3) was not reached the clinically meaningful difference (value of 10). More patients in mal-united group recognized the gross deformity of their wrist than well-aligned patients (52.9% versus 25.9%, P < 0.001 by Chi-Square test). Mean satisfaction VAS was lower in mal-united patients as 80.5 (versus 90.5 in well-aligned patients, P < 0.001 by Mann-Whitney test). Mal-united patients answered that they would choose surgery more than cast if they encounter same condition (13.3% versus 7.2%) but it was not statistically significant (P = 0.2332 by Fisher’s exact test). When we analyze the subset of patients older than 70 years old, we could get a similar trend with the whole set of patients. Conclusion: Our study indicated that the conservative treatment of the distal radius in elderly patients could show a good functional and patient perceived outcome despite residual deformity at fracture union. However, mal-united patients showed slightly less satisfaction in their management even in older patients over the age of 70 years old.

Johannes Rois

Trauma Center Vienna Meidling, Austria

Fractures of the distal radius are the most common fracture in the upper extremity. Open reduction and palmar fixed-angle plating is nowadays the most common used treatment method for unstable distal radius fractures. The complication rate of this treatment reported in the literature vary between 8% and 40%. The most common cause of wrist disability after distal radius fracture is the distal radioulnar joint (DRUJ) involvement. The aim of this study is to find sustainable solutions and to offer practical tips and tricks to prevent this type of complications. Based on an own retrospective study with 127 cases on the topic of palmar plating of unstable distal radius fractures, and on the literature review the different complication types were studied and classified. Focussed on preventable complications they were classified into surgeon-related and surgeon-independent complications. The surgeon-related complications (malunion, tendon complications, screw length, intraarticular screw placement, secondary dislocation,...) were analyzed. Based on these results and also taking into account biomechanical studies, possibilities of avoidance of complications on the DRUJ will be offered by means of case reports. To prevent complications is not restricted solely to the surgical technique – approach, reduction, plate position, screw position, screw length – but begins with the preoperative assessment of the fracture which results in surgery planning. It will definitely not be possible to achieve a complete avoidance of complications that are associated with palmar plating of unstable distal radius fractures. Awareness of the possible complications and how to deal with them may help to minimize the complication rate and on the other hand to recognize complications at an early stage allowing timely treatment.

Masato Shigi, Takeshi Egi, Yusuke Sogabe

Osaka Saiseikai Nakatsu Hospital, Osaka, Japan

[Objective] Volar locking plate fixation generally leads to satisfactory postoperative outcomes in patients with distal radius fracture, but correction loss may occur in unstable cases, such as an association of osteoporosis. The purpose of this study was to investigate association between correction loss after surgical operation for distal radius fracture and osteoporosis. [Method] 35 patients (32 females and 3 males) who performed open reduction and internal fixation using volar locking plate for distal radius fracture at our facility between April 2016 and July 2017 over 50 year of age (mean age of 68 years, range 50-86) was evaluated retrospectively. All of them had gone through measurements of bone mineral density (BMD) of lumber spine and femoral neck measured by dual-energy x-ray absorptiometry as well as measurements of serum levels of N-terminal propeptide of type I procollagen (P1NP) as a bone formation marker and tartrate-resistant acid phosphatase 5b (TRACP-5b) as a bone resorption marker at the time of injury. And we collected data of ulnar variance (UV), volar tilt and radial inclination measured on plain radiography in the postoperative period as well as 3 months later. Statistical analysis was conducted using three steps. First, wrists were divided into two groups by degree of loss of correction (correction loss group and non-correction loss group). Age, sex, BMD and bone metabolism markers were compared between two groups using the nonparametric Mann-Whitney U test. Second, logistic regression analysis was performed to identify factors independently associated with loss of correction at 3 months after operation and to calculate odds ratios adjusted for other covariates. Third, receiver-operating characteristic (ROC) curve analysis was performed to assess the cutoff values and area under the curve values of the predictive factor. [Results] 14 patients (33 %) who had correction loss of UV more than 1 mm had mean percentage of the young adult mean (%YAM) of femoral neck of 60 % compared with 74 % among the non-correction loss group (21 patients). Univariate analysis demonstrated this difference of %YAM between two groups was statistically significant (p = .001). On the other hand, age, sex, mean %YAM of lumber spine and mean bone metabolism markers had no significant differences between two groups. We used logistic regression analysis to assess whether %YAM of femoral neck was predictive of correction loss independent of age, sex, and bone metabolism markers. That has revealed that lower %YAM of femoral neck was a risk factor for correction loss of UV (p < .05). ROC curve was produced to assess the ability of the predictive factor. The area under the curve (AUC) was 0.83. When the cut-off value of %YAM was 63 %, the sensitivity and specificity for the prediction of correction loss were 86 % and 79 %, respectively. [Conclusion] Osteoporosis had a negative effect on correction loss after volar locking plate fixation of distal radius fracture. For patients whose %YAM of femoral neck is below 63%, surgeons should identify high-risk patients and ensure stable internal fixation, close monitoring and careful postoperative therapy.

Youn Moo Heo 1, June Bum Jun 1, Sang Ki Lee 2

1 Konyang University Hospital, Daejeon, South Korea; 2 Eulji University Hospital, Daejeon, South Korea

Purpose: Radiocarpal dislocation (RCD) of the wrist is a very rare injury caused by high energy trauma. This injury is common to have a fracture of radial styloid of distal radius rather than a pure dislocation. And, it may sometimes has an avulsion fragment from volar rim of the lunate facet by short radiolunate ligament that origin at volar rim of the distal radius. The purpose of this retrospective study is to evaluate final results of RCD and to assess whether the repair of avulsion fragment is necessary in RCDs with avulsion fracture by short radiolunate ligament. Materials and Methods: From February 2008 to October 2016, we reviewed 1051 patients surgically treated for distal radius fractures or perilunate injuries. And 17 patients confirmed as RCD with follow-up over 12 months were enrolled in this study. There were 14 men and 3 women with a mean age of 40 years (range, 19-79 years). The mechanism of injury was motorcycle accident in 5 patients, vehicle accident in 4 patients, a fall from height in 5 patients, a fall from climbing in 1 patient, a fall from standing height in 1 patient, and industrial injury in 1 patient. Patients with RCD were divided into Group 1 and 2 using the classification by Dumontier et al. Additionally, we subdivided Group 2 as the following; 2A without avulsion fracture by short radiolunate ligament and 2B with avulsion fracture by short radiolunate ligament. In all RCDs, fracture of radial styloid were fixed with K-wires or plate. And pure injuries of palmar radiocarpal ligament were repaired primarily or using suture anchor and injuries of palmar radiocarpal ligament with repairable avulsion fragment were fixed with mini-screw. Carpal tunnel decompression was performed in 5 cases with median nerve symptom and additional external fixation was performed in 4 cases. Final results were evaluated using the Mayo Wrist Score and a patient-rated wrist evaluation. And a wrist range of motion and grip strength were assessed. Statistical analysis was performed with the Student’s t test. Results: All RCDs were included in Group 2 (4 and 13 patients in Group 2A and 2B, respectively). The RCDs (Group 2A/2B) was rated as excellent in 2 (1/1) patients, good in 8 (1/7) patients, fair in 4 (1/3) patients, and poor in 3 (1/2) patients according to the Mayo Wrist Score (p=0.09). The mean Mayo wrist score was 73.5 (range, 50–90). The mean patient-rated wrist evaluation score was 17.3 (range, 0–55). Total range of motion of the injured wrist obtained 86.9% and grip strength of injured site obtained 73.9% of the uninjured side. Conclusions: Common RCDs is a complex injury with fracture of radial styloid and injuries of radiocarpal ligament. Not only the fixation of fracture but also the repair of ligament is important to maintain the stability of the joint. Particularly, we think that relatively large avulsion fractures associated with injuries of palmar radiocarpal ligament are helpful in restoring the stability of the ligaments.

Kotaro Okamoto 1, Satoshi Takei 1, Takeshi Oki 1, Kiyohito Takamatu 2

1 Hankai Hospital Orthopedics, Japan; 2 Yodogawa Christian Hospital Orthopedics, Japan　

Introduction Fragility fractures such as proximal femoral and vertebral fractures affect both patient life expectancy and quality of life. Patients should be treated for osteoporosis at an early stage to prevent fragility fractures. Distal radius fractures (DRFs) and vertebral fractures comprise the osteoporotic fractures at the initial stage. However, DRFs do not affect life expectancy, suggesting that when patients presenting with DRFs are diagnosed with osteoporosis, it is a good opportunity to start treatment for osteoporosis. However, most patients presenting with DRFs are relatively young. Therefore, it is likely that they have not undergone a bone mineral density (BMD) test. Thus, they may miss the opportunity to undergo osteoporosis treatment at the initial stage. Purpose The purpose of this study was to investigate the current status of BMD examination and the treatment administered for osteoporosis in patients with DRFs at our hospital. Methods We investigated patients who were treated for DRFs at our hospital between 1 January 2010 and 31 December 2016, excluding patients aged <50 years and those with pathological DRFs. We determined the following factors: age at the time of developing DRFs, sex, affected arm, type of fracture, location of the injury, cause of the injury, method of treatment, history of osteoporosis treatment, history of fragility fractures and whether the patient underwent BMD tests before and after developing DRFs. Results One hundred and fifty patients (women250, men50) were included in the study; 250 of the wrists were of women and 50 were of men and of the 300 wrists, 117 were of the right hand and 179 of the left. The cause of injury was falling from a height in 75% of the cases, with most of them occurring inside the house. Operations were performed in 74% of the cases. At the time of developing DRFs, only 7% of the patients received treatment for osteoporosis and 8% had a history of fragility fractures. Only 3% of the patients had undergone BMD tests before developing DRFs, and 7% of the patients underwent these tests after the operation. After the operation, 13% of the patients received osteoporosis treatment. Discussion The examination rate for osteoporosis in Japan is approximately 5%. However, in patients with DRFs treated at our hospital, BMD examination rate before developing DRFs was even lower than that. In addition, BMD examination rate after developing DRFs was relatively low. Our results indicated that it is highly likely that we are overlooking patients who would benefit from early osteoporosis treatment. Conclusions In future, we need to increase BMD examination rate at the time of DRF diagnosis and start treatment in patients with osteoporosis at an initial stage to prevent additional fragility fractures that may affect their life expectancy.

Daichi Ota, Mikiro Kondo, Mikio Harada, Masatoshi Takahara

Center for Hand, Elbow and Sports Medicine, Izumi Orthopedic Hospital, Sendai, Japan

Objective: Cast immobilization after closed reduction is a standard treatment for distal radius fractures. The position of the wrist during immobilization is controversial.Our aim was to investigate the effectiveness and limitation of cast immobilization with the wrist of extension for the distal radius fractures in elderly patients. Methods: 33 patients with distal radius fractures (age: 60 years old and older, follow up periods: 8 weeks and longer), were included retrospectively. 26 out of the 33 patients underwent conservative treatment initially, 18 patients needed closed reduction, and 17 patients of the 18 (mean age: 76.8 (64-95), AO classification: A2,3；A3,7；C1,1；C2,6) were immobilized using cast with the wrist of extension. After manual closed reduction, cast were applied and were modeled to rigidly press the dorsal side of the wrist, including distal radius and proximal carpal raw toward the volar side. Thus the wrists were kept in extension. 2 cases were immobilized with above elbow cast and the others were immobilized with below elbow cast. The mean period of cast immobilization was 5.5 (4-10) weeks. The following clinical results were examined: complications, surgery after casting, bone union, and final outcomes of pain, range of motion (ROM), and grip strength. Radiographic findings were also evaluated, including volar tilt (VT）,ulnar variance (UV),radial inclination (RI) and correction loss. Results: No complications such as cast trouble were reported. 13 cases were non-operatively followed, although 4 patients underwent osteosynthesis, using volar locking plate between 6 and 12 days after casting (mean 7.5 days). All patients obtained bone union. mean VT was -7.0 (-23～10)° initially, +6.5 (-4～15)° immediately after casting, and +2.7 (-13～33)° at the final follow up. The mean UV was +1.8 (-1.0～3.8) mm initially, +1.5 (0.0～3.0) mm immediately after casting, +3.0 (0.5～6.5) mm at the final follow up. mean RI was 20.4 (8～29)° initially, 22.2 (13～30)° immediately after casting, and 21.5 (12～28)° at the final follow up. The mean correction loss was 3.7° in VT, 1.5 mm in UV and 0.6° in RI. Three patients complained wrist pain at the final follow up and 2 of the 3 had ulnar wrist pain. Mean ROM was 57.3 (40-80)° of flexion, 60.3 (40-80)° of extension, 81.5 (80-90)° of pronation and 81.5 (60-90)° of supination. Mean rate of grip strength compared to the opposite side was 73.0 %. In the patients who underwent osteosynthesis, the mean VT was -30.0 (-37～-25)° initially, and +2.0 (-9～10)° immediately after casting. mean UV was +2.7 (0.4～6.4) mm initially, and +0.7 (0～2)° immediately after casting. mean RI was 17.8 (12～21)° initially, and 22.5 (21～24)° immediately after casting. Conclusion: Our radiographic results showed relatively low correction loss in cast with the wrist of extension, compared to the conventional cast. It suggests that cast immobilization with the wrist of extension is safe, economic, and effective treatment of distal radius fractures in elderly patients. We recommend this technique as the first choice of the treatment for distal radius fractures which have unacceptable dorsal tilt. However, surgery should be immediately performed if the fracture has unacceptable shortening or articular displacement after reduction.

Jin Young Kim, Dong Mo Kang, Jae Hyun Kim

Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyang, South Korea

We attempted to investigate how accurately an extra-articular fracture was identified by plain radiographs. We also presented what types of intra-articular involvement commonly were found in extra-articular fractures misdiagnosed as by plain radiographs. The standard plain radiographs (AP and lat), oblique views and CT scan were taken for 464 distal radius fractures. The diagnosis of an extra-articular fracture was made by plain radiographs. Based on the findings of CT scans, diagnosis rate and sensitivity of the standard radiographs with/without oblique views for extra-articular fracture were calculated. We also investigated whether the added oblique views improved the diagnosis rate of extra-articular fractures. The common types of intra-articular involvement which were not revealed in plain radiographs was presented. The incidence of an extra-articular fracture was 19%. Diagnosis rate of standard plain radiograph for extra-articular fracture is 48%, and sensitivity is 96%. When oblique x-rays were added, diagnosis rate was 68% and sensitivity was 100%. A dorso-ulnar articular fragment was the most commonly identified in the misdiagnosed extra-articular fractures. In conclusion, the incidence of extra-articular fracture of distal radius was much lower than that in previous literatures. A large part of extra-articular fractures diagnosed as by standard plain radiographs conceals intraarticular involvement. Thus, CT scan might be necessary or at least, oblique view should be added, not to miss the fractures requiring surgery.

Adrienn Lakatos, Balazs Lenkei, Zsolt Szabo

Hand Surgery Center Miskolc, Hungary

Operative treatment of low energy distal radius fractures in elderly is increasing. The functional results of these patients are similar to the results of the young patients. The purpose of this study is to search for the factors influencing the functional outcome in these cases. The operated distal radius fractures were checked for the year 2016. We found 237 operated distal radius fractures. 121 of them were involved in the study. The functional outcome was evaluated with the quickDASH score. We collected data about the fracture type, the reduction quality, and the age of the patient. For evaluating the reduction, we created a scoring system based on the remnant gap or step in the articular surface and the remaining angulation in the fracture. The mean follow-up was 12,3 months. AO type A, B, or C type fractures were evaluated separately. Functional outcome was not significantly influenced by the fracture pattern. Comparing the reduction quality of all the patients the results were the following: on average 0 quickDASH score for perfect reduction, 14 quickDASH points for gaps 1 mm or angulation less than 10 degrees, 21 points for more than 1 mm gap, step or angulation more than 10 degrees. The overall quick DASH score of these patients did not vary significantly in the different age groups (6,3 points for 61-70 years; 7,9 points for 71-80 years; 5,4 points for 80+ years). Based on our results we conclude, that age of the patient should not be considered as contraindication for operative treatment. It seems that it is not the fracture type that is important, but the quality of the reduction which is the main influencing factor of the final functional outcome.

Emygdio JL de Paula, Edgard Novaes França Bisneto, Renata Gregorio Paulos

Grupo de Mão e Microcirurgia do Hospital das Clínicas da Universidade de São Paulo, Brazil

Purpose: To present long-term follow-up for pediatric patients following correction of forearm deformity with the use of distraction osteogenesis after distal radius physeal arrest in the setting of trauma. Methods: Retrospective review of a single surgeon’s experience using a circular External Fixator to correct forearm deformity in eight patients whose average age at time of application was 10.7 years. At time of lengthening, the ulnar phisys was left intact allowing its growth. After skeletal maturity, all patients underwent to a second acute lengthening procedure to restore radial/ulnar relation if necessary. All patients were evaluated clinically with radiographs, physical examination, and functional outcome assessments including the Short-Form 12, Disabilities of the Arm, Shoulder and Hand, and Mayo Wrist score. Results: At the time of long-term follow-up, at a mean of 120 months, all patients were nearly pain free. All were willing to undergo the same treatment again. Wrist flexion increased 150, extension decreased 4°, radial deviation decreased 10°, ulnar deviation increased 12°, and pronation and supination both decreased 7° on average. The radius was lengthened an average of 4.5 cm, with an average preoperative ulnar variance of +4,5 cm and an average postoperative ulnar variance of -3 mm. Mean outcome scores were as follows: Short-Form 12 was 84, Disabilities of the Arm, Shoulder and Hand was 10, and Mayo Wrist was 76. No complications were observed Conclusions: The use of distraction osteogenesis in pediatric patients with severe forearm deformity and dysfunction after physeal arrest in the setting of trauma is a reasonable alternative in association to a later osteotomy, bone grafting, and internal fixation. It provides good correction of deformity (cosmetic aspect) and maintains functional range of motion .

Shotaro Kamijo, Keikichi Kawasaki, Kazutoshi Kubo, Tetsuya Nemoto, Hiroshi Nishikawa, Katsunori Inagaki

Department of Orthopaedic Surgery, Showa University School of Medicine, Tokyo, Japan

[Objective] Variable angle volar rim plate (Depuy-Synthes Company, abbreviated as “VA-VRP”) is designed for distal radius marginal fracture. Because of its design, VA-VRP can cause flexor tendon ruptures and carpal tunnel syndrome (CTS), whereas recent studies showed the incidence of CTS in other volar plates was 0-9.9%. In this study, we evaluated whether carpal tunnel release can be necessary when VA-VRP is used for marginal fractures. [Methods] We reviewed the cases of marginal fracture, under 10mm of the longitudinal size of volar lunate facet fragment, treated with VA-VRP at our department from 2014. We excluded two cases who underwent carpal tunnel release combined with plating. We divided cases into two groups based on symptom and electrophysiological test: S group; cases with CTS before removal of plate system and N group; cases without CTS. As radiographic parameters, we examined volar tilt (VT), ulnar variance (UV), radial inclination (RI), carpal translation (CTL), carpal height ratio (CHR), distance between the volar edge of the plate in distal end and tip of hook of hamate in CT which was taken 3 months after operation. We also examined range of motion, percent grip power, Mayo wrist score as clinical evaluation. We evaluated these parameters between two groups. We performed numerous nerve conduction tests in S group. [Results] Twenty-six cases matched our inclusion criteria: S group; three cases (incidence of CTS 12%) and N group; 23 cases. The mean age was 60.0 year-old in S group and 55.1 year-old in N group. The fracture types were all cases Colles type in S group, and Smith type three cases and Colles type 20 cases in N group. AO classification were C2: 1, C3: 2 cases in S group and B3: 1, C2: 4, C3: 17 cases in N group. The averages of Mayo wrist score were 78.3 ± 10.4 in S group and 87.1 ± 8.3 in N group. The averages of percent grip power were 70.0 ± 21.8 in S group and 85.3 ± 24.2% in N group. Radiographic parameters showed no significant differences between S and N groups. We removed the plate system in all cases soon after bone union and combined carpal tunnel release surgery at removal of the plate in S group. [Conclusions] There were no significant differences between S group and N group in radiographic and clinical parameters; plate position and fracture reduction, but the incidence of CTS in marginal fractures treated with VA-VRP was higher than those of other plates, and the clinical results in S group tended to be worse than those of N group. Further investigation is needed to elucidate causes of CTS by VA-VRP, and Carpal tunnel release at open fixation surgery could be necessary to prevent CTS by VA-VRP.

M. Wehrli, E. Bodmer, M. Marks, St. Schindele

Schulthess Klinik, Zürich, Switzerland

Objective Computer-assisted surgical planning, including patient-specific surgical tools, have the potential to improve the preoperative understanding of patient anatomy as well as enhance the intraoperative accuracy of corrective osteotomies for malunited radius fractures. Standard anatomical plates for corrective osteotomy of the distal radius are prone to malpositioning because of missing anatomical landmarks, which results in a less precise correction. As there are significant correlations between malpositioning and poor clinical outcome, patients might benefit from custom-made patient-specific implants. The objective of this project was to describe the outcome of a pilot series of patients treated with radius corrective osteotomy using a patient-specific implant. Methods Preoperative 3D planning requires a CT scan of both the malunited and contralateral healthy radius. Based on these data, patient-specific osteotomy guides and custom-made plates were designed and printed. Patients receiving a personalized plate for corrective osteotomy due to distal radius malunion were retrospectively assessed between 6 and 12 weeks and 6 and 12 months after surgery. Results We included five distal radius malunion patients with a mean age of 50 years. Four radius fracture patients were each treated conservatively and one patient underwent enucleation of a cyst located in the distal radius prior to osteotomy. The mean time between injury or treatment and the corrective surgery was 6 years. The average follow-up time was 9 months. At follow-up, all patients stated that they would have the surgery again due to considerably improved wrist function and subjective stability. All patients had improved pronation/supination and flexion/extension compared to before the corrective osteotomy. No adverse events were documented to date. In one case, however, we plan to remove the implant because of a screw tip irritation at the extensor tendon. Conclusions The first results of patients treated with a custom-made implant for corrective osteotomies of the distal radius are promising. These implants offer the surgeon greater accuracy in the preoperative planning and implementation of the surgical procedure. As a next step, we plan to analyze the safety and effectiveness of these implants, and believe that this “gadget” has the potential to evolve into an essential tool for hand surgeons.

Takeshi Sakai 1,4,5, Keikichi Kawasaki 3, Naoya Nisinaka 1,2, Ken Yamasaki 4, Kouji Kanzaki 1, Katsunori Inagaki 3, Kenichirou Teramoto 5, Hidechika Nakashima 5

1 Department of Orthopedic Surgery, Showa University Fujigaoka Hospital Kanagawa, Japan; 2 Showa University Research Institute for Sport and Exercise Sciences Tokyo, Japan; 3 Department of Orthopedic Surgery, Showa University School of Medicine Tokyo, Japan; 4 Higashitotsuka Memorial Hospital Kanagawa, Japan; 5 Kumamoto Kinou Hospital Kumamoto, Japan

Objective: Double-tiered subchondral support (DSS) of the dorsal and central joint, using a monoaxial locking plate (MLP) for fixation in which the screw insertion angle is predetermined, is convenient for treatment and stability of distal radius fractures. The fixation strength between the screw plate provides better outcomes. However, DSS is not effective in all cases, with postoperative correction loss being reported in some patients. This study investigated plate position and screw length in patients who had postoperative correction loss after DSS using an MLP. Methods: Among 156 patients with a distal radius fracture treated using an MLP (DVR, Zimmer Biomet), 30 patients having correction loss with volar tilt (VT) 5°, radial inclination (RI) 5°, or ulnar variance (UV) 2 mm were defined as the re-dislocation group. This included 27 patients with AO type C fractures, mostly comminuted. Distance of the most ulnar / most radial distal plate edges from the articular surface, and between the plate ulnar edge and DRUJ, were measured by frontal view radiography. Distance between the most distal plate and the joint surface was measured by lateral radiography. In addition, the support rates were defined as the distal first and second row screw lengths divided by the joint surface length. The results were compared with a non-dislocated group and analyzed by the t-test. Results: In regard to plate position, frontal radiograph measurements in the re-dislocated group:non-dislocated group were: joint surface - most ulnar, 4.6:5.2 mm; joint surface - most radial, 17.1:16.1 mm; and DRUJ - ulnar edge, 3.5:2.7 mm. Lateral radiograph measurements were: joint surface - most distal plate, 2.1:2.3 mm. There were no significant differences. The support rates were: first row, 57.8:62.8% and second row, 79.8:85.8%. The second row support rate was significantly different. Moreover, additional treatment such as external fixation was required in three re-dislocation group patients. Conclusions: Prevention of correction loss when using an MLP requires careful consideration of plate position. In addition, care must be taken with screw insertion during DSS to ensure support of the dorsal joint surface. Patients treated surgically may still require additional fixation in some cases.

Hiroaki Ogihara 1, Emi Makino 1, Takao Omura 2, Michihito Miyagi 2, Kaori Sugiura 3

1 Japanese Red Cross Hamamatsu Hospital, Japan; 2 Hamamatsu University School of Medicine, Japan; 3 JA Shizuoka Kohseiren Enshu Hospital, Japan

(Objective) Although much attention has been paid to avoid incidence of extensor tendon injuries by screw perforation through the dorsal cortex of the distal radius during dorsal fracture fixation with volar locking plate (VLP), we sometimes encounter cases with screw penetration through the dorsal cortex on plain lateral radiograph. Recent reports have emphasized on the high importance of dorsal tangential view (DTV) on detecting screw penetrations. The purpose of this study is to evaluate the relationship between the in vivo screw tip cortex distance in vivo distance (STCD) and the postoperative STCD measured using DTV. (Methods) Forty nine hand of 47 patients who underwent VLP for distal radius fracture during 2016 to 2017 at Hamamatsu Red Cross Hospital were included in this study. The patients consisted of 6 males and 41 females with an average age of 70 years old. In vivo STCD was calculated by measuring the distance from the volar to dorsal cortex by depth gauge, then subtracting by the actually inserted screw length. Postoperative STCD was measured using DTV by plain radiograph. The discrepancy between In vivo and postoperative STCD was analyzed. (Results) Out of 364 inserted screws, there were 84 screws which showed discrepancy between in-vivo and postoperative STCD. Out of these 84 screws, 54 were placed, 24 were radial and 4 were on Lister’s tubercle. There were 35 screws with a between in-vivo and postoperative STCD discrepancy of 1 t o2mm. Out of these 35 screws, 22 were placed ulnar and 13 were placed radial. 15 screws showed discrepancy between 2 t o3mm with 8 screws placed ulnar and 7 screws place radial. Finally, 2 screws showed discrepancy of more than 3mm occurring on ulnar and radial side. (Conclusion) There was a 23% in-vivo and postoperative STCD mismatch with the majority occurring on ulnar side of the distal radius. The cause of this discrepancy may arise from the technical error while using the depth gauge, is comminuted dorsal radial cortex, firm fixation of the plate using proximal cortical screw and limited standard anteroposterior and lateral view by fluoroscopic images. We should select even shorter screws from in-vivo measurement.

R. Fujitani 1, Y. Dohi 1, S. Omokawa 2, Hiroshi Ono 2, Y. Tanaka 3

1 Department of Orthopedics, Ishinkai-Yao General Hospital, Japan; 2 Department of Hand Surgery, Nara Medical University, Japan; 3 Department of Orthopedics, Nara Medical University, Japan

Objective Fluoroscopy is used as the gold standard intraoperatively for the estimation of articular congruency for distal radius fractures (DRFx). However, impacted intra-articular fragments are difficult to judge under fluoroscopy. The purpose of this study was to arthroscopically assess the articular reduction after fluoroscopic open reduction and internal fixation of DRFx with impacted intra-articular fragment Material and Method Since 2014 to 2017, a total of 176 consecutive patients with intra-articular fractures were enrolled. Computed tomography (CT) scanning was obtained for all acute DRFx if articular incongruity is present or suspected. From a list of CT scans, we identified 13 CT scans that had impacted intra-articular fragments according to the classification by Medoff R. There were 6 women and 7 men with an average age of 59 years (range, 24-76 y). A flexor carpi radialis approach to the distal radius was used, the fracture was reduced using standard extra-articular techniques, and reduction was verified by fluoroscopic image. Once the reduction was deemed satisfactory by fluoroscopic imaging, a volar locking plate was applied. After the plate fixation, the reduction was assessed arthroscopically. A standard radiocarpal and mid carpal arthroscopy was performed. Step and gap deformity were then measured using a calibrated probe at the point of maximum displacement, even if this represented a small portion of total fracture line. In the preoperative CT scanning, we recorded whether there was a volar rim fracture fragment and the number of intra-articular fracture fragments based on the classification by Medoff R. Pre and intraoperative radiographs were examined teardrop angle. Single linear regression analysis was conducted to elucidate the association between the intraoperative teardrop angle and intraoperative arthroscopic parameters. A p value of ≦0.05 was considered significant. Results A volar rim fracture fragment was found in 12 of the 13 patients. The mean number of intra-articular fracture fragments were 4.7 (range, 4-5). The intraoperative gap was averaged 1.2 mm. The average step off was 1.3mm, and the averaged gap + step off 2.5mm. The average teardrop angle were 38.1°at preoperatively and 48.8°intraoperatively respectively. Linear regression analyses revealed that the intraoperative teardrop angle had a significantly negative correlation with postoprerative gap + step off in arthroscopy (R2=0.30, p=0.05). Conclusion We found that 12 of 13 patients had an articular step-off of more than 2 mm with arthroscopy evaluation, although the articular surface appeared anatomically reduced under the fluoroscopy. Arthroscopic reduction and fixation for optimal treatment for impacted intra-articular fragments of DRFx might be needed. Almost patients had volar rim fragment and more than 4 of intraarticular fragment. Increase of the intraoperative teardrop angle significantly corresponded with decrease of intraoperative gap + step off in arthroscopy. The teardrop angle measurement may be useful in intraoperative radiographs as well as intraoperative arthroscopic assessment.

Kozo Morita

The Department of Orthopaedic Surgery, International Goodwill Hospital, Yokohama, Japan

Objective : In recent years, various type plates for the distal ulna fractures (DUF) are developped. but we don’t know which type of plate is better to fix DUF. The purpose of this study is to compare different mechanism plate fixation for DUF with concomitant the distal radius fractures (DRF). Methods : A retrospective study was conducted to identify patients who had been treated with plate fixation for unstable displaced DUF with concomitant ipsilateral DRF was also treated operatively. 23 patients were identified with an average age of 66.9 years (range, 52-86 years) and with follow-up averaging 14.4 months (range, 9-20 months). Fracture types were classified type1: 7, type2: 1, type3: 10, type4: 5 cases in Biyani’s classification. We clasiified the cases into 2 groups : treated with fixed angle plate (FAP) (Stellar hook plate, HOYA technology, Tokyo, Japan) (HP group: 11cases) or polyaxial locking plate (Aptus2.5 distal ulna plate, Medartis, Basel) (PLP group: 12 cases) . We performed statistical comparison about radiological and clinical assessments between 2 groups using Mann-Whitney U-test. Results : All distal radius and ulna fractures united. In the average radiological parameters, range of motion, grip strength, Mayo’s wrist scoring system, the results were both satisfactory and they weren’t statistically significant. There were no severe complication. Conclusion : Both plate fixation for unstable DUF in the setting of an associated DRF, resulted in union, retaining to excellent alignment ,wrist motion and clinical assessment. There were no statistic difference between the two plate fixations. Both plate fixaition could stabilized unstable DUF by subchondral support, and exercize same post-operative therapy similar to that in the case of unilateral DRF.

J. Canosa, Ch. Gordo, J. Domingo, C. Esteve

Orthopaedic SErvice, Hospital del Vendrell, Tarragona, Spain

INTRODUCTION: Distal radius fractures (DRF) in people older than 65 years should be considered as a first alarm signal of an underlying osteoporosis (OP). DRF that occut between 65 and 75 years old are located in the "optimal segment" fior the realization of a detailed and rigorous study of the hideen OP because these patients are in a state of health that allows ample possibilities of implantation of a global paln of intervention anb prevention of a second fractures. We conducted a propective study of 15 patients diagnosed of DRF and treated in our Service and analyzed parameters that show that all of them have multiples "osteoporotic factors" that had not been previously shown. MATERIAL AND METHOD: Serie of 15 patients diagnosed with DRF. Ages between 65 and 74 years old. We revised of comorbilidities (CM) already diagnosed. Review of the consumption of drugs that interact wiht phosphocalcic metabolism and related to increased risk of fractures (corticosteroids, hynotics amb proton pump inhibitors. Radiological study of spine has been performed. BMD indication as part of the initial study. RESULTS: 13 women and 2 men. CM. 8 diabetes, 5 thyroid disfunctions and 4 renal insufficiencies. Combined 8 patients registered 1 CM, 4 with 2, 2 wiht 3 and 1 with 4. Drugs: corticosteroids 2, hypnotics 5, inhibitos of the proton pump 10. Spinal X_Rays: 6 patients with 1 or several dorsal or lumbar fratures not previously diagnosed. BMD at the diagnosis time: femur Z less than -2.5 7 patients, lumbar inferior to -2.5. 5. CONCLUSIONS: It reveals necessary to consider patients older than 65 years diagnosed with DRF as a "osteoporotic patients" The environment of osteoporotic requires a detalied study in order to determine the existence of comorbidities related to bone fragility, the presence of vertebral fractures and the consumption of "osteopenci" drugs. These paciente must be categorized within the group of "complex chronic patients". From the complete study of all the exposed parameters we can make a "map" that will allow us to elaborate a multidisciplinary action plan in order to reduce the future risk of new fractures.

Jaesung Lee, Hyungseok Jung, Donghoon Lee

Chung-Ang University Hospital, Seoul, South Korea

Introduction: Only volar approach is not always enough to provide anatomical reduction of the articular surface and secure fixation of dorsal fragment. The purpose of this study was (1) to provide a surgical technique about combined volar and dorsal approach for complex intra-articular distal radius fracture and (2) to assess the clinical outcomes. Methods: Combined approach was performed to 19 patients (6 males and 13 females, mean age 55.8) with AO C2,C3 comminuted intra-articular distal radius fractures. All patients were enrolled the following inclusion criteria: (1) have a free articular fragment without connection with a metaphysis, (2) distal migration of dorsal fragment or (3) impacted bony fragment within a radiocarpal articulation. Also, patients could be available for a minimum of 1 year follow up. 7 patients were treated by combined volar and dorsal plate fixation and the other patients were treated by volar plate fixation and dorsal approach (intra-articular reduction and fragment excision). Quick-DASH score, Mayo wrist score (MWS), VAS, range of motion, bone union time and any complication were evaluated. Results: 15 patients were AO type-C3 fractures, and 4 patients were AO-type 2 fractures. Mean follow-up period was 29 months and 3 patients were lost. Overall Quick DASH score averaged 20 and Mayo wrist score averaged 75 of being 5 excellent, 4 good, 8 fair and 2 poor. VAS averaged 2.4. All 19 patients showed bony union, the average union time is 8.2 weeks. Mean volar flexion was 47, dorsiflexion was 65, supination was 71, and pronation was 76. The patients who underwent dorsal approach for fragment excision showed better range of motion. Conclusion: Combined volar and dorsal approach for AO type C2,C3 can be a good option for good functional outcomes and further study about indications when dorsal approach should be done will be needed.

Sang-uk Lee, Ki-tae Na, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

Objective: Complex regional pain syndrome (CRPS) is a severe complication that affect as many as 10% of all patients with distal radius fracture (DRF). The pathophysiology of CRPS still unclear. Vitamin D regulates calcium and phosphorus absorption and plays a central role in mineralization, growth and remodeling of bone. Vitamin D deficiency causes osteomalacia in adults and chronic deficiency leads to increased bone turnover rate and progressive bone loss. In CRPS type I, patch osteoporosis due to osteoclast hyperactivity is a common radiographic finding. However, the relationship of vitamin D and CRPS type I is still unknown. The purpose of this study was to prospectively investigate the serum levels of vitamin D between CRPS group and control group. And the influence of vitamin D and other factors on the incidence of complex regional pain syndrome type I after fracture after distal radius fracture (DRF). Methods : A total of 62 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. We excluded patients who had gastrointestinal disease or renal disease. Because these factors could affect vitamin D level. We also excluded patients who had been taking vitamin D or osteoporosis medication at the time of injury. We used Budapest criteria to diagnose CRPS type I. The Budapest criteria require continuing pain disproportionate to the inciting event, symptoms in at least 3 of 4 sensory, vasomotor, sudomotor/edema, and motor/trophic categories, 2 or more signs at the time of evaluation, and absence of a plausible alterative diagnosis. The CRPS group was defined as patient with CRPS type I after surgically treated DRF (22 patients), the control group was defined as patients without CRPS type I after surgically treated DRF (40 patients). The factors assessed for the development of CPRS I were age, gender, the body mass index, the serum vitamin D level, alkaline phosphatase. A multivariate logistic regression analyses were conducted to identify independent predictors of CRPS I development after surgery for a distal radius fracture as well as to identify confounding effects of variables. Statistical significance was accepted for p<0.05. Results: The age of two group was similar (mean and standard deviation [SD], 67.25 ± 12.09 years versus 67.23 ± 10.06 years). Body mass index and alkaline phosphatase between CRPS group and control group are similar also. (21.99 ± 5.03 cm/kg versus 23.76 ± 3.07 cm/kg, 130.64 ± 84.05 U/l versus 147.32 ± 103.28U/l) The CRPS group was slightly lower vitamin D level than the control group (18.70ng/mL ± 6.38 versus 20.04ng ± 9.33) without statistically significance (p=0.55). According to the multivariate analysis, sufficient vitamin D and low alkaline phosphase did not reduce the incidence of CRPS. Conclusion: This study demonstrated that in patients with a distal radius fracture, the serum vitamin D level is not associated with the incidence of CRPS I.

Ajmal Ikram

University of Stellenbosch, Tygerberg Hospital Cape Town, South Africa

Aims of study: Assess and compare the functional and radiological results in patients treated with the dorsal locking plate (DLP), Volar Locking Plate (VLP) and Fragment Specific fixation (FSF) of distal radius fractures Method: All patients who presented to our institution with complex intra- articular distal radius fractures had C.T scan of the radius according to the fracture pattern either had volar lock plating or Fragment specific fixation or dorsal locking plate fixation of the distal radius. Dorsal radius locking plate was used for following indications, 1. Dorsal Barton fractures 2. Comminuted dorsal rim fracture of the distal radius 3. Suspected SL ligament injury with distal radius 4. Early intra-articular mal-united fractures needing intra-articular osteotomy These patients were then asked to be followed up at 2 weeks, 6 weeks, 3 months 6 months and 12 months. The radiological parameters, i e radial height, inclination and tilt were compared as well as the functional outcomes by means of DASH score. Incision size and tourniquet times were recorded. Complications were reviewed. Results: Currently we have included 12 patients each group. At 12 months the average DASH scores are 11. Tourniquet time is comparable in VLP and DLP group and longer in FSF patients. The radiological parameters are statistically comparable. We will be presenting our early results. Conclusion: Fixation of the distal radius fractures with dorsal plate allows direct visualization of joint cartilage to obtain anatomic reduction and assessment of intercarpal ligaments. Earlier dorsal radius implants had high complications but the new design and locking screws may allow stable fixation to get early range of movements as with other methods of fixation

Belén García-Medrano, Clarisa Simón Pérez, Blanca Ariño Palao, Gonzalo Martínez Municio, Miguel Ángel Martín-Ferrero

Hospital Clínico, Valladolid, Spain

INTRODUCTION The DRUJ instability, secondary to a distal radius fracture, causes pain in the ulnar border of the wrist, weakness and restriction of the range of motion. The severity of the fracture pattern and the magnitude of its displacement have been described as risk factors for DRUJ injury. MATERIAL AND METHOD Recording of fractures of distal radius, surgically synthesized with volar plate, in the period 2013-2015. Those that presented a fracture of the ulnar styloid base and / or sigmoid cavity were selected. Preoperative characteristics: epidemiological (age, sex, dominance, etiological mechanism), radiological (AO and Frykman classification, ulnar variance, volar tilt, radial inclination, radial translation, sagittal translation, DRUJ gap), postoperative (VAS, range of motion, grip / clamp strength, signs of DRUJ instability, malunions, ulnar styloid pseudoarthrosis). RESULTS 24 patients, 92% women, 11 of them with a sigmoid cavity fracture, 69 years on average, 22 low energy trauma. Classification: 71% of the fractures are included among the types AO A2, B3 and C3; 67% between types 2, 7 and 8 of Frykman. Mean preoperative radiological measurements: ulnar variance +2.42; volar tilt 20.69°; radial inclination 15.63°; sagittal translation 0.23; radial translation 0.17; DRUJ gap 1.39. Postoperative: VAS 1; 71.15º palmar flexion; 78,46º dorsal flexion; radial deviation 23,85º; ulnar 24.62º; 92% completed prono-supination; 4 cases of DRUJ crepitus and 2 of pain; grip strength 18.77 kg, clamp 6.31; 17% malunions and 46% pseudoarthrosis of the ulnar styloid. CONCLUSIONS The initial radiological study of a distal radius fracture can guide the risk of postoperative DRUJ instability. Although if radius reduction is correct, the percentage of secondary clinical instability decreases significantly.

Seoung-Joon Lee, Se-Bong Oh, Jung- Ho Lee

Department of Orthopedic Surgery, Konkuk University, School of Medicine, Seoul, South Korea

Objective : Distal radioulnar joint (DRUJ) instability commonly occurs in association with distal radius fractures. Injury of the triangular fibrocartilage complex (TFCC) associated with distal radius fracture can result in DRUJ instability. When treating a distal radius fracture, it is important to detect TFCC injury to prevent DRUJ instability. The purpose of this study is to evaluate the instability of DRUJ in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrist. Methods : 49 Patients who had distal radius fracture fixed with volar locking plate was enrolled. Patients with both radius fracture, previous distal radius fracture or those with distal radio-ulna osteoarthritis were excluded. Dorsal stress radiograph was evaluated on both injured wrist (affected) and non-injured (unaffected) wrist. Under general anesthesia, dorsal stress radiography of DRUJ was performed on unaffected wrist. After fixing distal radius fracture with volar locking plating, dorsal stress radiography of DRUJ was performed. Ulnar head translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic exam was done on all of the affected wrists to classify TFCC injury according to Palmer classification. Ulna styloid fracture was also classified to evaluate the correlation with UTR. We performed Pearson’s correlation analysis, logistic regression and Wilcoxon rank sum test using R program Results : 49 patients (Male; 14, Female; 35) were participated in this study. The average age was 59.1 years (19 to 86). UTR of affected wrist was significantly associated with TFCC injury palmer type Ib with age and gender-independent manner. Ulna styloid base fracture was significantly associated with UTR of affected wrist when only adjusted with age or gender. And as UTR difference between the affected and unaffected wrist enlarged it revealed significant tendency of DRUJ instability due to TFCC injury palmer type Ib. Conclusion : UTR difference between the affected wrist and unaffected wrist shows a strong correlation in detecting peripheral TFCC injury. We think that UTR measured from dorsal stress radiography of DRUJ in distal radius fracture patient could be a useful tool to evaluate the instability of DRUJ.

Daniel Vilcioiu 1,2, Dragos Zamfirescu 2, Florin Safta 1, Fabian Klein 1, Alexandru Firicel 1, Carol Birisiu 1, Ioan Cristescu 1

1 Clinical Emergency Hospital of Bucharest, Romania; 2 Zetta Clinic, Romania

Objectives. The current study investigated the incidence of complications after volar plating for distal radius fracture. We present our protocol in management of this complications and compare the results Material and methods. Between october 2016 and august 2017 a total of 57 patients treated for distal radius fracture were investigated. The patients, women and men, were older than 24 years and were observed for at least 12 weeks after surgery with a volar locking plate.   Results. The fracture consolidation rate was 100% but we found complications in 8.7% of the cases. The complications included carpal tunnel syndrome, volar escape, and tendon rupture or irritation (extensor pollicis llongus and flexor pollicis longus). Conclusions. The use of volar locking plates for surgical fixation of distal radius fractures has become very popular. However, several complications associated with this type of surgery have been reported. The implant should be well positioned, the screws should have appropriate length and some special tips and tricks should be used.

Kanwal Cheema, Raghunandan Kanvinde

Ysbyty Gwynedd, Bangor, Wales, United Kingdom

Objective: Open reduction and internal fixation is commonly accepted to be the ‘gold standard’ when treating distal radial fractures with radio-carpal joint disruption as absolute stability is provided and they have few complications. Methods/Results: In this case, a 63 year old female with rheumatoid arthritis had fallen sustaining an intra-articular distal radial fracture managed with a volar locking plate. The post-operative radiographs were satisfactory as were those taken during routine follow-up appointments. However, she presented to us after a further fall 8 years later that had resulted in failure of the plate and a consequent comminuted fracture at the distal radius. The hardware was removed, the fracture was reduced and an 8 hole volar locking plate was used to hold the reduced position. The post-operative radiographs were satisfactory and she has made a good recovery with full return of function. Conclusion: Mechanical failure of distal radius volar plates is a rarely reported complication, and all previous cases have reported failure within 12 weeks of fixation. To the best of our knowledge, late failure for this type of fixation has not previously been reported. This case study highlights late hardware failure as a potential complication that surgeons should be aware of when considering the options for fixation and when undertaking this commonly performed procedure. This is of particularl importance in those with poor bone quality as severe comminution at the time of re-injury may ultimately require wrist arthrodesis, a procedure requiring prolonged rehabilitation to allow continued function with a limited range of movement.

Dupuytren (24 abstracts)

Karim Latrach Tlemsani, Teka Maher, Sabeur Saadi, Hamza Kefi, Yadh Zitoun, Faouzi Abid

University Hospital of Mahdia, Tunisia

Objective Dupuytren’s disease is a benign fibroproliferative disorder that paradoxically progresses to permanent flexion deformity of palmar joints and functional impairment. Despite the development of non-operative techniques, regional selective fasciectomy remains the gold standard. Methods In a retrospective study, a total of 25 patients, including 20 men and 5 women, were submitted from January 2007 to December 2011 with the diagnosis of Dupuytren's disease. All of them have exclusively performed regional selective fasciectomy. We managed 93 rays. Surgical treatment was indicated whenever the hand cannot be placed flat on a table. The mean follow-up duration was 18 months. We used Revised Tubiana’s Staging System and URAM scale to evaluate functional outcomes. Results The mean age was 57 years old with male predominance. Surgical treatment was performed in only 28 hands including 44 rays. The outcomes were excellent in 25 hands treated and good in the 3 remaining. All treated rays have been improved with a gain, at least, for one stage. A complete improvement (stage 0) was achieved for all the rays initially rated at I and II which are 35. The nine rays preoperatively rated at stage III have all gained 2 stages (passage to a stage I). In our series, we noticed only 5 cases of early complications quickly curbed. Late complications were dominated by algodystrophy with a total of 4 cases. We reported only one case of proximal interphalangeal joint stifness. No recurrence was recorded. Conclusion The management of Dupuytren contracture relies yet on surgical procedure. Selective fasciectomy offers better functional results with lower rates of complications and recurrence. However, the functional outcome remains significantly correlated with the preoperative status of the disease.

Ireneusz Walaszek 1, Elżbieta Gawrych 2, Justyna Rajewska-Majchrzak 2, Karolina Rosołowicz 1

1 Department of General and Hand Surgery Pomeranian Medical University, Szczecin, Poland; 2 Department Of Pediatric Surgery and Oncology Pomeranian Medical University, Szczecin, Poland

Dupuytren's contracture is a proliferative connective tissue disease, which affects the palmar aponeurosis. Although it is considered to be primarily a disease acquired in adulthood a few pediatric cases have been reported in literatur. The 16 year-old patient presented to our out-patient clinic with a decade-long history of right little finger contracture. The patient was otherwise symptom-free, but according to the patient’s parents the contracture has been progressively increasing in severity and they were anxious to exclude malignancy. Examination revealed a 90 degree contracture at the proximal interphalangeal (PIP) joint with a palpable, fibrous cord, approximately 3-5mm thick and 3 cm long extending along the ulnar aspect of the affected finger. There was no sensory or vascular impairment nor was there limitation in the PIP joint The ultrasound examination revealed a typical solid, hardened, fibrotic mass in the subcutaneous tissue. The patient underwent a local fasciectomy, which was performed in a typical manner. During the procedure a typical fibrous cord, attached proximally to lateral digital sheet and distally to Grayson”s ligament, was exposed and excised. Digital nerves and arteries were also identified. After the removal of fibrotic corda a full extension of pip joint was obtained and no need for arthrolysis was accounted. The excised mass was sent for histological examination which confirmed the diagnosis of Dupuytren's fibromatosis. The surgical incision healed with no complications. At a 6-month follow-up no recurrence of was noted. It is a worth to highlight the fact that the patient was qualified for surgery despite the absence of symptoms. Such a procedure, other than in the case of adult patients, was dictated to excude the development of the neoplasm instead of contracture. Dupuytren's contracture is a rare disease in children, and each tumor of soft tissue in young patients should raise oncological alertness. In such case, surgical treatment along with subsequent histological examination seems to be mandatory , particularly with the short history of the growth.

Sonja Elisabeth Pelzmann

Institute for Physical Medicine and Rehabilitation, Wilhelminenspital, Vienna, Austria

OBJECTIVE: Application of orthoses are an essential part of treating patients with Dupuytren´s disease, especially after surgery, collagenase injection treatment or as an conservative option. The goals of treatment are the retrieval of normal range of motion and an adequate hand function. Research on the effectiveness of orthosis and their use is poor. This review provides a synthesis evaluating the scope of research on use and implementation of orthosis treatment in clinical practice. METHOD: Multiple electronic databases and journals which are handling with orthosis treatment in this disease were searched for available information. The studies were classified using the Oxford Level of Evidence and the Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS: Different types of orthosis with different utilization are applied in the 31 analyzed studies (two RCTs two CCTs, one Delphi study, five review reports, 13 ODs, eight expert opinions). The sample size of the studies had a range from four to 268 patients. The Level of Evidence (Oxford) of included articles ranged from Ib to V. The ratings of the SEQES-Score ranged from six to 43. The authors gave information about wearing of orthosis in a range of two weeks to six months. In general, evidence for the effectiveness of hand therapy in range of motion, physical function, and satisfaction was not found. CONCLUSION: The effect of orthosis treatment is rarely investigated or researched in common with the surgical or the pharmacological intervention. Thus is difficult to determine the effect of the method of orthosis treatment and the contribution on treatment outcomes. The nonexistent heterogeneity of disease history, small sample size of studies, and short follow-ups are also reasons for these results. There is a need for more high quality studies examining the methods of orthosis treatment in regards to effectiveness. LEVEL OF EVIDENCE: V

Rasmus Wejnold Jørgensen, Lars Solgård, Jens-Christian Vedel, Claus Hjorth Jensen

Hand Clinic, Department of Orthopedics, Herlev-Gentofte University Hospital of Copenhagen, Denmark

Objective Complications following fasciectomy for Dupuytren’s Disease (DD) include digital nerve injury, wound healing complications, necrosis, hematoma formation and infections. The purpose of this study was to evaluate the number of postoperative complications, and hematomas in particular following fasciectomy for DD. Methods 362 patient charts were retrospectively reviewed. Postoperative events were recorded. Student T-test was used for numerical values. Chi-Square and Fisher’s Exact test was used for binomial outcomes. P<0.05 was considered statistically significant. Results No patients had ongoing treatment at the time of follow up (1-3 y). The mean age at follow-up was 67.6 years (SD 9.1, range 34-95 y). There were 43 wound defects (11.9 %), 27 hematomas (7.5 %), 14 recurrences (3.9 %) and 11 infections (3 %) postoperatively. Those with postoperative hematoma had a mean of 9.75 (SD 4.2) outpatient visits postoperatively, those without had 3.71 (SD 2.8), P<0.0001. Infections occurred in 2.3 % of patients without postoperative hematoma and in 16.7 % of patients with postoperative hematoma, P=0.0065. There were no differences in wound defects or recurrence rates when comparing patients with postoperative hematomas to those without, P>0.05. The use of anticoagulants, the use of tobacco or whether the patients were operated on by junior doctors under supervision did not vary on any parameters, P>0.05. Operating on three or more fingers in one setting compared to one or two fingers resulted in more postoperative outpatient visits (P=0.007), wound defects (P=0.049), and hematomas (P=0.012). Conclusions Operating on three or more fingers leads to more complications and should be avoided when possible. A postoperative hematoma results in significantly more postoperative outpatient visits and more infections.

C Simón-Pérez 1, J Alía-Ortega 1, B García-Medrano 1, JI Rodríguez-Mateos 2, M Brotat-Rodriguez 3, H Aguado-Hernandez 1, MÁ Martín-Ferrero 1

1 Hospital Clínico Universitario de Valladolid, Valladolid, Spain; 2 Hospital Universitario Rio Hortega Valladolid, Spain; 3 Hospital Rio Carrion Palencia, Spain

Purpose: To determine the recurrence rate, possible adverse reactions and factors influencing recurrence and progression of Dupuytren’s Disease (DD) treated with Collagenase from Clostridium Histolyticum (CCH). Methods: Prospective study, 71 patients with DD treated with CCH from 2011 to February 2013, with a minimum follow-up period of 4 years. Clinical, functional, patient satisfaction, drug safety and factors influencing recurrence and disease progression were evaluated. Results: In all patients, the rupture of the cord was achieved after the injection, reducing joint contracture. In 5 patients (7%) we verified the existence of disease recurrence during the follow-up. In 11 patients (15.5%) there was a disease progression with a significantly lower degree of finger retraction than prior to injection, except in one patient. Three patients have been surgically operated, with no surgery difficulty; the rate of recurrence and progression was higher in grades III and IV of Tubiana, in proximal interphalangeal (PIP) punctures, and was earlier in patients younger than 65 years. Conclusions: The recurrence or progression of DD is mainly observed in young patients with greater severity of the disease and at the PIP level. Patients with the lowest rates of recurrence and progression were those with a single cord in the metacarpophalangeal (MCP), a grade II of Tubiana and were older than 60 years.

Steven Roulet, Jacques Guéry, Jacky Laulan

Hand Surgery Unit, Department of Orthopedic Surgery 1, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours, France

Objective : The objective of this study was to evaluate the results of treatment of Dupuytren disease by extended fasciectomy with the McCash open-palm technique. Methods: In 2003, 40 consecutive operated patients were assessed by an independent evaluator. Twelve patients were Tubiana stage 1, 16 stage 2, 9 stage 3 and 3 stage 4. They were again examined in 2016 by a second evaluator who was unaware of the clinical results in 2003. Results: Forty cases were evaluated. There had been no peroperative or postoperative complications. At the first assessment, mean follow-up was 7.32 years (range, 4.26 to 12.5 years). Recurrence occurred in 7 patients (17.5%) and extension of the disease in 15 (37.5%). Mean extension lag was 19.3°. Average improvement in finger extension was 53°. Thirty-four patients (85%) considered that their result was stable over time. On the second evaluation, 21 patients were examined with a mean follow-up of 21.50 years (range, 18.7 to 26.3 years). None of them had been re-operated and no extension of the disease was observed. No recurrence occurred in patients who had no recurrence in 2003. However, the disease had worsened in five patients (23.8%) of whom 3 already had a recurrence in 2003. Mean finger extension lag was 31.8°. Twenty patients (95.2%) had no functional impairment, and one (4.8%) a moderate disability. Twenty patients (95%) considered that their result was stable over time. Eighteen patients (85.7%) were very satisfied and 3 (14.3%) satisfied with the procedure. Three patients would not repeat the procedure, including two who experienced recurrence. Conclusions: CRPS was the primary cause of failure and poor results. The number of operated rays was the only statistically significant factor of poor outcome and overall loss of mobility, especially for the proximal interphalangeal joint.

Takuya Yokoi 1, Takuya Uemura 1, Kenichi Kazuki 2, Ema Onode 1, Kosuke Shintani 1, Mitsuhiro Okada 1, Hiroaki Nakamura 1

1 Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; 2 Gakuen-minami clinic, Nara, Japan

The ratio of the lengths of the second and fourth digits (2D:4D) has been described as reflecting endogenous prenatal androgen exposure. In general, 2D:4D is lower in men than in women and has potential as a biomarker or predictor for various diseases, athletic ability, and academic performance. Dupuytren disease has digital flexion contractures and is known to predominate in men, but the pathogenesis of the disease remains unclear. To clarify the relationships between Dupuytren disease and endogenous androgens, we performed a retrospective analysis of hand radiographs to investigate 2D:4D in Dupuytren disease. The study included male patients with Dupuytren disease (n = 22) and a control group (n = 18) of male patients with carpal tunnel syndrome. Only unaffected hands, without contractures or osteoarthritis, were evaluated for the purpose of radiographic assessment. The lengths of the phalanx and metacarpal bones in the second and fourth digits were measured by 2 independent observers who each performed 2 sets of measurements separated by a minimum 1-week interval. The 2D:4D was calculated separately for the phalanges and metacarpals, and a combined (phalanx + metacarpal) 2D:4D was also calculated. The reliability of the observer measurements was established using the intraclass correlation coefficient, and both the intra- and interobserver reliability showed excellent agreement. We found that compared with control group, the Dupuytren disease group had significantly lower phalanx and combined 2D:4D. These findings suggest that endogenous prenatal androgens could contribute to the development of Dupuytren disease, leading to its characteristic clinical presentation predominantly in men and affecting the ulnar rays.

Kazuya Odake1, Masaya Tsujii1, Takahiro Asano1, Haruhiko Satonaka1, Akihiro Sudo1

Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Japan

Objective Pathophysiology of Dupuytren’s disease (DD) remains unclear. Thrombin is a multi-functional serine protease and a potent inducer of fibrogenic cytokines in various cells. Osteopontin (OPN), one of ECM proteins, can also modulate a variety of cellular activities associated with various chronic inflammatory disease including myocardial fibrosis after ischemic heart disease, liver cirrhosis and lung fibrosis. Additionally, the thrombin-cleaved form of OPN is well correlated with various inflammatory disease activities. We herein presented that myofibroblast expressed OPN, especially of thrombin-cleaved form, and fibroblasts derived from Dupuytren’s fascia were differentiated into myofibroblasts by the administration of thrombin. Methods The study group was composed of 25 patients (4 women and 21 men) who underwent resection of the palmer fascia for DD. The patients’ mean age was 69.1 years (range, 58 to 82 years). All patients signed an informed consent document, and the study was approved by the institutional review board. The palmer apponeurosis resected in carpal tunnel release were used as control. Immunohistochemical studies were performed on serial sections with antibody against αSMA, OPN and thrombin cleaved-form of OPN. For the determination of effect of thrombin on DD, cells isolated from nodules and cords were starved in serum-free medium overnight prior to treatment with thrombin, 1 U/ml. After 24 hours, expression of αSMA and OPN were analyzed in total proteins collected from cells using western blotting. Results Morphometric analysis in immunohistochemistry showed that expression of αSMA was significantly correlated with that of OPN in the nodules of Dupuytren’s fascia. In addition, there was respective expression of OPN and αSMA in 16 (67%) and 5 (20%) in cord of Dupuytren’s fascia. Furthermore, thrombin-cleaved OPN was also immunolabeled on similar areas with OPN in nodules of Dupuytren’s fascia, considered that the majority of OPN’s expression was thrombin-cleaved form in the nodules centered in the pathology. In vitro study, the proportion of myofibroblasts in cell cultures from nodule was 11.3%, compared with 4.6% in cord (P=0.011). Palmer fascia from control contained only 1.9% cells with expression of αSMA. After treatment of thrombin, expression of αSMA and OPN were clearly upregulated in the cells from nodules as well as cords, although there were weak expression of these molecules without application of thrombin. Conclusion The present study showed myofibroblast expressed OPN and thrombin cleaved-form in the nodules as well as cords of Dupuytren’s fascia, with significant correlation of αSMA’s expression. Lenga described that OPN was required for the differentiation and activity of myofibroblasts based on the experiment using OPN-null fibroblasts. Thus, OPN could involve in the pathologic progression by modulating the activity of myofibroblast in DD. In addition, our in vitro study showed the application of thrombin induced myofibroblast transformation from fibroblast of the nodules as well as the cords. Besides, expression of OPN was clearly upregulated in the cells from both nodules and cords. Thrombin in bleeding with the surgery may participate in the pathology of progression and recurrence by direct effect or indirect pathway via cleavage of OPN.

Fernando Menvielle, Macarena Layús, Sergio Daroda, Rodeolfo Cosentino, Paul Pereira

Clínica de la Mano, GAMMA, La Plata, Argentina

Objective The aim of this study was to evaluate the results of Percutaneous Needle Aponeurotomy (PNA) for primary Dupuytren’s contracture in relation to the maintenance of the total passive extension deficit (TPED) improved and to do a subjective evaluation of the results with the Disabilities of the Arm, Shoulder and Hand questionnaire (Dash). Material and Methods A review of all patients with Dupuytren’s contracture treated with PNA from 2008 to 2014 was performed. Patient demographics and digits affected was recorded. Pre-operative, immediate postoperative and final follow up total passive extension deficit was measured with standard goniometer and stratified by Tubiana classification system. Recurrence, defined as an increase of the passive extension deficit of 30° or more compared to the immediate postoperative measurement, and other complications were also noted. Statistical analysis was performed using paired t-test (statistical significance p-value <0.05). All patients completed the DASH questionnaire. 57 digits in 43 hands were treated with PNA. 38 patients were male and 2 were women. Average age was 62.6 years. Results The mean follow up was 42.6 months, ranging from 9 to 68 months. The average preoperative TPED was 79.6° and the average immediate postoperative was 8.16° (90% correction) p= 0.042. The average TPED at final follow up was 13.3° (83% correction) p=0.000.The results in relation to the maintenance of the TPED improved at the proximal interphalangeal joint were worse than those at the metacarpophalangeal. Two patients experienced a slightly diminished sensibility on one side of the finger. There were no flexor tendon injuries. Recurrence was observed in 11 digits of which 9 were reoperated in an average time of 33 months with a range of 10 to 52. The mean results of Dash questionnaire was 3.2% Conclusions PNA is a safe and effective technique in the treatment of Dupuytren’s contracture. Long term correction is better maintained in metacarpophalangeal than proximal interphalangeal joints.

Taichi Saito, Yasunori Shimamura, Shunji Okita, Toshifumi Ozaki

Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

Objective: Patient satisfaction is an essential measure of quality of care for Dupuytren’s contracture. Previous research demonstrated that patient satisfaction improves after fasciectomy for Dupuytren’s contracture. However, the relationship between functional recovery and satisfaction is not clear. The purpose of this study is to reveal the correlation between functional recovery and patient satisfaction after surgery. Methods: We observed 22 patients with 27 hands who had total fasciectomy from 2007 to 2016. A zig-zag (Bruner’s) incision was performed with 13 hands and a longitudinal incision with Z-plasty was performed with 14 hands. We examined grip strength, range of motion (ROM), patient satisfaction with hand function, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and complications. We used Spearman coefficients to determine the correlation between objective measures of function and patient satisfaction. We also constructed receiver operating characteristic curves to identify optimal cutoffs in hand function that correspond with patient satisfaction. Results: Patents were followed for an average of 67 months after surgery. At the final follow-up, averaged grip strength and total extension deficit (TED) were improved from 31.0 kg to 36.2 Kg, and 78.7° to 17.6°, respectively. DASH was also improved from 7.3 to 0.8. After surgery, 72% of patients were very satisfied. One patient had a reoperation for recurrent Dupuytren’s contracture. TED after surgery was correlated with patient satisfaction. TED of 40° after surgery corresponded with very good satisfaction (sensitivity: 67%, specificity: 85%). Lack of improvement in grip strength was not correlated with postoperative patient satisfaction. The method of skin incision was also not correlated with satisfaction. Conclusions: Hand function was improved after fasciectomy. Most patients were satisfied with hand function and appearance. ROM corresponded with patient satisfaction in the postoperative period. The results of this study can help to adapt postoperative hand therapy protocols and goals to improve patient satisfaction.

Joachim Ganser, Moritz Scholtes

Department of Hand and Plastic Surgery, Kantonsspital Münsterlingen, Switzerland

Objective: Treatment for Dupuytren contracture in one or more finger rays with Collagenase Clostridium Histolyticum (CCH) becomes increasingly popular. With the last 4-7 years experience also adverse effects are being reported. These are local and systemic ones and allergic or non-allergic ones. As Dupuytren contracture is a localized disease (even in its manifestation as Morbus Ledderhose or Peyronie disease) and in itself not life-threatening, this study’s focus was set on systemic adverse effects possibly threatening the patient’s life or general medical condition. Methods: A retrospective study of 63 patients was performed based on patient charts, complete photo documentation and a subjective questionnaire. Patients were treated for Dupuytren contracture of one or more finger rays by injection of CCH between November 2014 and September 2017. Since January 2017, the majority of patient got two concurrent doses of CCH. Initial follow-up was performed until 6 weeks post injection. Patients were contacted in September 2017 and were invited to clinical follow-up. Results: Of the 63 patients, 47 (75%) returned the questionnaire and 17 (27%) followed invitation to clinical follow-up. Adverse effects, mainly seen within 2 days after injection, included either isolated or in combination: extensive ecchymosis up to the axilla and even one distant ecchymosis (eyelid), severe aseptic inflammation of the lymphatics, headache, pain in all extremities, chill, and dizziness. These complaints lasted up to 2 weeks. 1 frozen shoulder after CCH injection into the ipsilateral hand took 8 months to heal. 1 pulmonary embolism from a deep venous thrombosis of the lower leg occurred 3 weeks after injection. A bilateral basal pneumonia in an otherwise healthy and active patient, retrospectively diagnosed as probable pulmonary embolism, occurred 6 weeks after injection. 1 patient with known coronary heart disease died 6 weeks after injection, the cause of death was not further investigated. Conclusions: As a clearly visible effect, at least the local and distal ecchymosis after Collagenase Clostridium Histolyticum (CCH) injection could be related to affection on the vascular wall or to a disturbance of the blood coagulation system. Concerning pulmonary embolism and sudden death several weeks after injection, an adverse effect on the vessels or a coagulation disorder could be a possible explanation. Most of the adverse effects were not related to allergic reactions. On the other hand, the nature, the extent and the degree of the adverse effects was not related to the amount of CCH (one or two doses). Nevertheless, patients afflicted by a more severe adverse effect were not offered a second or third CCH injection of another or recurrent Dupuytren cord. Confronted with the major adverse effects we saw after CCH injection, we would like to propose further research regarding its systemic effects on vessels and the coagulation system.

Luca Lancerotto, Chris Garrard, Dominique Davidson

Edinburgh Hand Unit, Department of Plastic Surgery, NHS Lothian, UK

Objective: Percutaneous needle fasciotomy (PNF) is a minimally invasive option to treat Dupuytren’s palmar cords, but carries some risk of injury to digital nerves (DN). We performed an anatomical study to identify danger zones where extra care is advisable. Methods: the palm of 6 hands was dissected to investigate the relative position of DNs and longitudinal fibers of the palmar aponeurosis. Results: the index radial and little finger ulnar DNs lie along the outer boundaries of the palmar aponeurosis. The common DN to middle and ring fingers runs between the respective tendons, not crossing longitudinal fibers. The common DN to ring and little fingers originates from the ulnar nerve lateral to the little finger flexors and moves to the radial side where it lies proximally to the transverse fibers. It crosses tendons deeply and longitudinal fibers superficially mid-way between the distal margin of the carpal tunnel and the transverse fibers. The common DN to index and middle fingers less predictably crosses the flexors of the middle finger distal to the carpal tunnel. The 3rd ray pretendineous band does not exactly lie above the tendons, and the crossing with the band can be more distal. The DNs to the thumb emerge from the carpal tunnel at the intersection between the radial margin of the palmar aponeurosis and the distal border of the FPB, along which they proceed. Conclusions: we identified two “danger zones” for nerves during PNF. One more constant, where the common DN to the middle and ring fingers crosses the longitudinal fibers of the 5th ray. One more unpredictable, for the common DN to the index and middle fingers. PNF in the 1st web space should be safe if performed within and at some distance from the distal margin of the FPB and a line along the radial margin of the index finger.

Issei Nagura 1, Takako Kanatani 1, Yoshifumi Harada 1, Masatoshi Sumi 1, Atsuyuki Inui 2, Yutaka Mifune 2, Ryosuke Kuroda 2

1 Department of Orthopaedic Surgery, Kobe Rosai Hospital, Kobe, Japan; 2 Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan

Objective The technical instruction leaflet for collagenase injection recommends a “2-3mm depth” of injection, however, there is little supporting evidence. We consider that collagenase injection into the middle of the cord is optimal to avoid the possible complications of skin laceration or flexor tendon rupture. This study investigated using the long axis images of ultrasonography as a tool to determine the appropriate injection depth. Methods Sixteen male patients with Dupuytren’s contracture with a mean age of 72.2 years (range; 57-87 years) were included in this study. All patients showed fixed flexion contracture (FFC) of the MCP joint caused by a palpable cord. We marked the collagenase injection point on the skin above the cord and added two injection points proximally and distally with a 2mm distance. Then we measured the distance from the skin to the middle of the cord by high resolution ultrasonography with long axis images (SNiBLE; Konica Minolta, Tokyo, Japan). Results The average distance from the skin to the middle of the cord was 2.4mm (range; 1.8-3.0). There was no difference of the distance among the three points. Conclusions Injection of CCH to an adequate depth is very important not only to obtain the maximum effect of collagenase but also to avoid possible complications. By using ultrasonography, we demonstrated that the distance from the skin to the middle of the cord was comparable to that described in the technical manual for the CCH injection namely “2-3mm depth injection is recommended”. Using long axial images was practical for the measurement of the three injection points at one time.

Wan-Sun Choi 1, Kwang-Hyun Lee 2, Kyeong-Jin Han 1, Joo-Hak Kim 3, Chang-Hun Lee 4, Sung-Jae Kim 5

1 Ajou Univerisity School of Medicine, Suwon, South Korea, 2 Hanyang University College of Medicine, Seoul, South Korea, 3 Myongji Hospital, Goyang, South Korea, 4 Eulji Medical Center, Eulji University College of Medicine, Seoul, South Korea, 5 Hallym University Dongtan Sacred Heart Hospital, Dontan, South Korea

Introduction: To date, there have been few reports on the nationwide population-based epidemiology of Dupuytren’s disease (DD). We investigated the prevalence and incidence of Dupuytren’s disease in South Korea using the large dataset provided by the Korean Health Insurance Review and Assessment Service. This study is the second nationwide epidemiological study of DD after the study in Taiwan. Materials and methods: Records of patients diagnosed with DD between 2007 and 2014 were extracted from the large dataset by diagnostic code searching (International Classification of Disease 10th revision code M72.0) and were included in the study. We calculated the prevalence and incidence of DD based on the total population of South Korea provided by the Korean Statistical Information Service. Diseases associated with DD and the trends in surgery for DD were also analyzed. Results: A total 16630 patients were diagnosed with DD during the study period. The mean annual prevalence was 32.2 per 100,000 population (41.8 per 100,000 for men, 22.5 per 100,000 for women). The mean annual incidence was 1.09 per 100,000 population (1.80 per 100,000 for men, 0.38 per 100,000 for women). The common diseases associated with DD were hypertension (30.5%), diabetes mellitus (26.7%), hyperlipidemia (20.4%), ischemic heart disease (7.9%), and cerebrovascular disease (4.6%). The mean annual proportion of the patients who had surgery for DD was 5.24% of all DD patients. Conclusions: The prevalence and incidence of DD in South Korea were as small as 1/1000–1/100 of the western countries; however, it was slightly larger than that in Taiwan.

Sinolichka Djambazova 1, Dusanka Grujoska 2, Darko Petreski 3, Natalija Cokleska 4

Hospital for Orthopedic Diseases University, Skopje, Macedonia

Prospective study of needle fasciotomy for Dupuytrens contracture with two-year follow-up Objective Needle fasciotomy is a relatively new alternative in selected cases of Dupuytrens contracture. The advantage of needle fasciotomy is a very short recovery combined with high cost effectiveness compared to open surgery. The purpose of this study is to report results of needle fasciotomy in respect to reduction of contracture, complications and early recurrence after two years. Methods This study is a prospective study of patients with Dupuytren’s contracture treated with needle fasciotomy. The indication was contractures of the MCP joint and specifically in stages I and II with well defined fibrosis. Needle fasciotomy is a procedure where the contracted Dupuytren’s tissue is divided transversely along multiple points so that the finger can stretch out straight again. The procedure is performed with a needle through the skin and the sharp, small bevel of the needle is used to cut the Dupuytren’s tissue beneath the skin. We also administer a corticosteroid injection to the treatment area at the time of the procedure. Stretching, exercises and extension splinting during the recovery phase are important to gain maximum benefit from the procedure. The patients were evaluated preoperatively and per-operatively at one, two, four, eight, twelve, twenty-four weeks, after one and after two years. 87 patients with 98 fingers were operated. One of the operated fingers had recurrence after needle fasciotomy. Median age was 59 (44-74) with 79 man and 8 women. Results No cases of flexor tendons lesions, hematomas or infections were registered. The degree of the contracture, grip strength, pain, complication, recurrence, need for re- operation and sick leave were recorded. The patients were allowed to use the hand for their work or daily activities directly after the procedure. Conclusions Needle aponeurotomy does not involve incisions to the skin of the hand, so there is less tissue damage, less swelling, less pain, less down time and quicker healing. Needle aponeurotomy does not require a hospital admission or sedation. Needle fasciotomy is a good alternative to fasciectomy in cases with well defined fibrosis because of these preliminary good results and low morbidity.

Franco Bassetto, Regina Sonda, Erica Dalla Venezia, Diego Faccio, Cesare Tiengo

Plastic Surgery Department, Padova, Italy

Objective Several pathogenetic hypothesis were described but no one seems to be singularly responsible for fascia proliferation in Dupuytren’s disease. The surgical approach aim to treat the macroscopic manifestation of finger retraction, often with aggressive approach needed in the most advanced disease stage. It became necessary to investigate the cellular Dupuytren develop to find out new therapeutic approach to permit a more sparing surgery and to treat all severe cases. In fact some clinical studies assess as, in addition to fascia, palmar skin and fat-derived cells may be a potential source of cells causing the Dupuytren disease. Based on this observation, the introduction of the fat graft palmar replacement by lipofilling technique joint to traditional aponevrectomy have shown promising long term good result. Matherial and Method A retrospective study was performed on patients treated for Dupuytren recurrence by aponevrectomy joint to a fat graft from abdominal region. 30 patients, with a medium follow up of five years, were treated in our Centre for Dupuytren disease. An aponevrectomy was performed in all cases according to traditional surgical approach with complete removal of affected fascia. At the end of the skin closure all the surgical site and the unaffected neighboring rays were filled by fat graft harvested from the abdomen (mean 12cc of fat graft for each patient). Primary endpoint of the treatment was to evaluate the skin texture, scar quality, the tendon and finger gliding, pain, discomfort and all technique-related complication and a secondary endpoint was to observe the recurrence of the disease Results The patients were evaluated long-term for a stable result. Three cases are actually at five years of follow up. Five cases were submitted to ecography evaluation. All cases are submitted to clinical evaluation in term of maintenance of low contraction grade, mobility, pain, sensibility, strength, scar condition. Only three cases presented recurrence after two years and slide tendon and finger functionality revelead a satisfactory result. Ecography evaluation at six months and one year demonstrated also the permanence of fat pad under superficial skin layer, providing a sliding tendon good environment and, overall, a barrier from affected surrounding fascia. Discussion Fat grafting is a common procedure in reconstructive and aesthetic surgery and commonly defined as “lipofilling”. It’s commonly employed in several clinical field for its filler role in volume replacement both overall for its stem cell content known as adipose derived stem cell (ADSC) and its capability to provide numerous cytokines. Furthermore, for such reason, several clinical experience were based on its utilisation also in severe Dupuytren treatment even for providing a viable subcutaneous fat capable to protect the neurovascular and tendon structure even for its possible role in modulating the fibroproliferative diathesis. Preliminary satisfactory results have represent a stimulating challenge to introduce this procedure as scheduled with possible future perspectives of numerously clinical data collecting, specific examination, long term follow up, molecular studies and useful guidelines for therapeutic purpose.

David J Hunter-Smith, Jessie Xu, Theodore Lam, Daniel Reilly, Michael P Chae, Vicky Tobin, Warren M Rozen

Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston Victoria, Australia; Monash University Plastic and Reconstructive Surgery Group (Peninsula Clinical School), Peninsula Health, Frankston, Victoria, Australia

Objective: Determine the safety and efficacy of injectable collagenase clostridium histolyticum (CCH) for advanced Dupuytren’s Disease Methods: Patients presenting with advanced Dupuytren’ Disease (Tubiana grade 3 or 4) of the 2nd through 5th rays that were unsuitable for or declined surgical management were offered treatment with collagenase injections. Baseline demographic and medical data were collected. In addition, total passive extension deficit (TPED) and patient-reported outcome measures (PROMS) were recorded prior to treatment, and at 6 weeks post-manipulation. Patients underwent a standard treatment protocol of injection D0 and manipulation D7 under local anaesthetic on an outpatient basis. Results were collected prospectively and analysed using paired t-test. Results: 33 patients (25 males, 80.7%) with a mean age of 68.4 years (range 49.8-87.1) have been treated to date. In 43% of cases the disease represented a recurrence. There was a significant improvement in TPED across all injected rays (p<0.001). In addition, patients demonstrated highly significant improvement in function and quality of life on Southampton (p=0.0004) and URAMS (p=0.000001) questionnaires. No major complications were encountered. Conclusions: Our data suggest that collagenase, as a treatment option, is safe to use in patients with advanced Dupuytren’s Disease. It demonstrates significant improvements in objective and subjective measures of hand function. Whilst surgery remains the mainstay of management for advanced disease, CCH is a viable alternative for patients in whom surgery is not appropriate.

Ioannis Antoniou, Kostas Banios, Vasilis Kontogeorgakos, Zoe Daliliana, Konstantinos Malizos, Sokratis Varitimidis

Department of Orthopaedic Surgery, University of Thessalia, Larissa, Greece

Objectives: Dupuytren's contracture affects significantly appearance and function of the hand. In advanced stages use of the hand is difficult and sometimes includes risks. Operative treatment includes percutaneous division of the palmar fascia, partial and total excision of the palmar fascia. The aim of this study is to present complications and the long term outcome in a large group of patients in whom the disease was treated with resection of the contracted palmar fascia, only in the affected rays. Methods: From 2000 to 2015, 214 patients (170 men and 44 women) with Dupuytren's contracture were treated with excision of the contracted palmar fascia in the affected rays, Mean age was 67 years (from 37 to 86). The dominant hand was affected in 136 patients. The ring finger was most commonly affected (139 patients). Eighty eight patients presented with two or more finger rays affected. The procedure was performed under anesthesia with axillary block and with a tourniquet application. All diseased tissues (contracted fascia, skin, digital ligaments) were dissected and excised with great caution in the affected rays. Excision of the contracted tissues at the proximal phalanx was carried out in all patients to restore or improve range of motion Check rein ligaments in the PIP join were divided if there was stiffness of the joint. When skin was contracted and infiltrated by the disease, it was removed and the wound was left open to close by secondary intention. Non diseased palmar fascia of the adjacent finger rays was not excised. Results: Mean postoperative follow up was 9 years (from 2 to 15 years. Preoperatively, average extension deficit in the MCP and PIP joint was 38 and 32 degrees respectively. Postoperative values at the final follow up were 10 degrees in both joints presenting improvement of 28 and 22 degrees. Complications occurred in 56 patients (26%) and included 15 recurrences, 13 cases with complex regional pain syndrome, 1 amputation of the distal phalanx of the ring finger, 3 arthrodeses, 6 wound infections, 4 injuries of digital nerves that needed immediate repair, 7 sensory neuroapraxias that resolved after six months and 7 cases with cold intolerance which improved and resolved at two years postoperatively. Conclusions: Excision of the affected-contracted palmar fascia is effective in the treatment of Dupuytren's contracture. Although it is technically demanding in the advanced stages of the disease, it remains the most effective type of treatment in these late stages. Complications (early and late) are frequent with the most serious being a digital nerve injury, infection, complex regional pain syndrome and recurrence of the disease. Early complications needed immediate and appropriate treatment to obtain a satisfactory outcome.

Eva-Maria Baur, Robert Zimmermann, Verena Müller, Waltraud Mair

University Clinic of Plastic, Reconstructive and Aesthetic Surgery, lnnsbruck, Austria

In our clinic we are looking for the results after two minimally invasive treatments for Dupuytren disease in a prospective non-randomized study since 2011. With the upcoming possible treatment with collagenase the “”old fashioned" therapy with percutaneous needle fasciotomy (PNF) becomes a big revival. The purpose of the non-randomized prospective study was to Iook for differences regarding the two possible treatments. The results after 12 to 24 months was already presented. Now we get the results with a follow-up minimum of three years. In our clinic we propose and perform both treatments, the decision is taken together with the patient. Since more than 5 years we (try to) follow-up the patients regarding the results preoperative, after 3 weeks, 3, 6, 12, 24, 36, … months; regarding function, scars, and recurrence (worsening of contracture in comparison to 3 weeks postop at least for 20°). In the study since 1/2012 to 9/2016 we get overall 108 patients, overall we treated 185 minimal-invasive in this time. As a lot of people are not coming to the late clinical controls we start a recall to bring them back to the clinic. Now we got the following results with minimum FU of 36 months: Patients treated with Xiapex: 15 patients – 5 recurrences (2 in MCP and 3 in PIP joint) PNF: 23 patients – 6 recurrences (1 in MCP and PIP joint, 5 in PIP joint) Post “operative" treatment is night-splinting for 6 weeks. We report our results of both groups. As in our first report in 2014 and 2015 within results from 1 to 2 years postop, we cannot find a real difference between both groups. We report also the pros and cons of the two different treatment options. The groups are still very small, comparing to all the patients are treated, but it is very difficult to bring the people back to the clinic, if they don’t feel the need of further treatment (with or without a recurrence), but we are still trying to get more people back.

Özge İpek 1, Mustafa Nazım Karalezli 2, Oğuzhan Şamil Erciyes 2, Nevres Hürriyet Aydoğan 2, Kılıçhan Bayar 1

1 Muğla Sıtkı Koçman University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Muğla, Turkey; 2 Muğla Sıtkı Koçman University, Faculty of Medicine, Department of Orthopedics and Traumatology, Muğla, Turkey

Objective: Dupuytren’s disease (DD) is a common benign fibromatosis of the palmar fascia causing chronic contracture of the fingers. The exact etiology of DD have not been entirely identified. The general aspect is that a combination of risk factors can influence in genetically predisposed patients. These include diabetes, smoking, older age, menopause, alcohol consumption and male gender. The objective of this study was to investigate the etiologic factor of associated with DD. Methods: This study was planned as a descriptive study. Ethics committee approval was obtained for the research. A total of 120 patients who received the diagnosis of DD by the orthopaedic surgeon. All patients signed an informed consent form. A sociodemographic form was prepared by researchers used to evaluate etiologic factors of DD. All patients completed the questionnaire which related to gender, dominant hand, affected fingers, smoking and drinking alcohol habits and history. Results: A total of 50 patients with DD (16 female, 34 male) were participated voluntarily in the study. The average age of participants was 61.26±11.85 years. The mean height was 1.62±0.07 m, the mean body weight was 68±12.03 kg and the mean body mass index was 25.4±3.8 kg/m2. Weight, height and body mass index were not statistically correlated with DD. Both hands were affected in two cases (4%). In our study the most affected finger is 4th finger (n=30, 60%). 80% of participants used his/her right hand dominantly. No correlation was found between the dominant hand and the affected side (p = 0.45). The average duration of DD was 1.44±0.5 years. 14% of participants were smokers. No significant relation was found between smoking and DD in our study (p= 0.23). None of participants had drinking alcohol habit. This study found no correlation with drinking alcohol with DD in our population. Conclusions: Results show that the prevalence of DD was significantly higher among men than among women. The most affected finger is 4th finger. Our study found no correlation with smoking with DD. Further research must be undertaken to clarify the relation with the etiologic factors in large population with DD. In conclusion, a large-scale research is necessary to determine the etiology and in order to confirm the relationships between etiologic factors and DD.

Eric Camprubí Garcia, Silvia López Marne, Jose Moranas Barrero

Hospital Universitari de Bellvitge, Barcelona, Spain

Objectives: The objectives of the study are to asses: clinical success, recurrence rate, nondurability of response, progression of disease and occurrence of adverse effects (AEs) after a minimum follow-up of 3 years. Methods: All patients with Dupuytren’s contracture affecting at least one metacarpophalangeal (MCP) joint or one proximal interphalangeal (PIP) joint who received one or more CCH injections from 2012 through 2017 were included. The criteria for inclusion were palm and / or digital palpable cord, with contracture due to Dupuytren's disease (<20º), without contraindication to the injection and the acceptance of the CCH treatment by the patient. The Tubiana’s classification was used to quantify the initial severity of the contracture prior to treatment. Each cycle of treatment consisted of a single injection of 0.58 mg of CCH into the cord followed by a finger extension the next 24 or 48 hours. Patients were followed at day 30, 90 and once annually for 2 years after the first injection. Demographic and disease characteristics at baseline were recorded. At each visit, MCP and PIP joints were measured and changes in contracture were determined. Demographics and disease characteristics of treated joints were summarized. Incidence rates of recurrence, progression and worsening were calculated for all joints, by joint type and by joint severity. AEs to CCH injections were also summarized. Statistical analysis was performed by using SPSS v19.0 (IBM Corp., Armonk, NY, USA).. Results: We have followed the criteria defined in the CORDLESS study to classify the results into success, relapse or low response; obtaining overall results of 79.17% success, 10.42% recurrence and 10.42% low response to treatment. Of 79.17% of the successes, 84% corresponded to the MCP articulation and of these 50% to the 4th finger. All patients with grades I-II of Tubiana. Of 10.42% of the recurrences, 75% was presented in the 5th finger with a recurrence rate of 20% MCP and 16.6% IFP. 80% of these cases corresponded to the degree II of Tubiana. The average time of onset of recurrence was 6.6 months and in all cases, it was detected during the first year. Finally, of 10.42% with low response, the majority of cases were presented in the art PIP (80%) and in the 5th finger, reaching a low response rate of 50% in these cases. The majority of cases (80%) stage II of Tubiana. The side effects that have been observed more frequently have been pain at the injection site, hematoma, local edema, ecchymosis, skin laceration and lymphadenopathy. Conclusions: Collagenase treatment for Dupuytren's disease is effective, with a low complication rate and lower healthcare costs than surgery. The best results are obtained in the treatment of the art MCP of the 3rd and 4th fingers, with Tubiana I-II grades. The worst results are obtained in the treatment of the PIP art of the 5th finger and in the II degree of Tubiana. Recurrences usually appear between the 6th month and the year of treatment. With a greater selection of cases to treat, we can achieve results similar to those of open surgery.

Grigorios Kastanis, George Belivasakis, Petros Kapsetakis, Eirini Trachanatzi, Idomeneas Makrigianakis, Nikolaos Bounakis

General Hospital of Heraklion- Venizelio, Greece

Objectives: Dupuytren's disease is a fibroproliferative disorder of unknown origin causing palmar nodules and flexion contracture of the digits. The treatment of choice is surgical excision of the affected palmar fascia. The rate of postoperative complication is reached up to 17-19%. The purpose of this study is to analyze the functional outcomes and the rate of complications in patients with Dupuytren’s and concomitant Diabetes mellitus disease who undergoing surgical treatment with needle versus open fascietomy. rnMaterial & Methods: Between 2013-2016 38 patients (25 male- 13 female) with an average age 59 years old (48-69) were operated for Dupuytren’s contracture. 9 patients had diabetes mellitus type 1 and 29 type 2. The second digit was involved in 2 (5,2%) cases, the third digit in 7 cases (18,4%), the fourth digit in 8 cases (21%) and the fifth digit in 10 (26,3%) cases. In 4(10,5%)cases the contracture affected both middle and ring finger and in 7(18,4%) cases the ring and little finger. 22 patients were Tubiana type III, and 16 patients type IV. In 18 patients (11 Tubiana III and 7 Tubiana IV) was performed needle fascietomy (group A) and in 20 patients (11 Tubiana III and 9 Tubiana IV), open fascietomy(group B). A short arm splint was applied postoperatively to maintain the hand and fingers in extension. After the edema subsided, the splint was removed and rehabilitation initiated. All patients continued to use the extension splint at night for two more months.rnResults: The mean follow-up period was 28,2 months (range 14 to 38 ). In group A 9 patients (50%) had excellent results, 6 (33,3%) had good results and 3 (16,7%) had fair results. Mean Quick DASH score for this group at the final follow-up was 6.8. Complications rate was: 2 cases with digital nerve injury and 1 case with neuroma, 3 cases with hematoma and 2 cases with recurrence. In group B 11 hands (55%) had excellent results, 5 (25%) had good results and 4(20%) hands had fair results. Mean Quick DASH score for this group at the final follow-up was 4,5. Among the complications: 1 case with chronic regional pain syndrome, 2 cases with hematoma, 3 cases with infection, 1 case with recurrence. rnConclusion: Dupuytren’s disease appears in patients with diabetes mellitus in percent 25%. The contracture of the digits causes disability frequently in manual worker especially in late stage of the disease. Percutaneous needle fascietomy is a minimally invasive treatment modality with low rate of complications versus to open fascietomy especially in patients with diabetes mellitus.rn

David J Hunter-Smith, Robert Capstick, Rachael Leung, Angela Lei, David Nour, Warren Rozen

1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health; 2 Monash University Plastic and Reconstructive Surgery Group

Objective: In order to better inform patients we aimed to determine the morbidity of established interventions for Dupuytren’s Disease Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . We included published complications following treatment with radiotherapy, fasciotomy, collagenase, fasciectomy, aponeurotomy, and dermofasciectomy that assessed the treatment of primary Dupuytrens disease. 35 studies were finally included; evidence level 2 (6), level 3 (10) and level 4 (19). Results: A total of 3104 participants (mean 76 per study) were included. The mean follow up was 21.5 months. Study types included retrospective cohort (20), prospective cohort (9) and RCT (6). Calculated rates for infection, haematoma, nerve injury/neuropraxia, wound complications, and CRPS/neuropathy for all treatment types is reported. Conclusions: The quantification of complication rates following treatment for primary Dupuytren disease may facilitate decision making and patient counselling.

Stefano Galli

Orthopaedic Clinic - University of Brescia, Brescia, Italy

Objective: Regarding Dupuytren’s disease, in the literature of the last decades the lack of precise definitions concerning the therapeutic procedures, the lack of a single evaluation system of functional results, which can be applied to all available therapeutic procedures, the lack of a clear definition of recurrence and, consequently, of a relative staging system, has generated much confusion. These problems have become evident mainly thanks to the new interest in Dupuytren's disease caused by recent non-invasive therapeutic applications (Collagenase of Clostridium Histolyticum). The International Consensus Conferences of Rome 2013 (Felici et oth, 2014; Kan et oth, 2017) laid the foundations for an appropriate diagnostic-therapeutic framework that will allow the comparison of the results of future cases. We propose a new, and possibly simple, staging system that permit to evaluate clinical postoperative results and recurrence of contracture at follow-up . Methods: We considered as firm points results elaborated by the International Consensus Conference of Rome of 2013: to assess an extension deficit, the measurement of the passive extension deficit (PED) of each treated joint should be used, considering each joint as a separate entity. Time 0 is defined as the period between 6 weeks and 3 months after treatment. A PED of more than 20° for at least one of treated joints, in the presence of a palpable cord, compared to the result obtained at time 0 represented the definition of recurrence. But we considered that some authors in literature consider recurrence a PED of more than 30°. Furthermore a detailed definition for correction of contracture remains not clear too. Clinical studies of collagenase clostridium histolyticum provide a good example of how this can be accomplished (Peimer et oth., 2015). Finally we considered salvage procedures in which PED is not evaluable. Results:We firstly considered the single joint residual PED at time 0. We defined: T0 a successfully treated joint, or excellent result, if residual PED is 0° to 5°; T1 a measurably treated joint, or good result, if residual PED is > 5° but < 20°; T2 a not effectively treated joint, or poor result, if residual PED is 20° or more; T3 a joint treated with salvage procedures (as amputation, arthrodesis, corrective osteotomy). Than we considered recurrence rate at follow-up time, compared to results evaluated at time 0. We defined: R0 no recurrence; R1 a progression of the contracture < 20°; R2 a progression of contracture from 20° to 29°; R3 a progression of contracture of 30° or more. Example: MF5 T0R1: metacarpophalangeal joint of the fifth ray, with excellent result at time 0, with a progression of contracture < 20° at follow-up. Conclusions: We think that this staging system can be a useful instrument for evaluation treatment results and recurrence rate of Dupuytren’s disease and can be applied to all available therapeutic procedures actually described.

Elbow (45 abstracts)

Bertille Charruau, Steven Roulet, Jacky Laulan

CHRU , Service de Chirurgie Orthopédique et Traumatologique, Tours, France

Introduction. The Kaplan’s interval is the most common lateral approach for elbow surgery but involves a neurological risk. The approach, between extensor carpi radialis brevis and longus muscles, initially described for surgical treatment of the radial tunnel syndrome, allows a visual checking of the radial nerve and branches. For more than 20 years, we used this lateral approach for elbow arthrolysis and/ or synovectomy. Material and methods. The modified lateral surgical approach and its anatomical relationships have been assessed by an anatomical study in 1994. The exposure between the two extensor carpi radialis muscles, allowed to locate the radial nerve and its deep branch and permitted, together with a proximal extension of this interval, an excellent exposure of anterior capsule. Since then, this approach has been systematically used for arthrolysis and/or synovectomy. Results. It has been used in 43 patients, 30 men and 13 women whose mean age was 40.56 years (17-84). It always allowed, eventually in combination with a medial approach, a peroperative recuperation of a total or subtotal elbow extension, without neurologic complication. In association with the posterolateral approach, between anconeus and extensor carpi ulnaris muscles, it allowed a subtotal synovectomy. Discussion. The « classic » lateral approach goes distally through the lateral epicondylar muscles, approximately between extensor carpi radialis and extensor digitorum communis. The exposure of anterior aspect of the articulation imposes to cut the distal part of the extensor carpi radialis longus and the anterior part of the lateral epicondylar muscles, in practice the extensor carpi radialis brevis. This approach is distally limited by the deep branch of the radial nerve. The absence of visual control of the nerve, despite some tricks (short incision and pronation of the forearm), involves an important neurologic risk. The approach, between extensor carpi radialis brevis and longus, is different of the Kaplan exposure because the extensor carpi radialis brevis is left in place with the other epiconylar muscles. So, it is slightly more anterior than the Kaplan’s interval. It allows checking of the posterior interosseous nerve and a better exposure of the anterior aspect of the elbow. Conclusion. This surgical approach is more efficient to expose the anterolateral aspect of the elbow and less risked than the Kaplan approach. Initially described for the surgical treatment of radial tunnel syndrome, it must be recommended for elbow arthrolysis and synovectomy.

Isidro Jiménez, Pedro J. Delgado

Hospital Universitario HM Montepríncipe, Madrid, Spain

Proximal radioulnar synostosis is a rare but highly disabling posttraumatic complication in periarticular elbow injuries. Surgical treatment is an option for functionally limiting proximal radioulnar synostosis however, the approach can endanger local neurovascular structures especially if the synostosis affects the level of the bicipital tuberosity. The Sauvé-Kapandji technique was as a combination of arthrodesis of the distal radioulnar joint and ulnar resection-osteotomy proximal to the arthrodesis to restore pronation and supination of the forearm. In proximal radioulnar synostosis we already have the arthrodesis so we just have to achieve the nonunion of the proximal radius. We report two cases of proximal radioulnar synostosis with a preoperative prono-supination range of motion of 0 and 15º treated by a reverse Sauvé-Kapandji procedure resecting a 1-cm section of the radial shaft distal to the bicipital tuberosity and leaving the synostosis in place. An improvement in prono-supination arc of motion of 82.5º was achieved at two years of follow-up with no complications associated to the technique. According to the results published in the limited available literature and our own results, we believe that the reverse Sauvé-Kapandji procedure could be a valid option in the treatment of proximal radio-ulnar synostosis in cases where an aggressive excision of the bone bridge may result in a fatal iatrogenic injury to the local neurovascular structures.

Arun Hariharan 1, Christine Ho 2, Andrea Bauer 3, Charles Mehlman 4, Nathan O'Hara 1, Paul Sponseller 5, Joshua M. Abzug 6

1 University of Maryland Orthopaedic Associates, Baltimore, USA; 2 Texas Scottish Rite Hospital for Children, Texas City, USA; 3 Boston Children's Hospital, Boston, USA; 4 Cincinnati Children's Hospital Medical Center, Cincinnati, USA; 5 John's Hopkins Hospital, Baltimore, USA; 6 University of Maryland School of Medicine, Baltimore, USA

Objectives: Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. The purpose of this study was to assess the various injury patterns, treatments, outcomes, and complications in a large series encompassing multiple institutions. Methods: A retrospective review was conducted at five pediatric institutions to identify all transphyseal humeral separations in patients 0-3 years of age from January 1991- December 2016. Patient demographics, mechanism of injury, Child Protective Services involvement, diagnostic modality, time to surgery, configuration, and complications were recorded. Frequencies and means were recorded for demographic and epidemiological analysis. Results: Seventy-nine patients aged 0-46 months, with a mean of 17.6 months, were identified. The most common mechanism of injury was accidental trauma (62%), followed by non-accidental trauma (27%), Cesarean section (7%), and vaginal delivery (4%). Child Protective Services were involved in 39 cases (49%). Additional injuries were noted in 19 patients; most commonly additional fractures including the humerus, ribs, and skull fractures. All patients had elbow radiographs, while four patients also had an ultrasound and/or an MRI. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intra-operatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), 80% had two pins for fixation (n=63), and two patients underwent an open reduction. Ten complications were noted, including decreased range of motion (n=4) and cubitus varus/valgus (n=6) (8%). No cases of avascular necrosis or physeal arrest were found. No loss of reductions occurred. Conclusions: Transphyseal humeral separations have excellent outcomes in the vast majority of patients. We recommend high suspicion for non-accidental trauma with transphyseal humeral separations as Child Protective Services involvement was required in over half of the non-birth related injuries. The most common complication was distal humeral deformity; patients should be followed beyond pin removal to evaluate for residual deformity. This multicenter analysis provides the largest demographic and outcomes data pertaining to transphyseal humeral separations. It is important to consider non-accidental trauma for all of these injuries that do not occur during the birthing process.

Guiliana Rotunno 1, Mark Shasti 2, Alexandria L Case 1, Joshua M Abzug 1

1 University of Maryland School of Medicine, Baltimore, USA; 2 University of Maryland Orthopaedic Associates, Baltimore, USA

Objectives: Healthcare costs continue to increase, even for common orthopaedic procedures, such as closed reduction and percutaneous pinning (CRPP) of supracondylar humerus fractures in the pediatric population. Providers must investigate causes of monetary burdens placed on patients. One such cause may be location of care. The purpose of this study is to quantify the direct cost of CRPP for supracondylar humerus fractures to determine if there is a significant difference of cost between a tertiary care center and a community hospital. Methods: A retrospective chart and radiographic review of 136 supracondylar humerus fractures treated with CRPP over six years (2010-2016) was performed (74 male, 62 female). Fractures treated at a tertiary care center (n=106) accounted for 78% of the cohort and those treated at a community hospital (n=30) accounted for 22%. The primary outcome measure was the total operating room cost. Statistical analysis was completed using a two-sided T-test. Results: The data indicated that the average cost of treating supracondylar humerus fractures via closed reduction and percutaneous pinning is no different between tertiary and community care centers (p=0.4). The average cost of CRPP procedures at the tertiary care center was $2,292.93 (CI: $1,782.21-$2,803.65). The average cost of percutaneous pinning procedures at the community hospitals was 2,378.28 (CI: $2,169.48-$2,587.08). Conclusion: The average cost of closed reduction and percutaneous pinning of supracondylar humerus fractures is similar at various locations, with costs charged at a tertiary care center being largely the same as those charged at a community hospital. The current study suggests that the location of common outpatient or short stay pediatric orthopaedic procedures does not influence its cost.

Gonzalo Luengo Alonso, Leandro Ramos Ramos, Veronica Jimenez Diaz, Miguel Angel Porras Moreno, David Cecilia Lopez, Lorena Garcia Lamas

Hospital 12 de octubre , Madrid, Spain

Background Patterns of elbow unstable fracture-dislocations include transolecranon fracture-dislocations, among others. This pattern of is not that frequent, and occurs when a high-energy direct blow is applied to the dorsal aspect of the forearm with the elbow in mid-flexion. Objectives Analyze functional and clinical outcomes of this group of fractures treated surgically. Study Design & Methods Retrospective study of trasnolecranon fracture-dislocation surgically treated at our center (2007-2016). A total of 15 fractures were included. Patients with non-follow up, less than 6 months follow-up and ipsilateral acute fractures were excluded. Results Mean age was 62.53 (SD 19.2). Seven men and eight women. Average time to surgery was 5.27 days, and surgical time 92 minutes (SD 36.58). Associated fractures were present: 9 radial head, 2 coronoid process. Final range of movement was excellent: mean elbow flexion about 125-130 degrees, with only 5-10 extension loss. Pronation was complete in almost every single patient, as well as supination. Mean follow up was more than three years. There were no major complications associated to surgical treatment. Hardware removal was necessary in four cases due to discomfort. Finally, functional scores were very good: Mean DASH was 36.38 and Mayo Clinic Score was 100. Conclusions Transolecranon fracture-dislocations have good functional outcome if treated correctly, as there is no ligament injury. Surgical treatment allows earlier recovery and most of the times almost same range of motion as they had before the fracture.

Ana M. Far-Riera, Carlos Perez-Uribarri, Matias Esteras Serrano, José María Rapariz Gonzalez

Hospital Son Llatzer, Palma De Mallorca, Spain

1.- Aim Analyze the resutls of radial head prosthesis in three different patterns of instability: elbow triads, variation of Monteggia and comminutted no reparable head fractures. 2.- Background Surgical management of comminuted radial head fracture include excision of the radial head, reduction and internal fixation and arthroplasty. In our hospital we indicate radial head arthroplasty in fractures types III and IV of Mason with valgus instability or Essex Lopresti injury. 3.- Methods We made a descriptive retrospctive study of radial head fractures. Since 2005 to 2010 twenty-one radial head prosthesis were implanted in our hospital. We followed up 19 cases, during 54 months, 11 of them were women, with an average of 56 years. We had 9 elbow triads, 5 variation of Monteggia fractures and 5 radial head fractures associated with instability. 4.- Results Clinically, 12 patients achieved excellent results (6 triads, 3 variation of Monteggia and 3 radial head fractures associated with instability), and 7 achieved good results. According to the pattern of fracture, patients with elbow triad and Monteggia presented excellent results, and patients with radial head fractures associated with instability had good results. At DASH score we obtained an average of 11. Radiologically, 13 patients did not developed osteoarthritis in capitellum and 8 did not developed it in the ulno-humeral joint. Five patients developed heterotopic ossification. In 14 patients the neck was reabsorbed. Only 2 patients presented stem loosening, both long stem. No instability was noted. 5.- Conclusions In our series stress shielding was developed only during the first year, remaining stable thereafter. On our experience we can conclude that unlike other studies, we have found a low incidence of radiolucency and complications, and that all elbows have proved to be stable. The limitations we had in this study were those of a retrospective study, and a low number of patients. A more longer term study could be requiered to get more reliable conclusions.

Takuji Iwamoto, Tsuyoshi Amemiya, Taku Suzuki, Satoshi Oki, Noboru Matsumura, Kazuki Sato

Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

Objective: An olecranon osteotomy approach is the most common method recommended for intra-articular distal humeral fractures. This approach provides good exposure of the articular surface, enabling accurate articular reduction for intra-articular distal humeral fractures, however, this approach is associated with several complications, including symptomatic hardware prominence, nonunion or delayed union of the olecranon, and loss of osteotomy reduction. The purpose of this study was to assess the outcomes of the lateral para-olecranon approach for the treatment of intra-articular distal humeral fracture. Methods: Ten patients (4 males, 6 females) with a mean age of 55 years (range 23-85) were retrospectively reviewed. There were three C1, and seven C2 fractures according to the AO/ASIF classification. Type B3 and C3 fractures were excluded from this study because antero-lateral approach or olecranon osteotomy approach were indicated to visualize the anterior fragment. The triceps was split between the lateral triceps expansion and the central triceps tendon, and the anconeus muscle was incised from the proximal ulna. The lateral half of the triceps along with anconeus was retracted laterally as a single unit. After that, the medial half of the triceps muscle was released from the medial intermuscular septum and dorsal aspect of the distal humerus. The distal part of the humerus could be visualized from medial and lateral windows by retracting the medial half of the triceps. The articular fragment was anatomically reduced and fixed temporarily with Kirschner wire, and the reconstructed distal articular block was then fixed to the humeral shaft with double locking plates. Results: Technical difficulties during surgery were not encountered in this case series. No articular step-offs of more than 1 mm were seen on postoperative radiographs. Postoperatively, average elbow flexion was 128° (range, 110° to 145°), and extension was –12° (range, –22° to 0°) at the average follow-up time of 11.7 months (range, 8‒20 months). Eight patients had normal muscle strength against full resistance (manual muscle testing grade 5), and the other two patients had slightly reduced muscle strength (grade 4). Subcutaneous prominence of the hardware was observed in two cases, and removal of the implant was required. Transient postoperative ulnar nerve palsy was observed in two cases, but they resolved within 6 months. There were no cases of postoperative infection or heterotopic ossification. The average (± standard deviation) Mayo Elbow Score was 94 ± 5.8 points at the final follow up. Conclusions: The lateral para-olecranon approach is useful for the management of type C1 and C2 distal humeral fractures, preserving extension strength and providing satisfactory clinical outcomes, with no risk of olecranon osteotomy-related complications.

Osamu Soejima

Department of Orthopaedic Surgery, Fukuoka Sanno Hospital, School of Medicine, International University of Health and Welfare, Japan

Hypothesis: The pathologic entity of recalcitrant tennis elbow (lateral epicondylitis of the elbow: LEC) would be the impingement syndrome of the lateral elbow related to the radial head abutment during supino-pronation as the impingement syndrome of the shoulder. We hypothesize that the radial head of patients with LEC has poorer mobility. Thus, it is critical to release the tension of the radial head, therefore both the capsule and a part of the annular ligament must be resected during the surgery. Methods: 71 elbows in 68 recalcitrant LEC patients (26 males and 42 females) who underwent mini-open modified Boyd’s procedure were evaluated clinically, ultrasonographically, MRI findings, and histologically. The average follow-up period was 14.2 months. Results: JOA-JES score improved from 33.9 to 92.2. From the ultrasonographic analysis, the severe LEC group had poorer radial head mobility than the mild LEC group. From the MRI and histological evaluations, the degree of the MRI signal changes and histological character were correlated but the histological changes (e.g. fibrosis or angiogenesis) were randomized. Conclusions: The abutment of the radial head to the ECRB origin during the supino-pronation was confirmed, and the decrease of the elasticity in the ECRB origin and the inhibition of the normal radial head motion were observed in the ultrasonographic evaluations. The Degree of the MRI signal changes and histological character were correlated but the histological changes (e.g. fibrosis or angiogenesis) were randomized. Recalcitrant LEC has a progress cycle (micro tear → angiogenesis → remodeling → fibrosis). As this cycle progresses, the decrease of the elasticity in the ECRB origin and the inhibition of the normal radial head motion would occur like the impingement syndrome of the shoulder (Latera elbow impingement syndrome: LEIS). Thus, the key-point of the surgical concept for the recalcitrant tennis elbow is not only the debridement of the degenerative tissue at the ECRB origin but also the decompression of the peri radial head at the lateral elbow (Peri radial-head decompression: PRD). References: 1. Soejima O, Iwamoto R, Matsunaga A: Surgical treatment of lateral epicondylitis; Results of arthroscopic versus open procedure. FESSH, 2014 2. Muraoka K, Soejima O: Pathogenesis of the lateral epicondylitis; Ultrasonographic analysis. ASSH, 2016 3. Soejima O: New pathologic entity of tennis elbow: Lateral elbow impingement syndrome (LEIS). ASSH, 2017

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

BACKGROUND: Nowadays, the Wide-Awake approach is commonly used in hand surgery. However, it is rarely used in elbow surgery. Lateral and medial epicondylitis surgery mostly performed with tourniquet control under local, brachial plexus block or general anesthesia. The purpose of this study was to compare the perioperative pain and clinical outcomes of surgical treatment using Wide-Awake approach for lateral or medial epicondylitis. MATERIAL AND METHOD: 88 patients (93 elbows) underwent surgery for lateral (51 elbows, 48patients) or medial epicondylitis (42 elbows, 40patients). Patients were divided into two groups (lateral, medial epicondylitis) and then each group was subdivided into two groups based on their anesthesia method and tourniquet use. 1. Lateral epicondylitis (LE) (n=51 elbows, 48patients): 26 elbows were in wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 25 elbows were in the local anesthesia group (LA) who received lidocaine alone as a local anesthetic agent with a 250-mmHg tourniquet application 2. Medial epicondylitis (ME) (n=42 elbows, 40patients): 20 elbows were in the wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 22 elbows were in the general anesthesia group (GA) and a 250-mmHg tourniquet application The outcome was assessed regarding the pain using the visual analog scale (VAS), Roles & Maudsley score, and Nirschl & Pettrone grade. Results: Overall elbows (91%) achieved satisfactory results. There were no perceived outcome differences between any of these individual groups at final follow-up (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in LE(LA) group than LE(WA) group(p < 0.05). The postoperative pain during the first 1week after surgery were higher in ME (GA) group than ME (WA) group (p < 0.05). Conclusions: a Wide-awake approach to Lateral and Medial Epicondylitis offers better comfort for patients and reliable technique that eliminates the need for general anesthesia, removes the need for a tourniquet.

Minho Lee, Hyun Sik Gong, Seong Cheol Park, Sehun Kim, Goo Hyun Baek

Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective To determine whether olecranon fractures have osteoporotic features such as age-dependent low bone attenuation and low-energy trauma as a cause of injury. Methodology In a total of 114 patients (53 males and 61 females) with acute olecranon fracture, we retrospectively reviewed elbow CT scans and medical records for the causes of injury (high or low-energy trauma). Their mean age was 57 years. Bone attenuations were measured on the central part of the olecranon on sagittal CT images avoiding the fracture and on the distal humerus (distal metaphysis and medial and lateral condyles) on coronal CT images. We compared bone attenuations and causes of injury in each gender between younger (< 50 years) and older (≥ 50 years) patients. Multiple regression analysis was performed to determine the effect of age and gender on bone attenuation. Results Mean bone attenuations in older male or female patients were significantly lower than those in younger patients except in the medial condyle in men. The proportion of low-energy trauma in older male patients was significantly higher than that in younger male patients. In female patients, low-energy trauma was predominant in both younger and older patients. Age and female gender were found to have significantly negative effects on bone attenuation. Conclusions This study demonstrates that olecranon fractures have osteoporotic features, including age-dependent low bone attenuation and low-energy trauma as a predominant cause of injury. Our results suggest that osteoporosis evaluation should be considered for patients aged 50 years or more with an olecranon fracture.

Alexandria L. Case, Carissa Meyer, Ebrahim Paryavi, Joshua M. Abzug

University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: Supracondylar humerus fractures are the most common pediatric elbow fracture. As children can be difficult to examine and many may have associated neurovascular injuries that can alter timing of treatment, the purpose of this study was to assess adequacy and accuracy of documentation regarding neurovascular injuries. Methods: A retrospective chart review was performed to identify all pediatric supracondylar humerus fractures in children under the age of 15. Data collected included patient age, type of fracture (Type I, II, III extension, flexion), clinician type (Emergency Department or Orthopaedic surgeon) and level of training, motor exam documentation (anterior interosseous nerve (AIN), radial nerve and ulnar nerve function) and presence of a nerve palsy. Linear regression was used to analyze documentation with regards to patient age and clinician level of training. Results: Thirty patients were identified during the study period, including three patients with associated nerve palsies (two AIN and one radial nerve palsy). In all cases, the nerve palsy was not recognized by the ED physicians or the orthopaedic resident(s) prior to the orthopaedic attending’s evaluation. In patients with a nerve palsy, motor documentation continued to be incomplete or failed to document a nerve palsy in >50% of notes even after attending documentation of the nerve palsy. Incomplete motor exam documentation occurred in 97% of ED notes. There was no correlation between motor exam documentation and year of orthopaedic residency training. Documentation by orthopaedic residents was significantly improved as patients increased in age (p=0.046). Documentation was complete in 90% of patients aged six years or older. There was no correlation between improved motor documentation and correctly identifying a nerve palsy (odds ratio=0.88, p=0.43). Conclusions: Inadequate or incorrect documentation may occur at any step of the evaluation process and may persist despite appropriate documentation by an attending surgeon. Motor exam documentation improved with patient age and reached 90% for patients six and older, implying that barriers exist to appropriate neurologic examination in young children. Improved education of emergency department physicians and orthopaedic residents is important to provide specific and age-appropriate neurologic examinations in young children with skeletal trauma. Proper documentation is necessary to improve recognition and monitoring of neurologic status in pediatric patients with supracondylar humerus fractures.

Karan Dua 1, Andrew Fischer 2, Raymond A. Pensy 2, W. Andrew Eglseder 2, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA

Objective: “Terrible triad” injuries of the elbow consist of a posterior elbow dislocation with concomitant fractures of the coronoid process of the ulna and radial head. The purpose of this study was to evaluate the usefulness or lack thereof of placing a static external fixator to be used as a removable brace when treating patients with terrible triad injuries. Methods: A retrospective review was performed of patients treated for a terrible triad injury at a Level-1 trauma center over a 15-year period. Patient demographics were examined and outcome data was recorded regarding complication rates and post-operative range of motion (ROM). Statistical analysis was performed using two-tailed Fisher’s exact and t-tests assuming unequal variances. Additionally, data was analyzed when matching for age, body mass index (BMI), and presence of concurrent injury. Results: Ninety-three terrible triad injuries were reviewed including 13 that were treated with open reduction and internal fixation (ORIF) plus a static external fixator and 80 treated with ORIF alone. Patients treated with ORIF and an external fixator were older than those treated with ORIF alone (average 51 vs. 45.7 years). In the ORIF with external fixator treatment group, 61.5% had concurrent injuries compared to 33.8% of patients who underwent ORIF alone. Twenty percent of patients treated with ORIF alone needed a reoperation compared to only one of the 13 patients (7.7%) initially treated with ORIF plus an external fixator. Patients initially treated with ORIF and an external fixator had greater forearm pronation/supination and elbow flexion earlier in the rehabilitation period, but less elbow extension. The average arc of motion was greater in patients treated with ORIF and an external fixator later in the rehabilitation period. In obese patients (BMI ≥ 30), ORIF plus an external fixator allowed for significantly better forearm supination at the first and second follow-up evaluations. Patients <40 years of age with no concurrent injury treated only with ORIF had significantly better forearm rotation. Conclusions: The addition of a static external fixator when performing ORIF of terrible triad injuries serves to function as a rigid brace, which can be unlocked for supervised physical therapy leading to better postoperative ROM and lower reoperation rates, especially in obese patients.

Masao Okamoto

Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan

【Purpose】 To determine the incidence of ectopic ossification (EO) after double-plating fixation of comminuted fractures of the distal humerus and to characterize the extent of EO and the consequential functional impairment. 【Materials & Methods】 Fifteen patients with comminuted distal humeral fractures underwent open reduction and double-plating fixation between 2005 and 2017. Twelve men and three women were included in this study, with the average age of 41 years (range: 21–60 years). One fracture was AO type A3, three type C2, and five type C3, and eleven patients had open fracture. Definitive internal fixation was applied 16 days post-injury (range: 4–36 days), and a grafting of autogenous bone block was required in eight patients. Ten patients were transferred for rehabilitation 49 days post-operation, and the others were discharged on day 22. The average follow-up period was 3 years and 7 months (range: 6 months–9 years). The Mayo Elbow Performance Score (MEPS) system was used for all clinical evaluations. Radiographic changes were evaluated nearly every week post-operatively for 2 months and at final follow-up. 【Results】 Bony union was achieved in all the patients. According to the MEPS system, the results of the functional recovery were noted to be excellent in four, good in seven, fair in three, and poor in one patients. At the final follow-up, the average flexion was 119° and the loss of extension was 21°, producing an arc of motion of 98°. EO was shown on radiograph in ten patients and started to appear 26 days post-injury (range: 8–39 days). Five patients who did not present EO within 6 weeks post-injury showed similar findings at the final follow-up. We classified the extent of EO as Type I (slight), Type II (moderate), or Type III (severe). Among the ten patients, one patient was classified as Type I, who showed no changes at 7 months post-injury. Four patients were classified as Type II, with one underwent arthrolysis and the others remained contracture due to EO. Five patients were classified as Type III, with one being reported as excellent according to the MEPS system due to spontaneous reduction of the EO and the other three patients included one with ankylosis who underwent arthrolysis, and the remaining one patient resulted in severe contracture. There was an improvement in the mean flexion–extension arc of the four patients who underwent arthrolysis from 34° to 100° at the final follow-up. 【Discussion】 In ten (67%) patients, EO was shown on radiograph, which was more than expected compared to previous reports. The reasons for this discrepancy following comminuted fracture are manifold: a high-energy trauma, delayed definitive fixation, high rate of bone grafting, and so on. Because most cases of EO appear by 6 weeks post-injury, careful radiographic follow-up and various modalities for prophylaxis against EO post-injury deserve consideration. Although even severe EO may rarely diminish spontaneously, more moderate EO usually results in functional impairment. Therefore, surgical treatment should be considered at the appropriate time.

Sho Kohyama 1, Yuki Hara 1, Akira Ikumi 1, Eriko Okano 1, Yasumasa Nishiura 2, Masashi Yamazaki 1

1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan; 2 Tsuchiura Clinical Education and Training Center, Tsukuba University Hospital, Tsuchiura, Japan

Objective In osteochondritis dissecans (OCD) of the elbow, the state of the interface between the articular cartilage and the subchondral bone affects the prognosis and selection of treatment options; however, techniques that can precisely predict this preoperatively have not been developed. If subchondral bone visualized by computed tomography (CT) and articular cartilage visualized by magnetic resonance imaging (MRI) are fused three dimensionally and evaluated, the instability of the OCD lesion can be predicted, thereby enabling preoperative selection of appropriate treatment. Therefore, we sought to develop a preoperative evaluation and surgical simulation for OCD of the elbow using three-dimensional MRI-CT fusion images. Methods We enrolled 6 patients who had visited our hospital after April 2017 and were diagnosed with OCD of the elbow. Preoperative CT and MRI of the elbow were performed. A 320-row detector imager (Aquilion ONE, TOSHIBA, Japan) was used to obtain 1-mm thick slices during CT and to generate a 3D model of the humerus. A 3 Tesla imager (MAGNETOM Verio 3T, SIEMENS, Germany) was used for MRI. Images were obtained using 3D double echo steady sequence, with 0.4-mm thick slices. To widen the humeroradial joint space and clarify the articular cartilage outline, 7 kg of axial traction was applied to the elbow during MRI. Three-dimensional models of the humerus and articular cartilage were constructed. The CT and MRI images were integrated for further evaluation and surgical simulation. Materialise Mimics Innovation Suite (Materialise, Belgium) was used for 3D model construction. Materialise 3-matic (Materialise, Belgium) was used for MRI-CT fusion and surgical simulation. Using fusion images, the International Cartilage Repair Society (ICRS) classification, the gold standard for intraoperative OCD lesion evaluation, was predicted based comprehensively on articular cartilage shape (normal or irregular), existence of cartilage fissure or defect, and existence of isolated subchondral bone lesion. The proprieties of MRI-CT fusion; average distance error of fusion images; expected ICRS classification; selected treatment options; expected surgical procedures; intraoperative ICRS classification; and actual surgical procedures used in each patient were evaluated. Results Three-dimensional MRI-CT fusion images were successfully constructed in all patients. The average distance error of fusion images was 0.89 (range 0.6-1.0) mm. The expected ICRS classifications were classes II, III, and IV in 1, 3, and 2 cases, respectively. Of the 6 patients, 4 underwent surgery and their expected ICRS classes were II, III, and IV in 1, 2, and 1 case, respectively. The two other patients elected to undergo conservative therapy. Preoperatively, subchondral drilling for a class II case and a class IV case and costal osteochondral autograft for 2 class III cases were simulated. The intraoperative ICRS classification accurately matched the imaging-based predictions (class II, 1 case; class III, 2 cases; and class IV, 1 case). Surgeries were conducted as expected based on the simulations (subchondral drilling in 2 cases and costal osteochondral autograft in 2 cases). Conclusions Using 3D MRI-CT fusion images, the instability of OCD lesions was accurately evaluated. Pre-surgical imaging can facilitate lesion severity determination and precisely simulate the surgical procedure.

Sang Ho Kwak, Min Uk Do, Seung Jun Lee

Pusan National University Yangsan Hospital, Korea

Objective In lateral epicondylitis, even in the absence of apparent instability, subtle instability can be found under anesthesia. We wanted to ascertain: (1) how many elbows surgically treated with lateral epicondylitis showed subtle instability during examination under anesthesia (EUA), (2) how effective magnetic resonance imaging (MRI) was in predicting subtle instability, and (3) if any difference existed in demographic and preoperative clinical data between elbows with and without subtle instability during EUA, Methods Eighty-eight elbows (87 patients) diagnosed with intractable lateral epicondylitis underwent surgical treatment. No elbow showed apparent instability with conventional physical examination. Under general anesthesia, the elbows were examined for subtle instability via fluoroscopy and divided into an unstable and stable group. We performed open extensor carpi radialis brevis excision and lateral ulnar collateral ligament reconstruction for the unstable group and extensor carpi radialis brevis excision for the stable group. The MRI images were reviewed by two radiologists and demographic data were assessed retrospectively. Pain and functional scores were recorded preoperatively and 12 months after the surgery. Results Thirteen elbows (unstable group, 14.8%) had subtle instability in EUA while 75 elbows (stable group, 85.2%) did not. Lateral collateral ligament (LCL) complex injury was noted on 23 elbow MRIs. Twelve elbows showed subtle instability among 23 elbows with abnormal MRI (positive predictive value, 52.2%) while 55 elbows did not show subtle instability among 56 elbows with normal MRI (negative predictive value, 98.2%) The preoperative visual analog scale score was higher in the unstable group than in the stable group (p<0.001). Other demographic factors showed no significant differences between both groups. Conclusions Subtle instability resulting from LCL complex injury was noted in elbows with lateral epicondylitis. This could be visualized with fluoroscopic EUA and preoperative MRI could be used to exclude subtle instability. Surgeons should consider checking for subtle instability, especially when pain is severe and MRI indicates instability.

Young Hak Roh 1, Hyun Sik Gong 2, Goo Hyun Baek 2

1 Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea; 2 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective: Both obesity and diabetes mellitus are well-known risk factors for tendinopathies. We retrospectively compared the efficacy of single corticosteroid injections in treating lateral epicondylitis in patients with and without metabolic syndrome (MetS). Methods: Fifty-one patients with lateral epicondylitis and MetS were age- and sex-matched with 51 controls without MetS. Pain severity, Disability of the Arm, Shoulder, and Hand score, and grip strength were assessed at base line and at 6, 12 and 24 weeks post-injection. Results:The pain scores in the MetS group were greater than those in the control group at 6 and 12 weeks. The disability scores and grip strength in the MetS group were significantly worse than those of the control group at 6 weeks. However, there were no significant differences at 24 weeks between the groups in terms of pain, disability scores and grip strengths. After 24 weeks, three patients (6%) in the control group and five patients (10%) in the MetS group had surgical decompression (p = 0.46). Conclusions: Patients with MetS are at risk for poor functional outcome after corticosteroid injection for lateral epicondylitis in the short term, but in the long term there was no difference in outcomes of steroid injection in patients with and without MetS.

Hyun Il Lee 1, Jong Pil Kim 2, Jae Woo Shim 3, Min Jong Park 4

1 Department of Orthopaedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, South Korea; 2 Department of Orthopedic Surgery, College of Medicine, Dankook University, Cheonan, South Korea; 3 Department of Orthopaedic Surgery, Hallym University, Kangdong Sacred Heart Hospital, Seoul, South Korea; 4 Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea

Introduction Thickened synovial plica in radio-capitellar joint has been reported as cause of lateral-side elbow pain. However, there are few reports containing detailed descriptions of physical examination and MRI finding to aid diagnosis. Purposes of this study were to characterize clinical manifestations of this syndrome and to investigate clinical outcome of arthroscopic surgery. Method We analyzed 20-patients who were diagnosed as plica syndrome and underwent arthroscopic debridement between 2006~2011. Diagnosis was made based on physical examination and MRI finding and arthroscopic finding confirmed. Patients with lateral epicondylitis were excluded. Elbow symptom was assessed by pain visual analog scale (VAS), Mayo elbow performance score (MEPS), and DASH score at minimum 2-years after surgery. Measured thickness of plica in MRI was compared with normal data in literature. Results Plica was located on anterior in one patient, on posterior in 15-patients and on both sides in four patients. Radio-capitellar joint tenderness and pain with terminal extension were observed in 65% of patients, respectively. MRI showed enlarged plica consistent with intra-operative findings. Mean thickness of plica in MRI was 3.7±1.0mm and it was significantly thicker than normal value (P<0.0001). Lengths (mediolateral length=9.4±1.6mm and anteroposterior length=8.2±1.7mm) were also longer than normal values (P<0.0001). The pain-VAS was decreased from 6.3 to 1.0 after surgery. MEPS and DASH score was improved from 66 to 89 and from 26 to 14, respectively. Conclusion Specific finding of physical examination and MRI image could give clues in diagnosis of plica syndrome. Painful symptom had been successfully relieved after arthroscopic debridement.

C Chanes Puiggrós, J Martínez Zaragoza, A Petrica, L Trigo Lahoz, X Crusi Sererols, C Lamas Gómez

Department of Orthopaedics and Traumatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain

INTRODUCTION Heterotopic ossification (HO) can cause stiffness after an elbow injury. Its prevalence can range from 3% in simple dislocations to 45% in distal humeral fractures, however its prevalence in radial head fractures is not well defined. MATERIAL AND METHODS We retrospectively reviewed 51 radial head arthroplasty after non-synthesizable radial head fractures. We studied the demography, Mason type, posterior dislocation, concomitant coronoid or olecranon fractures, ligamentous injuries, time to surgery, site and size of HO and articular balance. We used Hastings-Graham functional classification and Brooker radiographic classification. RESULTS 51 patients with average age of 53.7 years. 34 Mason type IV, 15 type III, 2 type II. 51% associated to posterior dislocation. 53% of the patients developed HO: 100% of those with both coronoid and olecranon fractures, 87.5% of those with isolated radial head fractures and 35% of patients with concomitant coronoid fractures. The average size of the calcifications was smaller in isolated radial head fractures (7.5mm) and larger those with both coronoid and olecranon fractures (18.4mm). The HO was mostly located anteriorly. 38% of patients developed OH in only 1 site and 61.5% in 2 or more. Posterior dislocation, gender, age, Mason type, time to surgery or mechanism were not found to influence HO formation. Average follow-up was 20 months (6-125). CONCLUSION In concomitant coronoid and olecranon fractures associated with radial head replacement it is very likely to develop HO. It is also very prevalent in isolated radial head fractures but it usually consists in bone islands that will not affect function. Some factors expected to increase HO formation like posterior dislocation, time to surgery or high energy trauma did not influence in our study.

Takuro Wada, Takashi Oda, Akira Saito

Saiseikai Otaru Hospital, Otaru, Japan

Objective: Literature regarding the outcomes of revision arthroscopic surgery for tennis elbow is limited. The purposes of the study were to report clinical outcomes for a cohort of patients with chronic tennis elbow who underwent revision arthroscopic release of the extensor carpi radialis brevis (ECRB) tendon. Methods: From January 2003 to December 2016, 146 arthroscopic surgeries for chronic tennis elbow were performed by a single surgeon. Among them 5 patients had persisted elbow pain following a primary surgery and underwent revision arthroscopic surgery. Indications of primary surgery included failure of a minimum of 6 months of conservative treatment such as rest, activity modification, counterforce bracing, nonsteroidal anti-inflammatory medications, and corticosteroid injection. Operative treatment consisted of an arthroscopic inspection, debridement of the ECRB tendon origin, and resection of the radiocapitellar synovial plica if interposed in the joint. The mean age of 5 patients was 48 years; four were male and one was female. The average duration between primary and revision surgery was 11 months and the average follow-up period after revision surgery was 18 months. Outcome was evaluated on the basis of visual analogue pain score, range of motion of the elbow, grip strength, Japanese Elbow Society (JES) score, DASH score and patient satisfaction. Arthroscopic findings of the revision surgery were also evaluated. Statistical analysis was performed using a paired Student t test, with statistical significance set at p< 0.05. Results: Significant improvements were seen in terms of postoperative pain (p < 0.05), active extension and flexion (p<0.05), grip strength (p<0.05), the JES score (p < 0.05), and DASH (p<0.05). All of 5 patients satisfied with the operative results. Arthroscopic findings of the revision surgery included insufficient release of the ECRB origin in three patients and persisted impingement of the posterolateral synovial plica in two patients. Conclusions: Rate of revision arthroscopic surgery for tennis elbow was 3%. Incomplete release of the ECRB origin or synovial plica was considered to be a cause of persisted pain. Revision arthroscopic surgery resulted in reliable pain relief and improvement in elbow function in patients with persisted elbow pain following primary arthroscopic tennis elbow surgery.

Matias Núnez 1, Alberto Castellón 1, Ignacio Fernández 1, Felipe Hughes 1, Enrique Johow 1, Rodrigo Pérez 2

1 Instituto de Seguridad del Trabajo, Viña del Mar, Chile; 2, Universidad Andres Bello, Viña del Mar, Chile

Objective: To describe the functionality in patients undergoing cupulectomy versus radial head arthroplasty. Materials and Methods: A descriptive, comparative study was carried out. We reviewed 17 clinical records between January 2013 and December 2016. We were able to contact 14 patients, of whom 7 underwent a cupulectomy, and 7 patients with radial head arthroplasty. The procedures were performed by 5 different surgeons of the upper extremity team of our center. They were evaluated clinically and radiologically. For the classification of fractures the Mason classification was used, and the DASH and Broberg - Morrey scales were used for the functional evaluation. Results: No significant differences were found in relation to wrist pain, ulna valgus, instability or in the sensation of loss of strength. Patients submitted to cupulectomy, compared to those who underwent arthroplasty, had a higher frequency of arthritis of the elbow 100% vs 71% respectively. Patients undergoing arthroplasty had a higher incidence of functional limitations in their daily lives (85% of cases) versus 57% undergoing cupulectomy. Regarding the DASH assessment, the patients of this last group presented a lower average of disability (19.17 points vs. 25.58 average points in arthroplasty), as well as a greater presence of good results in terms of the Broberg - Morrey scale (57 % of cupulectomies Vs. 42% of arthroplasties). Conclusión: We can conclude that cupulectomy turns out to be a better surgical option, in stable lesions, due to the lower incidence of functional limitations. Faced with an unstable lesion, arthroplasty remains a good therapeutic option.

Takeshi Egi 1, Masato Shigi 1, Yusuke Sogabe 1, Masahiko Tohyama 2

1 Osaka Saiseikai Nakatsu Hospital, Osaka, Japan; 2 Osaka Rosai Hospital, Sakai, Japan

Objectives: When treating osteochondritis dissecans (OCD) of the capitellum, it is important how to manage to perform treatment with the pathological stage/condition. The objective of this study was to examine the postoperative results of removal of intra-articular loose body and abrasion of capitellum in patients with a relatively small affected area during the OCD fragment detached phase. Methods: From 2007 to 2016, we conducted a retrospective study which included 19 patients (1 female; 18 males) who suffered OCD with loose body. Mean age at the time of the procedure was 16 years (range, 12-35 years). Mean postoperative follow up period was 14 months (range, 3-24 months). All patients presented disability of upper arm extremities because of pain on motion, scratching and limitation of range of motion. The position where the loose bodies were present was preoperatively evaluated using three-dimensional computed tomography (3DCT). The bodies were classified into three locations (posterior to the olecranon fossa, lateral to the radial head region, or anterior to the capitellum region), a portal was selectively established with respect to the position of the body, and the bodies were arthroscopically extracted. In the case of the capitellum, this method was applied to patients with diameter of approximately 10 mm by CT and MRI. The remaining hyaline cartilage of the capitellum and the regenerated fibrocartilage that were found to be stable upon probing were left as they were, whereas those that were unstable were resected. Abrasion was performed by subchondral bone exposed with bleeding. Debridement was performed when osteophyte formation was observed on the tips of olecranon and/or coronoid process. Results: Loose bodies were noted anteriorly only in eight patients, posteriorly only in four, posteriorly and laterally in four, and anteriorly and posteriorly in three. The total number of loose bodies was as follows: anteriorly, 17; posteriorly, 14; laterally, eight (total: 39). Osteophyte formation was observed in the olecranon (five patients), olecranon fossa (two patients), and coronoid process (two patients). Regarding the range of motion, the preoperative average extension of -16±14 and flexion of 123±14 degrees significantly improved to post-operative average extension of -2±5 and flexion of 134±9 degrees. Average gain of motion was 27 degrees after the procedure. Regarding the Mayo Elbow Performance Score, the preoperative average of 73±9 points (range, 55-85 points) significantly improved to post-operative average of 98±6 points (range, 85-100 points). Regarding the Quick DASH score, the preoperative average of 11±8 points (range, 2.3-30 points) significantly improved to post-operative average of 0.4±1 points (range, 0-4.5 points) . Conclusion: This procedure provided pain relief, free from scratching, improvement of approximately 27 degrees range of motion and both objective and subjective excellent outcomes. These findings indicate that by targeting only patients with lesions up to 10 mm in diameter, and by selectively approaching the location where the loose bodies are present, it is possible to efficiently perform minimally invasive operative treatment. When the lesion is large, because this method does not maintain reconstruction of the joint surface well, osteochondral graft transplantation should be indicated.

Reza Sh. Kamrani 1,2

1 Tehran University of Medical Sciences; 2 Joint Reconstruction Research Center of TUMS

Objective: articular fracture of distal humerus is an uncommon fracture with significant complications. We report results of 14 patients treated by open reduction and pin and plate fixation technique. Methods: we used pin and plate fixation when screw fixation alone was impossible or inadequate to fix this fracture. We fixed fragments with k wires and augmented theme with a small plate. We reviewed all those patients. Results: 14 patients with distal humerus articular fracture were treated by pin and plate fixation. average age was 36.4 and mean follow up was 41.5 months. The average quick Disabilities of the Arm, Shoulder and Hand (DASH) score was 19.5 points and the mean points for Mayo Elbow Performance Index was 142.6. Mean Final arc of motion was 142.6 degrees which was 70 percent of uninjured elbow. Conclusions: Distal humerus articular fracture is sometimes difficult to fix with conventional methods. We used pin and plate technique and believe that this can lead stable fixation and early ROM with acceptable results.

Kensaku Kuga 1, Takashi Masatomi 2, Yoshinori Takemura 3, Narihito Kodama 3, Shinji Imai 3

1 Japan Comunity Health care Organization Shiga Hospital, Shiga, Japan; 2 Yukioka Hospital Hand Surgery Center, Osaka, Japan; 3 Shiga University of Medical Science Hospital, Shiga, Japan

(Objective) To evaluate the clinical outcome of total elbow arthroplasty for ankylosed elbow joint due to rheumatoid arthritis. (Methods) We reviewed five patients with ankylosed elbow joint due to rheumatoid arthritis, who underwent an unconstrained total elbow arthroplasty. All patients were women, and their mean age at the time of the surgery was 56 years old (range, 41 to 66). Although they had no pain, their daily activities were limited severely because of ankylosed elbow joint (Steinbrocker functional classification classⅣ). An unconstrained total elbow arthroplasty was performed for obtainment of elbow joint motion. The clinical outcomes were assessed according to Mayo Elbow Performance Score, radiological findings and complications. (Results) We followed all the patients at least more than 18 months . Mayo Elbow Performance Score with mean values improved from 45 to 87 points at the latest follow-up. The overall result was excellent for two patients and good for four. The mean flexion angle of ankylosed elbow joint was 92°at pre-operation. An average of elbow flexion was 130°, extension -55°, pronation 58°and supination 35°at latest follow-up. The patients’ daily activities of living, such as face-wash and eating, were improved greatly with much satisfaction postoperatively. There were no cases with implant loosening or periprosthetic fracture. (Conclusions) Total elbow arthroplasty for the patients with ankylosed joint due to rheumatoid arthritis is useful option. Since elbow flexion and forearm pro-supination are obtained , activities of daily living will improve.

Cristóbal Greene 1,2, Guillermo Droppelmann 1, Arturo Verdugo 1

1 Clínica MEDS, Santiago, Chile; 2 Hospital DIPRECA, Santiago, Chile

Introduction: Patients looking for care because of lateral epicondylitis is high with near a 3% of population experiencing a elbow injury and up to 40% of tennis player during their lifetime. Kocaushear and Nirsch suggested 4 stages in epicondylitis with a partial or complete tear of the tendon in stages 3 and 4. The importance of recognizing a tear tendon is based that in this cases other treatments could be adviced (PRP, Shockwaves, Surgery)(4). Hypothesis: With two clinical findings in phisycal examination you could diagnose extensor tendon tear in patients with Lateral Epicondylitis. Method: Patients with clinical history of lateral Epicondylitis were evaluated in an outpatient clinic. Clinical findings that were stablished to be associated with extensor tendon tear were fail to resist wrist dorsal extension against resistance (New Test) and nocturnal pain. In all patients the Cozen test was recorded. After evaluation all patients were studied with ultrasonography, the radiologist was blind to the clinical evaluation. Statistical analysis was made with Fisher’s Exact Test. Results: 38 patients were evaluated. There were no statistical difference between the Cozen Test and ultrasound with a tendon tear (p=0,157). There where statistical differences between the “New Test” with an ultrasound with a tendon tear (p=0,007). Statisitical diference was also significant with nocturnal pain an a tendon tear in the ultrasound in patients with Lateral Epicondylitis. Conclusion: The “New Test”, fail to resist wrist extension against ressistance and nocturnal pain correlates with the presence of a tendon tear in the ultrasound evalaution in patients with Lateral Epicondylitis

Kosei Ando, Kodama Narihito, Yoshinori Takemura, Kento Kuga, Yoichirou Kuyama, Shinji Imai

Shiga University of Medical Science, Otsu, Japan

(Objective) To evaluate the clinical outcomes of the elbow dynamic reconstruction by latissimus dorsi muscle transfer after resection of malignant bone and soft tissue tumors in upper arm. (Methods) All the patients were male with a range of 17 to 62 years old. Mean follow-up was more than 2 years. Two patients were affected with osteosarcoma, three with undifferentiated pleomorphic sarcoma (UPS), and one with liposarcoma. All the patients were underwent a latissimus dorsi muscle transfer in upper arm after curative wide resection of the sarcomas together with brachial, biceps, and/or triceps muscles. Clinical outcomes were postoperatively evaluated with elbow range of motion (ROM), muscle strength with manual muscle testing (MMT), International Symposium on Limb Salvage (ISOLS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications. (Results) Elbow ROM was a mean of 95 degrees (range, 80-120). MMT of elbow flexion or extension was 3-4 in all the cases. ISOLS score was a mean of 90% (range, 63-100). DASH score was a mean of 13.2 points. Two cases of subcutaneous hematoma were found on the surgical defects after resection of latissimus dorsi muscle. (Conclusions) Curative wide resection in bone and soft tissue sarcoma means composite resection of both of the tumors and the upper arm muscles such as brachial, biceps, and/or triceps. Consequently, a latissimus dorsi muscle flap was useful for not only coverage of large soft tissue defect but also reconstruction of functional muscles against the serious loss of elbow function. Our clinical results have shown that a latissimus dorsi muscle transfer is an acceptable surgical option in dynamic elbow reconstruction with muscle strength of upper arm.

IM Kurinnyi, OS Strafun, AS Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Results of treatment of 37 patients (19 men and 18 women) with neglected dislocations and fracture-dislocations of the elbow joint, including 29 patients with the "unhappy triad of the elbow joint" were analyzed. The patients' age was 38,5 ± 11,7 years in average. Patients were divided into four groups according to the type of lesion and time from injury: Group 1 - untreated patients (17), up to 4 weeks after injury; Group 2 - previously operated patients (9), with no signs of dislocation, but with pain, instability and contracture in the elbow; Group 3 - chronic instability or dislocations of the elbow joint (11 patients). In group 1, after elimination of dislocation, restoration of the anterior capsule integrity was performed with synthesis of the coronoid process of the ulna and head of the radius and suture of the damaged ligaments. In patients of 2 group arthrolysis of the elbow joint and restoration of ligaments were performed. In group 3, after elimination of dislocation or subluxation, anterior capsule plastic and radial head arthroplasty (in case of bone defects) were performed. In patients with Essex-Lopresti injury we also made ulnar shortening osteotomy. After surgery, we applied a posterior cast immobillisation on the upper extremity with elbow extended in 30 degrees. Rehabilitation started from the first day after the operation, and included immobilization in extension (30º) for night and flexion of the elbow (over 90º) during the day period. The average duration of such rehabilitation was 4,52 ± 0,89 weeks. Further development of movements we provide with increasing load on the elbow joint. In 12 patients with compression-ischemic neuropathy of the ulnar nerve transposition and neurolysis were also performed. Results: According to MEPS scale we obtained excellent and good results in group 1 in 84% of cases. In groups 2 and 3 with neglected injury we received excellent and good results in 53% patients, fair - in 31% and poor - in 16% of cases.

IM Kurinnyi, OS Strafun, AS Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Fractures of the head of the radius are about 20% of all fractures of the elbow joint. In 5 to 10% of cases, fracture of the radial head is complicated by dislocation of the forearm We have analyzed the surgical treatment of patients with fractures of the proximal parts of the radius. The total number of observations was 47, of which 22 were men and 25 women. The average age of patients was - 36,9314,7 years (varied from 7 to 71 years). Patients were hospitalized at different time after the injury - from 3-4 days to 6 months. Therefore, all patients were divided into 2 groups: 1 group - patients with fresh trauma (up to 4 weeks after injury) - 24 patients (51.1%), and 2 group - patients with delayed injury (more than 1 month after injury) - 23 patients (48.9%). In both groups of patients, depending on the severity of the injury, three types of surgical interventions were performed: open reposition and metal osteosynthesis in 28 patients (59.6%), radial head arthroplasty - in 5 patients (10.6%), head resection or fragments removal - in 14 cases (29.8%). The results of the treatment are analyzed in the period from 7 months to 3.5 years after the surgery. It was found that excellent and good treatment results according to MEPS were obtained in 79.2% cases (19 patients) in first group of patients (who performed surgery within 1 month after injury), and fair in 20.8% (5 patients). In patients with delayed injury (second group of patients) excellent and good results were obtained in 60.9% of cases (14 patients), fair - in 30.4% (7 patients), poor - in 8.7% (2 patients) cases . Based on the analyzed material - reconstructive surgical interventions on the radial head should be performed within the first 4 weeks after the injury.

Kayo Tsuzawa 1, Keikichi Kawasaki 1, Yukio Ueno 2, Katsunori Inagaki 1

1 Department of Orthopaedic Surgery, Showa University School of Medicine, Japan; 2 Ohta Nishinouchi Hospital, Japan

Supracondylar fractures of the Humerus are the most common fractures in children and sometimes involve complications such as vascular injury, nerve injury, malunion and cubitus varus. Avascular necrosis (AVN) after supracondylar fracture of the humerus is a rare but important complication. We report five cases with suspicion of AVN after supracondylar fracture of the humerus. Retrospective data were collected for the patients with supracondylar fractures of the humerus treated at our hospital and our affiliated hospitals from 2001 to 2015. Five cases were suspected AVN after supracondylar fracture of the humerus, two of them were male and three were female. Age at the injury was range from 3 to 7 years. Three cases were Gartland type 3 fracture and underwent surgical treatment. Two cases treated by closed reduction and casting, one was a nondisplaced Gartland type 1 fracture. Their treatments of period were from 12 to 71 months. The X ray check-up at 6.8 months on an average showed suspicion of AVN of medial condyle of the humerus. One postoperative patient had slight motion pain, but others had no clinical symptoms after all. Etiel et al. reported 5 cases with AVN of trochlea after supracondylar fracture of the humerus. They reported this complication are caused by the loss of blood supply of the trochlea and seen in displaced fractures but also in nondisplaced fractures. The lateral vessels considered to be interrupted by tamponade because of the fracture hematoma in intact capsule in nondisplaced fractures. In other reports Hegemann’s disease, osteochondrosis after sport activities and fishtail deformity are also thought to be caused by vessel interruption of growth plate at the trochlea and they presents late clinical symptoms; motion pain, loss of range of motion of the elbow, cubitus varus and so on. Our cases have no clinical symptoms, but AVN of the trochlea is rare and should be considered in late presentation of pain or loss of motion after treatments of supracondylar fractures of the humerus. Long-term follow-up could be necessary in the treatments of supracondylar fractures of the humerus in children.

Pierluigi Tos 1, Simona Odella 1, Bruno Battiston 2, Federico Palumbo 1, Sara Razza 1

1 Asst Pini-CTO, UOC Chirurgia della Mano e Microchirurgia Ricostruttiva, Milano, Italy; 2 AOU Città della Salute e Della scienza di Torino UO Ortopedia e Traumatologia, Chirurgia della Mano, Torino, Italy

OBJECTIVE Elbow ankylosis is a predictable complication in severe complex traumas of distal humerus of the proximal radius and ulna in which, in addition to rigidity, there is an important joint impairment but no prosthetic replacement is indicated. In young and motivated patients, the retrieval of range of motion can be restored by fascia lata interposition arthroplasty. The purpose of the work is to produce our experience of a case study of four patients who had surgery between 2009 and 2016 with this method. METHODS Four patients had surgery: we performed arthrolysis using a medial access performing epitroclea osteotomy and fascia lata interposition (age 35, 40, 45 and 50 years - 2 women and 2 men). In three cases at the end of surgery and legaments reconstruction, the use of the external fixator was necessary, while in one case the elbow had good residual stability and was not protected. The minimum follow-up was 8 months, the maximum 7 years. Twice the affected side was the dominant one. As for etiology, there were three post-traumatic cases and one post coma. The ankylosis was present at 90 ° in three patients and at 70° in the other. Patients were evaluated with MEPS. Once the fascia lata was an autograft from the triceps of the patient. The other three times the grafts were from bank tissue and folded on herself. Techniques are reported. RESULTS There were no major complications. In all patients, a degree of satisfactory, pain-free range of motion was achieved, three of theme could lead the hand to the mouth and the last patient 5 cm from the face. There have been no cases of secondary instability. Two cases have been classified as good (80 MEPS score) and two as discreet (70 MEPS score); the ROM were between 50 and 100 degres. CONCLUSION Arthroplasty of the elbow with fascia lata or triceps band interposition is a viable alternative in those patients with severe functional limitations that have no indication for an elbow prosthesis. The loss of movement of this joint is poorly tolerated and constitutes an important functional impairment for a young patient

Zacharias Christoforakis 1, Petros Kapsetakis 1, Spyros Gigourtakis 2, Gregory Chlouverakis 3, Anastasia Pitikaki 2, George Kontakis 1, George Koumantakis 4, Ioannis Galanakis 1

1 Orthopaedic Department, University Hospital of Heraklio, Greece; 2 Physiotherapy Private Practice, Heraklio, Greece; 3 Medical School, University of Crete, Greece; 4 401 General Military Hospital of Athens, Greece

Objective: to functionally and objectively evaluate patients undergoing surgical repair of distal biceps tendon rupture by anatomic reattachment of the tendon with a bone tunnel technique and using a single anterior incision. Methods: 16 male patients operated by the same surgeon have been retrospectively evaluated. Operative technique involves initially the passage of a guide wire from the anatomic footprint of the tendon attachment on the radial tuberosity towards the dorsal surface of the forearm. Then, a tunnel of one cortice is created with a cannulated dril over that guide wire. A no5 Ethibon suture, previously attached on the tendon stump, is driven via the guide wire on the dorsal forearm. By pulling the suture, the tendon is advanced into the tunnel. Final tensioning and securing of the tendon is attained by tightening the suture over a gauge on the skin of the dorsal forearm. The study consisted of patients more than 1year from surgery all of whom had a clinical assessment and elbow ROM measurements, a self-reported subjective outcome evaluation via specific questionnaires (satisfaction scale, DASH, Oxford Elbow Score, Mayo Score, VAS) and an objective analysis by using an isokinetic device (HumacNorm, CSMi) based on a concrete protocol. The latter comprised isometric and isokinetic torque measurements of elbow flexors – extensors and supinators – pronators (the isokinetic in a slow speed of 60º/sec and a rapid one of 120º/sec), as long as endurance of the above muscle groups. Both elbows of each patient were evaluated and t paired statistical analysis of the results was done comparing injured with non-injured side. Results: three patients had bilateral tendon surgery and eight had their dominant arm affected. Mean age at the time of surgery was 47 years (24-60) and the average follow-up was 62 months (range 12-174). 94% of patients were highly satisfied, with DASH and OES scores of 2,5+/-10 and 47,2+/-2 respectively. All patients reported no pain at all. The only statistically significant difference was detected in testing isokinetic elbow flexion at the speed of 60º/sec, giving an advantage, regarding peak torque, for the noninjured side (noninjured, 53.62+-15.69 Nm; injured, 49.77+-13.96 Nm; P=0.043). For the rest of torque and endurance measurements a slight superiority of the uninvolved elbow was noted but this did not reach significance. Conclusion: our technique gives satisfactory and reproducible results for active patients requiring surgery after distal biceps rupture, and makes up a reliable and cost-effective alternative to other modern techniques arising last decades for addressing this rare injury. Keywords: distal biceps repair; bone tunnel; single insicion; functional; isokinetic assessment

Verónica Jiménez-Díaz 1, David Cecilia-López 1, Lorena García-Lamas 1, Raúl Barco-Laakso 2, Jose Ramón Sañudo-Tejero 3

1 Hospital Universitario 12 de Octubre, Madrid, Spain; 2 Hospital Universitario La Paz, Madrid, Spain; 3 Universidad Complutense de Madrid, Spain

Objective: The aim of the present study is to describe the proximal origin of extensor muscles (ECRB, EDC, ECU, anconeus) around the lateral epicondyle, as well as the proximal origin of lateral colateral ligament and its relationship with the surrounding muscles. Methods: 25 cadavers preserved in formaldehyde, 11 men and 14 women were dissected. Dissections were carried out in 48 elbows, 25 were right elbows and 23 were left elbow; two left elbows could not be dissected because of bad preservation of soft tissues due to poor perfusion. Skin and subcutaneus tissue were removed of elbow and forearm. Fascial tissue was also removed exposing the muscle bellies. All muscles were desinserted distally and a distal to proximal dissection was carried isolating each muscle belly till its proximal origin in the epicondyle. Length, width and the estimated area of each of them were measuring. Likewise, the proportional size with respect the perimeter of the lateral epicondyle was calculated. The proximal origin of lateral colateral ligament was also studied. Length and width of the lateral epicondyle were measured, estimating its perimeter and its area. Results: The mean width of the proximal origin of the extensor muscles was 6.67 ± 1.39mm for ECRB, 7.38 ± 1.11mm for EDC, 5.25 ± 0.8mm for ECU and 7.71 ± 1.06mm for anconeus. Mean length was 8.8 ± 1.06mm for ECRB, 9.23 ± 0.99mm for EDC; 6.82 ± 1.06mm for ECU and 10.98 ± 1.28mm for anconeus.The area was 59.5 ± 18.61mm² for ECRB, 68.74 ± 15mm2 for EDC, 34.96 ± 11.64mm2 for ECU and 85.03 ± 16.16mm for anconeus. Perimeter that occupies each muscle with respect to the epicondyle was about 3.38 ± 1.12mm for ECRB, 4.19 ± 1.1mm for EDC, 2.82 ± 1.13mm for ECU and 7.39 ± 1.36mm for anconeus. Multivariate analysis showed that there were differences in gender, being those parameters greater in men. Anconeus muscle have the greatest length, width and surface area occupied by the perimeter of the epicondyle followed by EDC, ECRB and ECU. The proximal origin of the lateral ligament presents dimensions of 7.65 ± 1.04 mm in length, width of 3.92 ± 0.83 mm an area of 30.02 ± 7.45 mm2. The lateral epicondyle has an average length of 18.35 ± 1.63 mm, width of 11.7 ± 1.85 mm, perimeter of 36.91 ± 5.8 mm an area of 111.07 ± 38.05 mm2. These parameters present a positive correlation with arm and forearm length; once again there are differences in sex, being greater values in men. Conclusions: Proximal origin of LCL is underlying the proximal origin of ECU around the lateral epicondyle. Proximal extensor origins around the epicondyle have been isolated, being able to measure length, width and area, as well as to estimate the relative length with respect to the perimeter of the lateral epicondyle. Muscles are placed bordering the lower half of lateral epicondyle in a semicircumferential form following the order from anterior to posterior: ECRB, EDC, ECU and anconeus.

Hiroyasu Ikegami, Takanori Shintaku, Shu Yoshizawa, Hideaki Ishii, Takeo Mori, Yoshiro Musha, Takao Kaneko

Department of Orhopaedic Surgery, Toho University, Tokyo, Japan

Objectives: Treatment of unreconstructible comminuted fractures of the radial head remains controversial. Radial head arthroplasty is an alternative treatment for unreconstructible comminuted fractures with traumatic elbow instability. The purpose of this study was to evaluate the results of the bipolar radial head prosthesis after more than ten years. Methods: Fifteen patients (seven females and eight males; mean age, 47 years old (26-71) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a bipolar radial head prosthesis (Tornier). There were six Morrey type-III and nine Morrey type-IV injuries. Two of these injuries were isolated, and thirteen of them were associated with other elbow fractures and/or ligamentous injuries. The outcome was assessed using the Mayo Elbow Performance Index (MEPI) at a mean follow-up of thirteen years and six months (10 to 18 years). Results: There were eight excellent results, four good, and three fair according to the MEPI. The mean elbow flexion arc was 105 degrees and forearm rotation arc was 155 degrees. All elbow joints remained stable and no implant required revision. There was no evidence of overstuffing of the joint. Six patients had radiographic changes of lucency around the neck and stem of the prosthesis that was not associated with pain, five patients had heterotopic ossification, and three patients had proximal migration of the prosthesis against the capitellum. Conclusions: Arthroplasty with a bipolar radial head prosthesis for unreconstructible radial head fractures associated with elbow joint instability had satisfactory results during midterm of follow-up. However, high prevalence of radiographic changes suggesting osteolysis is noted and more than twenty-year follow-up is necessary to use this prosthesis.

Sang-uk Lee, Ki-tae Na, Do-yeol Kim, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

OBJECTIVE Nonunion is one of the most common and challenging complications of distal humeral fractures. Recently, patients with severe bone loss or old age were recommended for arthroplasty rather than osteosynthesis, because of high failure rate and severe joint stiffness after osteosynthesis. However, the complication rates of arthroplasty is also high. Chronic kidney disease (CKD) affects calcium and phosphorus metabolism and interfere with bone union. We present a case of successfully treated CKD patient with distal humerus nonunion using an autogenous pillar bone graft. METHODS A 67-year old female got injured to her left elbow containing arteriovenous shunts when she slipped down 6 months ago. Patient was treated conservatively at local orthopaedic clinic. Despite a follow-up of more than 4 months, bone union could not achieved. When her first visited the outpatient department of our hospital, her elbow joint was marked deformed and range of motion was limited due to pain. Palin radiographs and CT-scan revealed nonunion and displacement of the distal humerus with several bone fragments around the fracture site. Surgery was done under pneumatic tourniquet control, despite the injured limb included arteriovenous (AV) shunts for hemodialysis. Large bone defect at humeral metaphysis obstructed anatomical reduction of distal humerus. Autogenous strut bone graft was inserted between the hole of distal fractured bone fragment and intramedullary canal of proximal fragment. And then the orthogonal locking plate fixation with corticocancellous bone graft was applied via the posterior campbell’s approach. RESULTS The duration of the postoperative follow-up period was 9 months, and the subject’s elbow motion values were 0°, 140°, 80° and 80° during extension, flexion, pronation and supination. The patient visual anaglog scale; QuickDASH score; and Mayo elbow performance score were all excellent, and bony union was achieved. No complications related with AV shunt were noted. CONCLUSION Anatomical locking plate fixation with autogenous pillar bone graft might be useful for treating distal humerus fracture or nonunion with metaphseal bone defect to restore alignment, anatomical length, bone defect, and contour for anatomical locking plate positioning.

Hiroyasu Ikegami, Takanori Shintaku, Shu Yoshizawa, Hideaki Ishii, Tako Mori, Yoshiro Musha, Takao Kaneko

Department of Orthopaedic Surgery, Toho University, Tokyo, Japan

Objectives: Fractures of distal humerus in elderly patients are difficult to treat, as diminished bone mineral quality and increased trauma-associated articular surfaces destruction may make stable joint reconstruction even more difficult. In active patients, internal fixation is still a primary choice because of use age of total elbow replacement, but disagreements have still existed on how to treat these fractures in elderly patients. The purpose of our study was to evaluate objective, subjective as well as radiographic results after total elbow arthroplasty (TEA) for the fractures of the elbow. Methods: Between 2000 and 2008, 25 cases (man 6, woman 19) underwent TEA for the fractures of the elbow and were followed for a mean of 8 years (5-13). The mean age at operation were 76 years old (66-86). We examined treatment results of each case according to operation method, length of stay in hospital and an external fixation period. Results: Among nine cases operated within three weeks from injury, there were 6 trauma of rheumatoid patients, 2 comminuted fracture distal humerus, and one breast cancer terminal pa- tient. As for 16 cases that underwent operation after three months or more from injury, they were 9 non-unions after transcondylar fractures of the humerus, 5 trauma of rheumatoid patients, and 2 old fracture dislocations of the elbow. The used TEA systems were ten K-NOW, unlinked type, and 15 linked type (Coonrad-Morrey 13, Snap-in type K-NOW 2). Bone transplantation was performed to ten examples. The length of stay was 1 to 4 weeks (avg. 13 days), and the excursion acquisition training started 2-14 days after the operation (avg. five days). The external fixation period was 3 days to 6 weeks. As for the fresh cases, JOA Score was 83-92 points (avg. 87). As for old trauma cases, JOA Score was 31-43 points before surgery (avg. 37) and 82-90 points after surgery (avg. 86). Conclusions: In case of comminuted fracture of elderly people or rheumatoid patients, the frac- ture of the distal humerus is difficult to treat even when it is fresh, still more when it becomes old trauma. As we reported, even for fresh cases TEA can be one of the choices. For old cases, espe- cially in case of elderly or rheumatoid patients, TEA can provide a better and more stable result than ORIF (open reduction and internal fixation), considering the long term of bony and soft tissue incongruence, wear of the cartilage of a humeroulnar joint, and the period of social rehabilitation.

Yutaka Kubota, Keikichi Kawasaki, Hiroki Nishikawa, Sadaaki Tsutsui, Tetsuya Nemoto, Kazutoshi Kubo, Katsunori Inagaki

Showa University School of Medicine, Tokyo, Japan

[objectives] The authors present the treatment result of Monteggia fracture in children in particular the cases with ulna Acute plastic bowing(APB) [materials and methods] 26 children with Monteggia fracture treated in our department since 2001 were retrospectively reviewed. Among them,7 cases presented with APB and 19 cases were without APB. In the APB group, (2 male, 5 female), average age of 7.4 years (5-13), injury mechanism was fall in all the cases. 5 cases were referred to our hospital from local doctors and 3 cases among them had non-displaced olecranon fractures as a complication. All cases were Bado type 1. Mean time to operation from injury was 2.1 days (0-7). 4 cases were treated with manual reduction and 3 cases underwent operation. Different operative procedures were performed: one case underwent manual reduction of an ulna and removal of annular ligament emboly, one case underwent intramedullary nailing and radioulnar joint fixation after open reduction of the ulna, and one case required plate fixation and radioulnar joint fixation after ulna osteotomy. The mean post-operative follow-up period was 10.6 months (3-25). We compared the treatment results of the APB group with the non-APB group. [results] None of the cases in the APB group presented with re-dislocation of the radial head. The mean elbow joint ROM was flexion 139.3°, extension 2.9° ,pronation 87° , and supination 90°. Among the five referred cases, three patients did not have ulna APB pointed out. Ulna bone union was achieved and radial head dislocation was not presented in all the cases in the non-APB group. The mean elbow joint ROM was flexion 135.9° extension 2.5° pronation 86.6° and supination 90.3°. In both groups, none of the cases had functional impairment and there were no significant differences in the treatment results between the two groups. [conclusions] We experienced relatively high prevalence (7 cases: 26.9%) of ulna APB. Furthermore, there were 3 cases with non-displaced olecranon fractures, so called Hume fracture. We suspect that in case of a fall on the outstretched arm, ulna APB occurs due to the axial load, and furthermore olecranon fracture occurs consequently by the impact to the humeral olecranon fossa. In 3 of the 5 referred cases the ulna APB was not diagnosed. We recommend an accurate radiographical examination of forearm in both sides. When examining a dislocation of the radial head without an ulna fracture, it is necessary to suspect the possible existence of APB

Ki Jin Jung, Jae-Hwi Nho, Byungsung Kim

Soonchunhyang University Hospital, Cheonan, South Korea

Objective Analyze the results of various radial head arthroplasty in the treatment of complex fractures associated with elbow joint instability. Material and methods Retrospective design study of 12 patients, 7 men and 5 women with a mean age of 50 years (24-76) who suffered radial head fractures (Mason III) in the context of an unstable elbow injury. Mean follow-up was 17 months (12-60). Radial head replacement was performed with Ascension(®) Modular Radial Head [MRH], Modular Evolve prostheses(Wright Medical Technology and Judet bipolar Tornier SAS and associating repair of concomitant lesions. The Mayo scale Elbow Performance Score (MEPS) was used to perform the functional assessment. A radiological evaluation was performed at the last follow-up and the complications were recorded. Results Mean motion arcs were 131° in flexion-extension and 155° in pronation-supination. At final follow-up, 89% of results were satisfactory according to the MEPS. The 40% of patients had radiographic signs of lucencies around the stem, although most of them were asymptomatic. None of them needed a second surgical procedure. The lateral ulnohumeral space was 3.3mm and medial ulnohumeral facet was 2.7mm. There was one patients with ectopic ossification. Discussion Radial head implants are an adequate treatment option for restoring stability in complex radial head fractures. The associated injuriesto bones and ligaments and the measures taken to repair them influence the prognosis. Periprosthetic osteolysis could be associated with the presence of pain, so it is necessary to perform long-term studies to test the potential complications of this finding.

Rhyou In Hyeok

Semyeong Christianty Hospital, Pohang, South Korea

Purpose this study was to compare the outcomes of patients who underwent open or arthroscopic release in patients with both lateral and medial epicondylitis that did not respond to conservative management. Materials and methods from 2011 to 2016, 11 patients with lateral and medial epicondylitis who did not respond to conservative management for more than 6 months were included. 4 patients underwent arthroscopic release, and 7 underwent open surgery. Preoperative and postoperative clinical results were measured MMES, DASH, grip power and VAS. Results the final MMES was 85, DASH 12.22, VAS 2 in arthroscopic release, and final MMES was 75.8, DASH 24.23 and VAS 1 in open surgery Conclusion arthroscopic or open surgery of the patients with lateral and medial epicondylitis did not show any significant difference at final follow-up. However, arthroscopic release is more advantageous in case of cosmetic side or immediate post-operative pain

Rhyou In Hyeok, Lee Jung Hyun

Semyeong Christianity Hospital, Pohang, South Korea

Introduction The study of conservative and surgical treatment of distal biceps tendinopathy and associated biceps tendon partial rupture. Materials and methods Twenty - one cases with distal biceps tendonitis and partial rupture were studied in 20 patients who visited our clinic from June 2010 to August 2017. The mean age was 57.1 years (39 ~ 69 years), 14 males and 6 females. The mean duration of symptom at the time of first visit was 6.2 months (0.2 ~ 14 months). Ultrasonography and MRI were performed for patients with severe symptoms. According to the severity of the symptoms, splint immobilization, oral NSAIDs, and ultrasound - guided steroid injection were performed. Surgical treatment was performed if the patient did not respond to conservative treatment for 3 to 6 months or longer. Results There were 9 cases of partial rupture of the distal biceps tendon associated with distal biceps tendinopathy on imaging studies. Conservative treatment showed symptomatic improvement in 15 of 21 cases. In 3 cases with a relatively mild symptom, anti-inflammatory analgesics and intermittent splinting showed good result. In 12 cases, symptoms improved after ultrasonography - guided steroid injection. Surgical treatment was performed on 5 cases that did not respond to conservative treatment. All 6 cases that underwent surgery had distal biceps partial rupture. The symptoms resolved after 3 months after surgery in 4 cases, and 15 months after surgery in 1 case. Conclusions Conservative treatment of distal biceps tendonitis may promise good results. However, in case of partial tear of the distal biceps tendon and refractory to conservative treatment, surgical treatment may be needed

Isabella Fassola, Kay Krüger, Benedict Kunz, Jens Hahnhaußen, Wolfgang Ertel, Senat Krasnici

Department of Orthopedic, Trauma and Reconstructive Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany

Introduction: The dislocation of the elbow joint associated with fractures of the radial head and ulnar coronoid process is known as Terrible Triad Injury (TTI). The purpose of this study was to evaluate the results from the surgical treatment of terrible triad injuries of the elbow in our institution. The purpose of this study was to evaluate the results from the surgical treatment of terrible triad injuries of the elbow in our institution. Material and methods: We retrospectively reviewed 21 consecutive patients treated for TTI of the elbow, including 5 polytrauma patients. In 17 cases CT scan images were available in addition to the standard radiographic images to support the preoperative planning. Included in this series were twelve males, nine females aged on average 53.3 years. The reported mechanism of injury was fall on the outstretched hand (47.6%), bike accident (23.8%), fall from height (23.8%) and sport accident (4.8%). The fractures of the radial head were classified according to Mason in type I (5 cases), type II (5 cases), type III (10 cases) and type IV (1 case). The fractures of the coronoid process of the ulna were classified according to Regan and Morrey in type I (7 cases), type II (11 cases), and type III (3 cases). The elbow dislocation was posterior in 85.7% of cases. In 76.2% of cases the injury was associated with an ipsilateral fracture involving the olecranon (31.3%), the lateral epicondyle of the humerus (31.3%), the medial epicondyle of the humerus (6.3%), the extra-articular proximal ulna (12.5%). In addition, a trans-scaphoid-perilunate dislocation and a triquetrum fracture were diagnosed in 12.5% and 6.3% respectively.   The average interval between the trauma and the definitive treatment was 5.1 days (min 1, max 10). Initial treatment after closed reduction of the dislocation was splint immobilization (71.4%) and temporary external fixation (28.6%). The surgical approach was via a combined lateral and anterior approach in 7 cases (33.3%), a lateral approach in 6 cases (28.6%), combined lateral and medial approach in 5 cases (23.8%). In the remaining 3 cases, a combined medial and anterior or isolated medial or isolated longitudinal posterior approach (4.8% of cases each) was used. The treatment of the radial head and of the coronoid fracture was mostly surgical (85.7% and 61.9%, respectively). The LUCL and the MCL were repaired in 42.9% and 23.8% of cases, respectively (suture or anchor). The average follow-up was 16.6 months (range 1-38.2). Results: Average results were: arc of flexion-extension 76 degrees (range 55-110), flexion 109 degrees (range 85-140), extension loss 32 degrees (range 30-40), arc of prono-supination 130 degrees (range 110-150), pronation 82 degrees (range 75-90) and supination 47 degrees (20-75). Average DASH was 19.5 (range 6.7-39.2) and average MEPS was 80.0 (range 70-85) Two (9.5% of cases) complications occurred: one rigidity and one delayed union of the radial head. Both required surgical revision. Heterotopic ossification was present in 3 cases (14.2% of cases). Conclusions: The surgical treatment for the terrible triad of the elbow generally provided satisfactory results.

Dawid Mrozik 1,2, Agnieszka Jackiewicz 1,2

1 HANDPROJECT Clinic, Gdańsk, Poland; 2 SWISSMED Private Hospital, Gdańsk, Poland

BACKGROUND: Lateral epicondylitis or tennis elbow is a noninflammatory, degenerative condition of the origin of the ECRB or EDC, clinically associated with overuse and characterized by: absence of inflammatory cells, profusion of disorganized collagen and fibroblastic hypertrophy, disorganized vascular hyperplasia with avascular tendon fascicles, nutritional flow is compromised, making it difficult for tenocytes to synthesize the extracellular matrix necesary for repair and remodelling. A principal aim in treatment of tendinosis is to establish a biologic healing response. THE PURPOSE of this study was to evaluate the long-term results, safety and effectiveness of using RF-based microtenotomy to treat lateral epicondylitis of the elbow. MATERIAL and METHOD: It was prospective, nonrandomized, two-center clinical study. Into the study were involved 49 patients (28 men and 21 women) with symptomatic epicondylitis lateralis (tennis elbow) for at least 6 months and had failed conservative treatment. The average age of patients was 44,9 years (range: 26-57). Dominant limb was involved in 89% of the patients. As operative method we used bipolar microtenotomy of extensor carpi radialis brevis and/or common extensor tendom using TOPAZ Microdebrider device (ArthroCare, EU). Before operation was done VAS, DASH and clinical examination. Postoperative clinical assessment: 2 and 14 day. Follow-up: 12 and 24 months after oparation: VAS, DASH, USG, clinical examination. USG: LOGIQ e GE Healthcare device with a 7,7-15Mhz linear transducer RESULTS: The dominant arm was involved in 89% with unilateral involvement. There were no perioperative or postoperative complications related to the procedure. The mean VAS decreased from 8,8 before operation to 2,6 (p=0,001). Postoperative DASH value was 21,6. There were found ultrasonography abnormalities 24 months after operation: - focal hypoechoic area: 36 patients (74%) - focal anechoic area: 16 patients (33%) - cortical irregularity of the lateral epicondyle: 34 patients (70%) - tendon thickening: 13 patients (27%) - intratendinous calcifications: 11 patients (22%) - increased vascularity: 9 patients (18%) CONCLUSIONS: 1. RF-based microtenotomy appears to be a safe and effective method for treating patients with chronic tendinosis. 2. Microtenotomy is a technically simple procedure to perform and is associated with a rapid and uncomplicated recovery. Pain relief was achieved rapidly in all patients and diminished even further with time. 3. Ultrasonography is a widely and inexpensive imaging study for assessing tendons providing useful information on the severity and stage of tendon pathology.

I M Kurinnyi, O S Strafun, A S Lysak

State institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Purpose. To evaluate the results of surgical treatment of nonunions and defects of the distal humerus. Methods. The surgical treatment of 63 patients (41 men, 22 women) with the consequences of treatment of fractures and nonunions of the distal humerus were analyzed. The average age of patients was 48.4 ± 15.6 years. All patients had been operated previously, but due to various reasons, consolidation of the distal humerus did not occur. Patients were hospitalized in 6.8 ± 5.4 months after injury. During clinical investigation all of them had pathological mobility at the level of nonunion, movements in the elbow joint were significantly limited. In 17 cases, the treatment of patients began with the skin defects substitution at the level of the elbow joint. At the first stage of treatment, osteosynthesis of the distal humerus was performed with bone plastics. Technically, this stage was rather complicated due to a significant violation of the anatomical relationships between the bones, presence of thick scar tissues, adhesions and defects in the bone in the area of injury. After the first stage surgical intervention, an early rehabilitation with two removable splints in the position of flexion and extension, was carried out. As a rule, the range of movements in the elbow increased to a satisfactory level. After 1 year or more, the 2nd stage of treatment was performed - removal of the metal fixators and mobilization of the elbow joint. After bone consolidation and improvement of anatomy of distal humerus the range of movements in the elbow joint was improved to a 90 degrees or more. After the operation, an early rehabilitation treatment was also carried out using cast in full extension at night and a sling in flexion for a day time. Results After the first stage of surgical treatment (osteosynthesis and bone plastics) on the MEPS scale, good results were obtained at 55.6% and satisfactory - 44.4% of patients. After the 2nd stage (mobilization of the elbow joint), good results were observed in 79.4% of cases, and satisfactory - in 21.6%. The main factor limiting the ability to renew movements in the elbow joint was the degree of preservation of the shape of the articular surfaces of the distal humerus. Conclusions. Osteosynthesis with bone plastics and mobilization surgeries in cases of severe injuries of distal humerus allowed to obtain good results of treatment in 79.4% of cases.

Hiroki Nishikawa 1, Keikichi Kawasaki 1, Kazutoshi Kubo 1, Tetsuya Nemoto 1, Sadaaki Tsutsui 1, Yutaka Kubota 1, Katsunori Inagaki 1, Jun Ikeda 2, Takuma Kuroda 2, Yukio Ueno 3

1 Showa University Hospital, Tokyo, Japan; 2 Showa University Northern Yokohama Hospital, Kanagawa, Japan; 3 Ohta-Nishinouchi Hospital, Fukushima, Japan

Objective: Humeral condylar fractures in the elderly are challenging to treat due to fragility of the bones, and have high rates of delayed or nonunion due to small contact area of the fragments, small proportion of cancellous bone and the fact that it is intra-articular. Recently, surgical treatment with locking plates is becoming more common. We report the treatment results of humeral condylar fractures in the elderly operated at our hospital and affiliated hospitals with locking plates. Methods: We retrospectively reviewed 38 patients over the age of 65 who were operated with locking plates in our department and in our affiliated hospitals between May 2005 and November 2015, and were followed up over at least three months. Mean age at the time of injury was 77.0 (65-93). Results: The mean postoperative follow up period was 19 months, and bone union was achieved in 33 patients. However, there were two cases of nonunion, one case of condylar necrosis and two cases of postoperative re-displacement of which one case underwent revision surgery. The mean postoperative ROM of those cases with bone union was 123.8 degrees of flexion and -15.1 degrees of extension, and the mean Mayo elbow performance score (MEPS) at the latest check-up was 91.1. Comparison between the age groups of sixties, seventies and eighties revealed that older groups had progressively smaller arc of motion and lower MEPS at the latest check-up. No case acquired infection. Complication of numbness of the ulnar nerve area was seen in one case, transient radial nerve palsy in one case and heterotopic ossification in one case. Conclusions: Treating humeral condylar fractures in the elderly with locking plates are often reported to have good results, and our results were similarly good. However, some cases developed nonunion, condylar necrosis and postoperative re-displacement, which suggest the need for careful indication and accurate operative techniques for this treatment. Primary total elbow arthroplasty for humeral condylar fractures in older patients is also achieving good results in our department and this may be an efficient alternative for some types of fractures, although careful consideration is needed for its indication.

T Tawonsawatruk 1, P Tuntiyatorn 2, T Kanchanathepsak 1, I Watcharananan 1

1 Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2 Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Abstract Background: PRP contains several growth factors which can improve functional outcomes in tendinopathies especially for the Tennis elbow. However, there is no previous report on the clinical use of PRP injection in cases with previous corticosteroid injection. Hypothesis: PRP injection can improve the elbow function of the elbow tendinopathy in patients who have a history of previous corticosteroid injection. Methods: Six-teen lateral epicondylitis (Tennis Elbow) patients who had a recurrent symptom or failure treatment from previous corticosteroid injection therapy were included into this study. Autologous PRP was injected to the ECRB origin for all patients under ultrasound-guidance in order to improve the accuracy of the injection to ECRB location. Means follow up time, VAS score, Quick DASH score, Mayo elbow score and patients’ satisfaction score were comprehensively collected both before and after PRP injection to evaluate functional outcomes. The result: Three patients were loss of follow up, then only 16 patients were analyzed in this case series. Means follow up time was 16.94 months. VAS score, Quick DASH score, Mayo elbow score were significantly improved after treatment (8.78 and 1.78, 47.35 and 5.48, 65.42 and 96.25 respectively P<0.0001). All patients satisfied with treatment demonstrating by the patient satisfactory score. There was no complication from skin allergy after PRP injection. Interestingly, there was no patients underwent surgery at last follow up. Conclusion: Ultrasound guided PRP injection can improve functional outcomes in the lateral epicondylitis patients who had previous failure from corticosteroid injection. Keywords: Platelet rich plasma, Recalcitrant lateral epicondylitis, Recurrent lateral epicondylitis, Corticosteroid, Ultrasound-guided injection

Muhammad A Quolquela

Tanta University, Department of orthopaedics, Tanta, Egypt

Objective Tennis elbow or lateral epicondyltis is a common patient presentation in any office of orthopaedic practice. Most patients respond well to non operative measures as anti-inflammatory drugs, splints and local cortisone injections. Very few patients are candidates for surgery usually as a release of the common extensor origin at the lateral epicondyle. This kind of surgery is fraught with complications as persistence of pain due to adhesions and inflammatory reactions at the surgery site together with weakness of wrist extension due to lengthening of the extensor carpi radials longus muscle (the main wrist extensor) .Weakness of wrist extension has a deleterious impact on hand grip strength as the former is a conjuncture to finger flexion. Denervation of the lateral epicondylar region through division of branches of posterior cutaneous nerve of the forearm (PCNF) was proposed as a simpler procedure to alleviate pain without drawbacks of muscle release. Methods During the last five years, 21 patients having tennis elbow and not responding to non operative treatment for at least 9 months were subjected to denervation procedure. They had an average age of 29 years old. Dominant arm was involved in 18 patients. On a scale of pain severity from 0 (no pain) to 10 (most excruciating pain), patients reported an average of 7. Patients lost an average of 25º to full elbow extension with full flexion. Hand grip strength averaged 60% of the other side. Mayo elbow performance score (MEPS) was evaluated to be 60 points on the average. Through a longitudinal incision along the upper arm a hand breadth proximal to the lateral epicondyle, main trunk of PCNF was severed, ligated with non absorbable suture and buried through a slit in the fascia covering the triceps lateral head to avoid neuroma formation. Results Average postoperative follow up was 3.5 years. On the 0 to 10 pain scale, 94 % of the patients reported no pain at all and the rest reported an average of 3. Loss of full elbow extension averaged 8º. MEPS averaged 90 points. Average hand grip strength improved to 88% of the other side. Conclusions Denervation of the elbow through division of the posterior cutaneous nerve of the forearm for management of tennis elbow is a simple safe procedure with apparently better outcome compared to the classic common extensor release at the lateral epcondyle.

Young Ho Lee 1, Jung Eun Lee 2, Jihyeung Kim 1, Hyun Sik Gong 3, Goo Hyun Baek 1

1 Seoul National University Hospital, Seoul, South Korea; 2 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea

Purpose: In the treatment of simple transverse fracture of olecranon, it is known that tension band wiring technique is effective. However, complex transverse fracture of olecranon, the Schatzker type B fracture, which has the articular impacted-depression fragment, loses the anterior bony buttress against the compression force of the articular surface of the trochlea, so that tension band wiring technique will be able to cause secondary reduction loss. Therefore, for using a stable tension band wiring technique, the anterior buttress of olecranon notch should be restored. The purpose of this study was to report the clinical outcome of tension band wiring fixation of complex transverse olecranon fractures. Patients & Method: We treated the complex transverse fracture of olecranon which had joint-impacted fragment from 2010 to 2016. Articular impacted-depression fragment was restored anatomically to proximal or distal segment using longitudinally inserted absorbable pins. After switched to simple transverse fracture of olecranon in this way, bone defect was supplemented with autologous iliac bone graft followed by fixation by tension band wiring using eyelet pins. The functional evaluation of the elbow joint was measured by MEPS (Mayo Elbow Performance Score) and the range of the motion of the elbow joint was evaluated, and the radiologic outcomes were evaluated in simple X-ray. Results: All olecranon fractures were united without secondary reduction loss in the average 6 weeks. Two patients showed joint subsidence of 1.2 mm and 2.2 mm respectively, but they did not report subjective discomfort. The mean elbow joint flexion range was 132 degree and the mean elbow joint extension range was 4 degree. There was no migration of the implant in the final image, and there were no symptoms by metal implants. The mean postoperative first year MEPS score was 94, 25 of the 26 cases (96%) achieved a good or excellent outcome. Conclusion: In the complex transverse fracture of olecranon which has the joint-impacted fragment, tension band wiring fixation after conversion to a simple transverse facture by anatomical restoration of articular fragments using absorbable pins supplemented with autologous bone graft is considered as good option.

Hand therapy (5 abstracts)

Koji Fujita 1, Takuro Watanabe 2, Yuta Sugiura 2, Akimoto Nimura 1, Atsushi Okawa 1

1 Tokyo Medical and Dental University, Tokyo, Japan; 2 Keio University, Kanagawa, Japan

Objective The importance of postoperative rehabilitation is well-acknowledged in the field of hand surgery. Daily rehabilitation supervised by trained hand therapists is ideal, but daily hospital visits can be burdensome. Home-based self-rehabilitation is recommended; however, doctors are not aware of when and how it should be performed. In this study, we developed a tablet-based application (app)for home-based rehabilitation of patients with postoperative carpal tunnel syndrome. The app reminds patients to perform daily finger rehabilitation exercises and enables doctors to confirm compliance remotely from the hospital. Methods The study was approved by the institutional review board in Tokyo Medical and Dental University. Three patients who underwent carpal tunnel release surgery for severe carpal tunnel syndrome with thenar muscle atrophy were included. We developed an app that stimulates palmar abduction of the thumb, consisting of a game that is played by sliding the thumb to receive points. Prior to starting every game, range of motion in the thumb was automatically measured. The game then started the range of thumb motion slightly wider than the pre-measured range so the patients unconsciously abducted their thumb. Usage status and all parameters including speed, score, and range, were confirmed remotely. Prior to surgery, the patients were educated on how to use the app, and they began using it two weeks postoperatively. They received feedback from their doctor during each postoperative hospital visit. Results All patients used the app postoperatively on a daily basis for three months. Compared to preoperative values, speed and range of thumb motion improved. These results showed the potential usefulness of a tablet-based app that promotes home-based rehabilitation. Rapidly developing network technology enables us to monitor patients’ physical activities outside of the hospital, which was not easily accessed before and also promotes adequate postoperative movement through tablet or smartphone-based apps. We hope to develop new apps for adaptable hand diseases to reduce the physical and economic burdens on both patients and medical staff. Conclusion We developed a tablet-based rehabilitation app for postoperative patients with carpal tunnel syndrome. This app promoted home-based rehabilitation and could confirm the results remotely.

Ahmet Fahir Demirkan 1, Ali Kitis 2, Umut Eraslan 2, Hande Usta 2, Merve Kalpak 2

1 Pamukkale University, Medical Faculty, Department of Orthopaedics and Traumatology, Denizli, Turkey; 2 Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey

OBJECTIVE: The aim of this study was to investigate the effect of early physiotherapy program on range of motion (ROM) and grip strength in zone I extansor tendon injuries. METHODS: Thirty-two patients aged from 16 to 66 (36.56±12.95) years who were diagnosed with zone I extansor tendon injury between 2014 and 2017 were included in this study. Injury severity was assessed with Modified Hand and Forearm Injury Severity Scoring (MHISS). All cases were followed-up every week for wound care, edema control, pain control and active joint motion exercises for uninvolved joints from the first postoperative week. A static volar finger splint was used for involved distal interphalangeal (DIP) joint for 8 weeks. Active blocking exercises were started when splint was removed at 8th week. At 9th week tendon gliding exercises and at 10th week mild resistence exercises were started. The physiotherapy program continued for 12 weeks. The descriptive information of the cases were recorded. ROM (by distance measurements) at 8th and 18th weeks after injury, and the grip strengths at 12th and 18th weeks were evaluated. At postoperative 12th week, the disability and symptom status was evaluated with the Turkish version of Disabilities of the Arm, Shoulder and Hand Score (Q-DASH). The results were analyzed by Paired Samples t test. RESULTS: Sixteen cases were female (50.0%) and 16 cases were male (50.0%). 29 cases had right hand dominancy (90.6%) and 3 had left dominancy (9.4%). Sixteen cases (50.0%) had injury on dominant and 16 (50.0%) had on nondominant side. 19 cases were followed by conservative treatment (59.4%) and 13 (40.6%) had a surgery. The mean MHISS score was 8,56 ±2,72 and Q-DASH score was 26,89±16,09. At 18th week, flexion of the 3rd, 4th and 5th fingers were significantly higher when compared to the 8th week results (p<0.05). However, there was no significant difference in hand and pinch grip strength at 12th and 18th weeks (p>0.05). There was no extension deficit. CONCLUSIONS: As a result of this study, at 18th week finger ROM was more than 8th week. But there was no difference in grip and pinch strengths. In order to be able to interpret the results more clearly we think that in the larger sample groups, evaluations in the late period and long intervals are needed. Keywords; extansor tendon, rehabilitation, functional status

Anna Pantouvaki, George Velivasakis, Petros Kapsetakis, Grigorios Kastanis

General Hospital of Heraklion - Venizelio, Greece

Objectives: Perilunate injuries affect both soft tissues and bony element and account 5-7% of all wrist injuries. The early surgical management is the treatment of choice, following a rehabilitation program in order to gain normal function of the wrist. The purpose of this study is to describe the functional outcomes after use deep friction massage together with manual therapy of this type of injury. Material & Methods: Two patients with average age 40 years after a traffic accident had sustained trans-Scaphoid volar dislocation of lunate of the right wrist. The patients underwent surgery treatment and they started rehabilitation therapy after an average time of 7 weeks from the surgery. Physical therapy included conventional intervention with ultrasound, ice and deep friction massage directed to the ulnar and radial collateral ligaments as well as to the extensors apparatus of the wrist plus the dorsal capsular - ligamentous complex of the wrist. Deep friction massage was performed three times per week for 3-5 minutes in areas described above. Mobilization techniques were utilized to promote pain -free wrist and finger mobility. The patients followed a supervised physiotherapy treatment three times a week for one hour. The rehabilitation program included also an individualized exercise regimen performed three to five times daily according to given instructions at intensity and number of repetitions. Results: The mean follow-up was approximately 12 months. The results were based upon Quick Dash Score, Mayo Wrist Score, and range of motion. The patients were measured at the start of the rehabilitation program, at 3, 6, 12 months. The Quick Dash Score was 4,5 and 6,8 while the Mayo Wrist Score was 80 and 75 .The final range of motion at one year , were: extension 40°/45 - 41°/ 46° , flexion 60°/65°- 59°/67°, radial deviation 21°/24°- 23°/25° and ulnar deviation 30°/32°- 30°/34°. The motions were pain free and the patients return to the previous status of functionality after one year. Conclusion: The combination of deep friction massage, manual therapy, and exercise as well as ultrasound and ice intervention proved successful to these patients. Deep friction massage may contribute to painful syndromes in the tendon and ligament complexes that cross the injured joint due to decrease of the inflammation process and pain, while mobilization techniques may increase the range of motion rapidly due to effective joint alignment coupled with active exercises.

Ishan Radotra, Benjamin Baker, Stuart W McKirdy

Department of Plastic Surgery, Royal Preston Hospital, Preston, UK

Severe flexure contractures of the hand cause pain, palmar hyperhidrosis, ulceration, and nail plate deformities. Non-operative management includes splinting, that can be very painful, and botulinum toxin injections, which provide only a temporary solution. Surgical treatment includes soft tissue release, tendon transfers, and release of the flexor and intrinsic muscles, but may not be acceptable to patients with anticipated functional recovery due to permanent effect on hand function. We present the first documented case in the literature of flexion contractures of the hand managed using the Inflatable Carrot orthosis. In a patient with unsatisfactory results from botulinum toxin injections and for whom surgical intervention was not considered in their best interests, the inflatable carrot provided an alternative non-surgical solution for management. We demonstrate efficacy with medical photographs and objective measurements with no associated complications. Awareness of this alternative orthosis amongst hand surgeons will broaden our armamentarium for this difficult clinical problem.

Agnes Sturma 1,2, Laura A Hruby 1, Cosima Prahm 1, Johannes Mayer 1, Oskar C Aszmann 1,3

1 Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Vienna, Austria 2 Master Degree Program, Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria 3 Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria

Objective: Successful motor function recovery following nerve transfers depends on the re-innervation of the new target muscle by regenerating axons as well as adequate motor learning. As this learning process is cognitively demanding for the patient, a structured rehabilitation program is needed. Our objective was to evaluate such a protocol in a pilot study. Methods: Five patients after severe injuries of their brachial plexus were included. On all patients nerve transfers were performed to restore biological upper extremity function. Muscle strength was assessed with the British Medical Research Council (BMRC) muscle scale before surgery and after completion of rehabilitation. Explorative statistics were applied. All patients did undergo a structured rehabilitation regime in three phases. In the first months after neurotization no active movements are possible and therapy therefore focused on enhancing cortical representation of upper extremity motor areas. This included motor imagery as well as mirror therapy. As soon as the patients could activate the re-innervated muscles, the second phase started. Here, otherwise undetectable motor activity was visualized using surface EMG biofeedback. Patients were educated on what activation patterns to use as, after motor nerve transfers, muscular activation requires thinking about the movements the nerve was initially responsible for. Subsequently, they were educated to also think about the intended movements. The third phase started when patients could initiate movements that were easily detectable with naked eye. Here the focus lied on relearning the original movement pattern. This was done by asking the patient to execute the intended motor task without co-contraction of the muscles the donor nerve had originally innervated. This cognitively demanding task was supported using surface EMG. This allowed patient and therapist to see a visualization of the activity of both muscles and thereby receive precise feedback on performance. Finally, fine motor tasks and activities of daily life were trained. Results: All patients completed rehabilitation and had an improved muscle strength. While all patients had a severely impaired elbow flexion with BMRC grade 0 (n=4) or grade 1 (n=1) before surgery, function clearly improved to BMRC grade 3 (n=3), grade 3+ (n=1) and grade 5 (n=2). In the 4 patients with impaired deltoid function, a similar improvement was seen. Additionally, all patients regained a better triceps function. Two patients had no function in the forearm and hand before surgery and regained some muscle strength. Full hand function, however, could not be achieved. But one patient, who had impaired wrist and hand function before surgery, could regain full muscle strength and functionality. Conclusions: As all patients completed the rehabilitation program, it can be considered feasible. The functional outcomes were better than or equal to those described in literature. Although many factors influence the outcome after neurotization, the structured rehabilitation programm can be considered as supportive. It can help in the cognitively demanding process of establishing new motor patterns.

Imaging (13 abstracts)

Stefanie Wieschollek, Karl Josef Prommersberger, Rainer Schmitt, Karl Heinz Kalb, Georgios Christopoulos, Roland Geue

Klinik für Handchirurgie, Campus Bad Neustadt, Germany

Hypothesis: Evaluation and understanding of location, dislocation, humpback deformity and misalignment of scaphoid fractures is essential for the decision of the following treatment. Therefore a CT scan in the long axis of the scaphoid (CTsc) is more significant and reliable than a CT scan in the plane of the wrist (CTw) . Methods: We tested the interobserver reliability of those two CT scan methods. 42 patients with scaphoid fractures had a CT scan in the long axis of the scaphoid (CT-scaphoid). CT reformations along planes relativ to the wrist (CT –wrist) were made. Those 84 cases were anonymised and put in a random order. They were presented to 4 clinical observers (2 handsurgeons and 2 radiologists) for fracture evaluation regarding: localisation, humpback deformity, offset (radial/ulnar and palmar/dorsal) and classification by Herbert. Additionaly the surgeons shoud decide for palmar or dorsal approach, open or percutaneous technique. Statistical analysis was made between 2 and 4 observers, using Cohen´s kappa coefficient, Pearson coefficient, Fleiss´ kappa, interclass correlation coefficient (Shrout and Fleiss) and Spearman-Rho coefficient. Results: Observer CT w CTsc Localization Cohen´s kappa 2 0,609 0,730 Fleiss´ kappa 4 0,442 0,695 Humpback Pearson coefficient 2 0,037 0,760 Shrout and Fleiss 4 0,047 0,938 Offset r/u Spearman-Rho 2 0,271 0,395 Shrout and Fleiss 4 0,652 0,661 p/d Spearman-Rho 2 0,431 0,597 Shrout and Fleiss 4 0,759 0,885 Herbert Cohen´s kappa 2 0,371 0,559 Fleiss´kappa 4 0,321 0,533 Approach Cohen´s kappa 2 0,483 0,545 Technique Cohen´s kappa 2 0,362 0,413 Interpretation: 0-> no correlation; 1->high correlation Summary: - regarding evaluation of humpback deformity there was a significantly higher interobserver correlation in CTsc than CTw - regarding evaluation of localisation, offset, Herbert classification, approach and technique there was a slightly higher interobserver correlation in CTsc than CTw - in all evaluated parameters the interobserver reliabilty was slightly higher in the CT scan in the long axis of the scaphoid For evaluation and understanding of scaphoid fractures the CT scan along the long axis of the scaphoid is more significant and reliable than the scan in the plane of the wrist and therefore preferable.

Michaela Huber, Rebecca Woehl, Johannes Maier, Christoph Palm

Department of Trauma Surgery and Emergency Department, University Medical Center Regensburg

Objectiv Scaphoidectomy and midcarpal fusion can be performed using traditional fixation methods like K-wires, staples, screws or different dorsal (non)locking arthrodesis systems. The aim of this study is to test a new locking plate and to compare the clinical findings to the data revealed by CT scans and semi-automated segmentation. Methods This is a retrospective review of eleven patients suffering from scapholunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC) wrist, who received a four corner fusion with a plate (Aptus 4CF) between August 2011 and July 2014. The clinical evaluation consisted of measuring the range of motion (ROM), strength and pain on a visual analogue scale (VAS). Additionally, the Disabilities of the Arm, Shoulder and Hand (QuickDASH) and the Mayo Wrist Score were assessed. A computerized tomography (CT) of the wrist was obtained six weeks postoperatively. After semi-automated segmentation of the CT scans, the models were post processed and surveyed. Results During the six-month follow-up mean range of motion (ROM) of the operated wrist was 60°, consisting of 30° extension and 30° flexion. While pain levels decreased significantly, 54 % of grip strength and 89% of pinch strength were preserved compared to the contralateral healthy wrist. Union could be detected in all CT scans of the wrist. While X-ray pictures obtained postoperatively revealed no pathology, two complications were found through the 3D analysis, which correlated to the clinical outcome. Conclusion Due to semi-automated segmentation and 3D analysis it has been proved that the plate design can keep up to the manufacturers’ promises. Over all, this case series confirmed that the new plate can compete with the coexisting techniques concerning clinical outcome, union and complication rate.

Takahiro Asano 1, Masaya Tsujii 1, Kazuya Odake 1, Yoshinori Makino 2, Ryu Iida 2, Akihiro Sudo 1

1 Department of Orthopaedic Surgery, Graduate School of Medicine, Mie University, Mie, Japan; 2 Nagai Hospital, Mie, Japan

Objective Triangular fibrocartilage complex (TFCC) injury, especially at the fovea, is a serious complication leading to chronic pain of wrist joint associated with the distal radius fracture. The prevalence were reported based on the evaluation using arthroscope and MRI, although these are impractical to be routinely performed. The purpose of this study is to find the predictor in X-ray of TFCC foveal tear in analysis of the relationship between X-ray parameters of distal radius fracture and foveal tear of TFCC on computed tomography (CT) arthrography. Methods Thirty-six wrists of 35 patients (8 men and 28 women; mean age, 69 years) were surgically treated with volar locking plates for distal radius fracture. Immediately after the surgery, 5ml non-ionic contrast material was injected within the distal radioulnar joint under the fluoroscopy. Within 10 minutes after the injection, the CT was taken using a helical CT unit (Aquilion 64, Toshiba, Tochigi, Japan). We determined the foveal tear of TFCC on the slice of coronal and radial view centered on the ulnar styloid process. Furthermore, radiological parameters were measured on X-rays after the surgery, including radial inclination (RI), volar tilt (VI), radial translation (RT), and radial translocation of the ulnar styloid (UT). The radiological parameters were statistically assessed between the patients with (group T) and without foveal tear on CT arthrography (group N) using Mann-Whitney U test and multiple logistic regression analysis. Results Out of 36 wrists, 21 wrists (61%) were diagnosed as foveal tear of TFCC on CT arthrography, of which 10 did not have ulnar styloid fracture. In group T, the mean value of RI, VI, RT, and UT was 13.8°,-12.3°, 3.7 mm, 2.6 mm, respectively, in which the degree of RT and UT was significantly greater than the value (17.7°,-6.2°, 1.7 mm, and 0.2 mm, respectively) in group N. Additionally, multiple logistic regression analysis revealed that translocation of fractured ulnar styloid was an independent risk factor of TFCC foveal tear. Conclusion CT arthrography immediately after the surgery could be easily performed without additional pain due to the injection, because of the anesthesia for the plate fixation. As a result, the clear images made us diagnose foveal tear of TFCC in 61% patients of this series. In addition, the radial translocation of ulnar styloid fracture was shown to be an independent risk factor of the foveal tear. Distal radius fracture accompanied with greater ulnar styloid dislocation should be carefully treated, including cast and surgical treatment for foveal tear of TFCC.

Pascal Ducommun, Urs Hug

Division of Hand and Plastic Surgery, Lucerne Cantonal Hospital, Switzerland

Introduction Wrist pain is frequent and can be caused by a diversity of pathologies. Depending on the symptoms conventional X-rays, MR, CT or ultrasound are the imaging possibilities for evaluation of wrist pain. Fractures, osteoarthritis and inflammatory diseases might be sufficiently diagnosed with x-rays or ultrasound. Despite this armamentarium the etiology can not always be found. SPECT/CT (Single photon emission computed tomography/ computed tomography) is used additionally, especially in the hand. Abnormal scintigraphic uptake in asymptomatic joints and bones are described, but remains unclear in its significance. Objective The aim of this study is to evaluate the prevalence and prognostic value of abnormal uptake in bone SPECT/CT in asymptomatic wrists. Patients and Methods 44 patients (18 women, 26 men) with pain in the symptomatic wrist (SW) and asymptomatic contralateral wrist (AW) were examined with SPECT/CT and included in this study. Dual phase planar and SPECT/CT images of the symptomatic and asymptomatic wrists were obtained between July 2014 and September 2016 and retrospectively evaluated regarding presence, localization, intensity and origin of uptake using a four-point grading scale. Furthermore clinical investigation on the asymptomatic wrist with higher uptake in SPECT/CT was performed after one year. Results 31 (70%) patients showed increased uptake in the SW and 14 (32%) in the contralateral AW. Mean uptake grade in the SW was 1,48 (range 0 - 3) and 0,48 (range 0 - 2) in the AW. The SW showed significantly (p <0.01) more locations with increased uptake and significantly (p<0.01) higher uptake grades compared to the AW. In the AW abnormal uptake was observed in osteoarthritis (n=8), mechanical overload (n=5) or traumatic (n=1). In the SW abnormal uptake was related to osteoarthritis (n= 13), osteoarthritis (n= 5) mechanical overload (n= 14), carpal boss (n= 4) or other etiologies (n=7). No patient of the follow-up group (n=14) had spontaneous pain in the primarily asymptomatic wrist but in 50% patients local pain could be triggered during wrist examination and matched exactly with the initially increased uptake observed in SPECT/CT. Conclusion Increased uptake in SPECT/CT in asymptomatic wrists can be found in one third of patients and are often low to intermediate. The majority of uptake in asymptomatic wrists do not have a clinical relevance in short time follow-up and can therefore be neglected.

D. Bakker 1,3, G. A. Kraan 1, N. M. C. Mathijssen 1, J. W. Colaris 2, G. J. Kleinrensink 3

1 Reinier de Graaf Groep, Department of Orthopaedic Surgery, Delft, The Netherlands; 2 Erasmus Medical Centre, Department of Orthopaedic Surgery, Rotterdam, The Netherlands; 3 Erasmus Medical Centre, Department of Neuroscience, Rotterdam, The Netherlands

Objective Injuries of the scapholunate interosseous ligament (SLIL) are considered to be the most frequently diagnosed cause of carpal instability. In order to improve the post-operative rehabilitation process, it is necessary to obtain a better understanding of the biomechanical properties for commonly used reconstructions like capsulodesis. Therefore, the aim of this cadaveric study was to assess the stress strain relation of the wrist during palmar flexion and to determine the type of failure after capsulodesis. Methods Ten cadaver wrists were used for this study. To obtain the stress strain relation, a differential variable reluctance transducer (DVRT) was placed on two intervals, on the scaphoid and the lunate, and on the dorsal intercarpal complex and Lister’s tubercle. To quantify palmar flexion a digital goniometer was attached at the dorsal aspect of the hand. All wrists were cycled five times through a neutral position to 70° arc. Results The mean strain on the dorsal intercarpal reconstruction at 70° palmar flexion was 0.8mm. (SD±0.6). No failure of the dorsal intercarpal reconstruction was seen during all tests. The maximum strain on the dorsal intercarpal complex was 3.9mm. (SD±1.7) at 70°. Conclusions The stress strain relation shows that the dorsal intercarpal reconstruction undergoes a minimal amount of strain. Furthermore, no failure of the dorsal intercarpal reconstruction occurred. These findings supports the concept that the capsulodesis stabilizes the scaphoid and lunate. The slight strain on the dorsal intercarpal complex suggests that a faster start of the post-operative rehabilitation process might be possible.

Kazutoshi Kubo 1,2, Boran Zhou 2, Yu-Shiuan Cheng 2, Kai-Nan An 2, Steven L. Moran 2, Peter C Amadio 2, Xiaoming Zhang 2, Chunfeng Zhao 2, Katsunori Inagaki 1

1 Orthopedic Surgery Department Showa University School of Medicine, Tokyo, Japan; 2 Mayo Clinic, Minnesota, USA

Carpal tunnel pressure is considered a key factor in the etiology of carpal tunnel syndrome because disease condition in most of carpal tunnel syndrome results in tunnel pressure elevated. We believe that measuring carpal tunnel pressure leads to help to diagnose carpal tunnel syndrome as well as to understand carpal tunnel syndrome comprehensively. Numerous approaches have been conducted to measure carpal tunnel pressure. However, most techniques are invasive and take time and effort. We have developed an innovative approach to non-invasively assess the tunnel pressure by using the ultrasound surface wave elastography (USWE) technique. In a previous study it was shown that the shear wave speed propagating in a tendon increased linearly with increasing tunnel pressure enclosed the tendon in a simple tendon model. This study aimed to examine the relationship between the carpal tunnel pressure and the shear wave speeds inside and outside the carpal tunnel in a human cadaveric model. A total of 10 fresh frozen human cadaveric forearm hands were used to study. The result showed that the shear wave speed inside the carpal tunnel increased linearly with created carpal tunnel pressure, while the shear wave speed outside the carpal tunnel remained constant. These findings suggest that noninvasive measurement of carpal tunnel pressure is possible by measuring the shear wave speed propagating the tendon in the carpal tunnel. After fully establishing this technology and being applicable in clinic, it would be useful in the diagnosis of carpal tunnel syndrome. For that reason, further validation with this technique in both healthy controls and patients with carpal tunnel syndrome is required.

Keitaro Fujino, Katsunori Ohno, Atsushi Yokota, Kenta Fujiwara, Masashi Neo

Department of Orthopedic Surgery, Osaka Medical College, Osaka, Japan

Objective: When we evaluate the thenar muscles using ultrasound, with the transducer directly contacting the skin, the morphometry may easily change with transducer pressure on the curved surface of the thenar region. The aim of this study was to compare reliability and measurement between water bath technique (WBT) and the direct contact method (DM) in ultrasound quantification of thenar muscles and to determine whether measurements were influenced by transducer compression. Method: This study included 40 healthy adults (19 men and 21 women; mean age, 37.8 years; range, 23 - 56 years). The abductor pollicis brevis (APB) of 80 hands was measured with axial ultrasound scans using WBT and DM. Subjects were in relaxed sitting position with the elbow in 90°flexion, forearm in supination, hand in neutral position, and thumb in maximum abduction. WBT was performed in a plastic container filled with water. The forearm and hand were immersed in the container. The transducer was placed adjacent to the skin surface without touching it. DM was performed with sufficient transmission gel in the same container. For ultrasound evaluation, the transducer was placed onto the skin with the least compression possible. A line was drawn between the radial sesamoid of the thumb and the scaphoid tuberosity. An axial image was acquired at the midpoint of the line and the transducer was adjusted to find the location where the flexor pollicis longus tendon was brightest. Thickness and cross-sectional area (CSA) of the APB were calculated with the measurement function of the ultrasound device. In axial images, APB thickness was calculated on a perpendicular line at the most volar point of the first metacarpal. APB CSA was measured simultaneously in the image. All subjects underwent third ultrasound examinations by two examiners a week apart. Interclass correlation coefficients (ICC) were calculated to estimate inter- and intraobserver reliability. Bland-Altman analysis was performed to compare the agreement between measurements by WBT and DM. Limits of agreement were defined as the mean difference ± 1.96 standard deviaion (SD). Result: Thickness and CSA of the APB by both methods showed almost perfect interobserver reliability (ICC range, WBT 0.90 - 0.94, DM 0.87 - 0.94) and intraobserver reliability (ICC range, WBT 0.91 - 0.95, DM 0.90 - 0.95). The mean ± SD (WBT/DM) of APB thickness was 5.76 ± 0.90/5.83 ± 0.90 mm and CSA values were 0.88 ± 0.20/0.91 ± 0.21 cm2. In the Bland-Altman analysis, measurements by WBT were found to overestimate the APB thickness by an average (limits of agreement) of 0.05 ± 0.38 mm, 0.01 ± 0.07 cm2, respectively. Conclusion: Ultrasound quantification of thickness and CSA of APB by both methods showed almost perfect reliability. Although compression by the transducer cannot be completely avoided, the clinical difference may be very small. This result indicates that use of sufficient transmission gel and careful transducer compression on the curved surface of the thenar area will have little influence on measurements of APB thickness and CSA.

Leen Vanlaer 1, Loïc Vercruysse 2, Pieter Caekebeke 1, Arne Decramer 2, Joris Duerinckx 1

1 Ziekenhuis Oost-Limburg, Genk, Belgium; 2 AZ Delta, Roeselare, Belgium

Correct implant position is essential to obtain good results in ball-in-socket trapeziometacarpal total joint arthroplasty. Adequate placement of the cup in the trapezium can be challenging, but is one of the most important factors to prevent postoperative complications. The purpose of this study was to determine if intra-operative fluoroscopic control improves cup position. We evaluated cup centring and cup inclination on postoperative radiographs of 114 trapeziometacarpal joint prostheses. Half of the cups were placed with visual inspection only, the other half was positioned with intra-operative fluoroscopic control. The mean difference in cup centring was not statistically significant between both groups. Mean cup inclination was significantly better in the fluoroscopy-assisted group. Between patient variability was significantly less in the fluoroscopy-assisted group, both for cup inclination and cup centring. The use of intra-operative fluoroscopy results in a better inclination of the cup. It also decreases variability in cup position, providing more consistent radiographic results with less outliers.

Diego Junqueras, Pablo Orellana, Francisco Melibosky, René Jorquera, Peter Cobb, Juan José Valderrama

Clinica Indisa, Chile

Introduction: The fracture of the distal end of the radius is the most frequent fracture of the upper extremity with an annual incidence of 16.2 per 10,000 people. Its surgical treatment with blocked volar plates is currently the gold standard in most fractures. However, it can present complications such as extensor tendon injury and the presence of intra-articular screws. To prevent these complications, the projections of intraoperative radioscopic support "Skyline and Facet View" have been described in recent years, to improve their research and modify their position. The objective of this work is to determine the usefulness of the intraoperative radioscopy using the projections mentioned, to identify screws in an inadequate position, comparing them with a postoperative TAC of control. Patients and Method: A retrospective review of clinical records and image files was performed, where 4 hand surgeons independently and blindly evaluated the "Skyline and Facet View" radiographic images of 24 patients operated for distal radius fracture. Screws were identified in the dorsal or intraarticular position, respectively, and then compared with the postoperative CT Results: There was a low interobserver concordance between what was recorded in fluoroscopic images by each surgeon and the findings in the postoperative CT scan. In addition, low values ​​of diagnostic accuracy are obtained for Skyline View and acceptable values ​​for Facet View. A low detection capacity of dorsal screws in the 1st and 2nd extensor compartment of the wrist was also observed. Conclusion: Our study shows that intraoperative fluoroscopy with Skyline and Facet View projections has low reproducibility and diagnostic accuracy compared to that observed in the control with CT. We believe that the use of this tool should be in a complementary way during the surgical act, keeping in mind its limitations in complex wrist fractures.

Hongje Kang, Daejin Nam, Seng Hwan Kook

Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea

To compare the results of Ultrasonography guided percutaneous A1 pulley release and blind percutaneous A1 pulley releases techniques in a patient with trigger finger, a retrospective study was performed. From February 2012 to February 2016, 34 patients (45 fingers) underwent blind percutaneous A1 pulley release, and 26 patients (30 fingers) underwent ultrasonically guided A1-transcutaneous transcutaneous dissection from August 2014 to February 2016. The mean age was 56 (38-65) years of blinded percutaneous releases techniques, and 54 (35-60) years of ultrasound-guided percutaneous release. The blind percutaneous incision was performed in 8 cases of thumb, 9 cases of 2nd finger, 9 cases of 3rd finger, 6 cases of 4th finger and 2 cases of 5th finger. Ultrasonically induced percutaneous incision was performed in 5 cases of thumb, 2 cases of 2nd finger , 8 cases of 3rd finger, 8 cases of 4th finger and 1 case of 5th finger. The residual postoperative trigger symptom and VAS score were confirmed, and the range of motion of the joint was compared. At the last follow-up, in all cases with ultrasound-guided percutaneous release trigger symptom had disappeared, but three patients who underwent blind percutaneous incision underwent revision surgery for postoperative trigger symptom. The duration of pain after the procedure was 2.0 ± 0.5 days from 0 to 17 days, at the last follow-up, all were recovered. The VAS score was 2 points in the ultrasonography group and 4 points in the blind group at the 2nd week after surgery, at the 4th week after surgery, the VAS score was 1.2 points in the ultrasound group and 2.3 points in the blind group. In the 3 months after the operation, 1.1 points in the ultrasound group and 1.4 points in the blind group. There was a statistically significant difference at 2 and 4 weeks after surgery. No rupture of the tendon was observed, and no other complications such as nerve injury or surgical site infection were observed. The range of motion showed complete recovery in all cases after the procedure, but complete restoration of the range of motion was not obtained when the joint stiffness remained originally. All patients with the procedure was satisfactory, and responded that he would choose the treatment through this method in the future. As conclusion, ultrasound-guided percutaneous A1 pulley release as surgical treatment for trigger finger is considered to be a treatment with low risk of complications such as nerve injury and tendon rupture and highly satisfied after treatment.

Seung-Han Shin, Yong-Suk Lee, Yang-Guk Chung

Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea

Background: Forearm pronation is known to aggravate the ulnar impaction via the increase of ulnar plus variance. However, currently the ulnar variance is measured on two-dimensional (2D) images, and thus does not reflect the effect of dorsal translation of the ulnar head in pronation. Therefore, the actual ulnocarpal distance in pronation could be different in three-dimensional (3D) space. Materials and Methods: We investigated wrist 3D-computed tomography (CT) images of 21 patients, which were taken once with the forearm pronated and then with the forearm supinated. The shortest distance between the ulnar head and the lunate (ulnolunate distance) was measured. Dorsal translation of the ulnar head from its anatomic position in the center of the sigmoid notch was measured using a technique described by Lo et al (radioulnar ratio, RUR). Comparison between pronation and supination and correlation analysis between ulnolunate distance and dorsal translation of the ulnar head were performed. Results: The mean ulnolunate distance was significantly greater in pronation (2.2 mm) than in supination (1.6 mm). The mean dorsal translation of the ulnar head (RUR) also was significantly greater in pronation (0.13) than in supination (-0.14). When those who had greater ulnolunate distance in pronation (n = 18) were analyzed, the difference of ulnolunate distance in pronation and supination had significant correlation with the difference of dorsal translation of the ulnar head in pronation and supination Conclusion: The actual ulnolunate distance in 3D space is greater in pronation, due to dorsal translation of the ulnar head. Dorsal translation of the ulnar head in pronation may be a necessary and protective mechanism which prevents ulnolunate impingement.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

Purpose: We evaluated the relationship between the area around the distal radioulnar joint (DRUJ) according to the ulnar variances and the cross sectional area (CSA) using magnetic resonance images (MRI) in this prospective study of patients with carpal tunnel syndrome (CTS). rnMethods: From among a total of 243 patients who had been diagnosed with CTS between March 2012 and February 2017 at our hospital, 41 patients with positive ulnar variance were enrolled in group 1. As control groups, 39 healthy volunteers who underwent MRI evaluations were included in group 2 (neutral ulnar variance) and group 3 (negative variance). Basic demographic data, including age, gender, and body mass index (BMI) were recorded for all three groups. An area encompassing the contents of carpal tunnel (nerves/tendons) was designated as area “A,” and the area just beneath the subcutaneous fat was designated as area “B” at the levels of the lunate (L) and pisiform (P) on axial MRI. Ratios of these areas (“A/B at L” and “A/B at P”) were evaluated in terms of their correlations with ulnar variance. rnResults: Mean age, gender, and BMI were not statistically different among the groups, respectively. Within each group, there was no difference between “A/B at L” and “A/B at P”, respectively. When comparing the three groups, “A/B at L” and “A/B at P” were all significantly decreased in group 1 than in other groups. Regardless of the group, ulnar length negatively correlated with both “A/B at L” and “A/B at P” ratios.rnConclusions: We found a positive relationship between decreased CSA around the DRUJ and positive ulnar variance on radiologic investigation. These findings show the importance of variance in the positive ulna variance to the development of CTS.rn

Jamila Hussein Eriksen 1, Niels Søe Nielsen 2, Dimitar Ivanov Radev 2, Charlotte Strandberg 2, Merete Juhl Kønig 2, Eva Balslev 3, Lisbeth Vesterløkke 2, Helle Raagaard Larsen, Nana Vermehren 4, Gudlaug Rosa Sigurdardottir 2, Britt Ebstrup 2

1 Nordsjællands Hospital, Hillerød, Denmark; 2 Gentofte Hospital, Denmark; 3 Herlev Hospital, Denmark; 4 Alexis-Hamlet Hospital, Denmark

Objective: There are still many questions regarding the origins of the clinical dorsal wrist ganglion. In this study we seek to discover the processes that initiate and maintain this disease by closely examining the patient history coupled with the exact location and pathology of the tissue. By learning more, it is our hope that treatment of the disease, which has shown to relapse in 5-10% of lege artis operated patients, can be improved. Our hypothesis is that the clinical dorsal ganglion is a result of a change in mesenchymal cells to mucin-producing cells and that there is a connection to the female gender, anatomy, former trauma to the wrist and the occupation of the patient. Methods: The prospective cohort study will examine approximately 40 patients with clinical dorsal wrist ganglion included consecutively over 1-2 years. Excluded are those formerly operated with clinical ganglion excision in the same wrist region. The included patients will undergo a preoperative evaluation with x-ray, MRI and ultrasound of the wrist before excision of the tissue by the same surgeon. The tissue removed is examined by the same pathologist for its components. Results: Preliminary results show that the clinical dorsal ganglia are located primarily dorsal to the scaphoid, lunate and capitate joints and volar to the extensor tendons. Most are cystic structures with surrounding inflammatory changes. Of the 6 patients included in the study to date, only 1 patient has shown signs of having a mucin-producing cyst. The remaining 5 patients have presented cysts that are synovial in origin. Conclusions: Little is known of the ætiologi and pathogenesis of the clinical dorsal ganglion. Our hypothesis is that the cysts develop as a result of change of mesenchymal cells to mucin-producing cells. Our preliminary results have shown that the cysts are mainly synovial in origin. Further study is needed in order to reach a conclusion which may change the public view of what the clinical dorsal ganglion is.

Implants (13 abstracts)

Benjamin Degeorge, Lionel Athlani, François Dap, Gilles Dautel

Centre Chirurgical Emile Gallé, Nancy University Hospital, Nancy, France

The Tactys implant is a new total anatomic gliding and modular prosthesis for the proximal interphalangeal arthrosis. 33 implants in 27 patients with a mean age of 67 years were operated. Surgical approach was mid-line dorsal trans-tendinous. All patients were evaluated (pain, range of motion, strength, function, X-rays) by an independent examiner. The mean follow-up was 21 months (range 12–30). Pain decreased from 7,4 to 1,6 on VAS scale. Flexion–extension range of motion increased from 32,1° to 59,2 and pinch strength from 1,8 to 2,4KgF. Four patients were reoperated on: 3 dorsal tenoarthrolysis and 1 swan neck deformity correction. Asymptomatic peri-prothesis calcification were noticed in 39% of cases on X-rays. There were no signs of implant migration or loosening. The modularity of the Tactys prosthesis seems to maintain range of motion of the PIP joint. It is a reliable alternative to other conventional PIP implants.

Francesco Smeraglia, Sergio Russo, Giovanni Balato, Maria Rizzo, Massimo Mariconda

University Federico II, Naples, Italy

Objectives The goal of this study is to prove the efficacy of Pyrodisk which is a biarticular convex disc made of pyrocarbon designed to act as an interposition spacer after minimal resection of the TMC joint. The implant and TMC joint are stabilized by a hemi- transfer of flexor radialis carpi passed through the implant itself. Study Design & Methods This is a prospective case series analysing 27 consecutive Pyrodisk implants in 25 women for advanced osteoarthritis of the TMC joint (Eaton II or II). Function assessment were made preoperatively and at 1, 3,6 and 12 months postoperatively, and annually thereafter. We obtained the DASH score, VAS score, Kapandji test, patient's satisfaction and pinch strength. Furthermore we requested an x ray to each follow up visit. Results All patients experienced a reduction in the DASH score 1 month postoperatively. The VAS score for pain and the opposition of the thumb also showed significant post- operative improvement. Further positive changes in the DASH score, VAS score for pain, and key pinch strength occurred progressively over the first postoperative year, whereas the opposition of the thumb steadily improved from the first to the sixth postoperative month. All the patients except one were satisfied with surgery. One patient had improvement in the DASH score but she still experienced an high VAS score and reduction of the pinch. She had a slightly hyperextension of the metacarpophalangeal joint. After 4 years she underwent further surgery (trapeziectomy and Ceruso's artrhoplasty). Conclusions Partial trapeziectomy with pyrocarbon arthroplasty may prove to be a successful option for the treatment of trapeziometacarpal joint osteoarthritis. Further long-term comparative studies are warranted.

Jean Louis Bovet 1, Marion Bricout 1, Moujoud Morchikh 1, Hugues Tiemdo 1,2

1 Polyclinique Jean Villar, Bordeaux, France; 2 Clinique Charles de Gaulle, Douala, Cameroun

Objective : Failures of a total TM prosthesis are mainly due to cups non embedment. In this cases many authors suggest the ablation of the implant followed by trapezectomy. We present a way to preserve the trapezium and thereby preserve thumb length, stability, and grasp. This technique is not indicated if the trapezium is fractured. Methods : 37 patients are included in this series, 2 cup loosening and 35 cup non embedment. The series includes 25 Electra , 4 Maia, 3 Arpe, 3 Isis, 2 others implants. It starts from 2005 All the cases had the same procedure. Through a dorsal approach, ablation of the implant avoiding a metacarpal corticotomy is performed. The reconstruction of the trapezium is made by filling it with bone chips from the ipsilateral radius .The first metacarpal basis is resurfaced through the interposition of a CMI pyrocarbon implant. The void created inside the first metacarpal is filled by the CMI stem sometimes completed with apatite. The cicatricial carpo-metacarpal capsulae is tightened with resorbable suture , any complementary ligamentoplasty is employed. Immobilisation is done for 3 weeks . Results : Evaluation was done on X rays, pain, satisfaction, mobility, grasp. Owing to belated beginning 18 cases could not be rewieved. Radiologic evolution shows a corticalisation in contact with pyrocarbon of the chips grafted inside the trapezium. None extrusion of the stem inside the first metacarpal was noticed, none osteophytes or calcification found in the neojoint. Clinically the main fact is the preservation of thumb opposition tests and grasp force (diagram 3) Complications : (diagram 4) none on the donor site, 3 neuritis of the radial sensory branch, 2 SDD Conclusion : This technic is easy to drive, in one time surgery, in one on only operative site. Since for such difficult cases one reprise is already too much, it stands out to become in our practice a "gold standard " for that situations.

Jean Louis Bovet 1, Hugues Tiemdjio 2

1 Clinique jean Villar Bruges Bordeaux France;2 Clinique Charles de Gaulle Douala Cameroun

Objective : Tow lesions close to the articular corticalis of the first metacarpal basis could not be treated without sacrifying the TM joint . This poster will show a combined treatment using after curettage of the tumor a filling of the bone with bone chips from the ipsi lateral radius and the use of a Maia prothesis to reconstruct the TM joint . Method : The first report is a case of Chondroma in right hand of a female secretary aged 45 , without any signs of arthrosis. Pain was the main complaint and leads to discover it . The second report is a giant cyst lacunae combined with arthrosis of the TM joint on the right hand of a physiotherapist aged 63 starting to retire from his job .Pain was the main complaint, the arthrosis was known but neglected and certainly related to his hard massage job. Technic applied was the same for both cases : Under loco regional anesthesia, dorsal incision, full curettage of the lesion, taking chips from the ipsi lateral radius to feel the defect , insertion of the Maia stem amoung the chips in a press -fit manner , and then completion of the procedure on the trapezium .Splinting was applied for 3 weeks . Autoreeducation was enough without need of physiotherapy. Caution was asked in everyday life for 3 months . Hard works authorized only after 6 months Results : Evaluation was done at 1 month , 3 month , 1 year , last control is 8 years for the chondroma and 5 years for the cyst. Both recovered a complete opponens and antepulsion of their thumbs. Pain have totally disappeared. No complaint due to surgery. No complications on the donor site. Any radiological recidive of the lesions . Full incorporation of the bone grafts. No signs of implant descellement. Conclusion: Combination of bone grafts and articular reconstruction allows to keep a normal function, without shortening the thumb , and preserving the trapezium.

Annelien Brauns, Pieter Caekebeke, Joris Duerinckx

Ziekenhuis Oost-Limburg, Genk, Belgium

It has been suggested that in trapeziometacarpal total joint arthroplasty, the trapezial cup should be positioned parallel to the proximal articular surface of the trapezium (PAST). This suggestion was based on the radiographic measurement of the range of motion of healthy joints. The goal of this study was to biomechanically test this statement. 5 fresh frozen cadavers hands were mounted in a test jig. An Arpe metacarpal stem and medium offset neck were implanted. 3D-printed trapezium cups with different inclinations relative to the PAST (neutral, 10°; 20°; 30°, 40°) were implanted. The stability of the prosthesis was tested through its entire range of motion for the different cup inclinations. We assessed is which positions and with which inclinations the prosthesis dislocated.This is important information to determine ideal cup position.

Damian Sutter 1,2, Dzhuliya V. Dzhonova 2, Jean-Christophe Prost 3, Cedric Bovet 3, Yara Banz 4, Jean-Christophe Leroux 5, Robert Rieben 2, Esther Vögelin 1,2, Jan A. Plock 6, Paola Luciani 5,7, Adriano Taddeo 1,2,8, Jonas T. Schnider 1,2,8

1 Department of Plastic, Reconstructive and Hand Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland; 2 Department for BioMedical Research, University of Bern, Switzerland; 3 University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Switzerland; 4 Institute of Pathology, University of Bern, Switzerland; 5 Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zürich, Switzerland; 6 Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Switzerland; 7 Department of Pharmaceutical Technology, Institute of Pharmacy, University of Jena, Germany; 8 contributed equally

Study Vascularized composite allotransplantation (VCA), the transplantation of a hand, face, abdominal wall or uterus is an emerging field. Thus far, over 120 upper extremity transplantations in at least 75 patients have been performed around the globe within the past few years. Most recipients are otherwise healthy individuals. After transplantation however, they are in a need for life long systemic immunosuppression to prevent graft rejection. This therapy comes at the cost of considerable morbidity and even mortality preventing a wider clinical application of vascularized composite allograft. Contrary to solid organ transplants, their composition of different tissue types makes them highly immunogenic and particularly challenging to treat. On the other hand, hand and face transplants are accessible for visual inspection, allowing treatment of an acute rejection episode to be initiated promptly. In addition, local treatment is also used to treat rejection episodes. Expanding on this concept, VCA offer the unique opportunity for local delivery of immunosuppressive treatment directly to the graft, possibly without the need for systemic treatment altogether. In this study, we developed a vehicle to locally deliver rapamycin to an allograft. We hypothesize that locally delivered rapamycin using this system may lead to immunomodulation of the graft microenvironment with improved graft survival, minimization of immunosuppression and expansion of regulatory T cells. Methods Drug release pattern of in situ forming implant loaded with 5 mg rapamycin (Rapa-ISFI) was analyzed in vitro and in vivo. The effect of Rapa-ISFI on VCA rejection was analyzed in the Brown-Norway-to-Lewis hindlimb allotransplantation model. Rapa-ISFI was injected in the groin on the transplanted (group A) or contralateral non-transplanted side (group B). Control group consisted of absence of immunosuppression (group C). Rejection was graded macroscopically and histologically. Rats were followed until grade 3 rejection or for 100 days. Tacrolimus levels and regulatory T cells and chimerism levels were analyzed in blood throughout the experiment using LC-MS and flow-cytometry. Results In vitro and in vivo analysis of the Rapa-ISFI showed sustained release with subtherapeutic systemic drug levels. All the untreated rats (group C) died within 30 days. Rapa-ISFI significantly prolonged graft-survival with 83.3% of the rats in group A (p=0.0007 versus group C) and 50% of group B (p=0.007 versus group C, p=ns versus Group A) reaching the 100 days end-point. Rapa-ISFI injection induced an initial burst-release of rapamycin, constant levels between day 23 and 58 and undetectable levels (i.e., <1.5 ng/mL) afterwards. Rapamycin in VCA-skin in groups A and B showed similar tissue levels. Rapa-ISFI treatment promoted the expansion of Helios-negative regulatory T cells and peripheral chimersim both in the peripheral blood and in the transplanted skin. Conclusion We show a novel approach for drug delivery in VCA. The treatment is able to promote VCA survival and induce the expansion of T regulatory cells as well as myeloid chimerism.

Lea Estermann 1, Elvira S. Bodmer 1, Miriam Marks 2, Daniel B. Herren 1

1 Department of Hand Surgery, Schulthess Klinik, Zurich, Switzerland; 2 Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland

Objective The Amandys® implant is an interpositional pyrocarbon implant for wrist arthroplasty. For patients with well-aligned wrists and competent capsuloligamentous structures, this implant offers a good alternative to more invasive procedures involving a total wrist prosthesis or total fusion. Based on the few case series showing promising results of pain relief and patient satisfaction, we began using Amandys® mainly for revision surgery after failed wrist procedures. We noted complications with this implant after a short follow-up period, which led to further revision surgery. The objective of this analysis was to investigate possible factors explaining the problems we encountered with this implant. Methods This retrospective analysis focused on five consecutive patients who underwent wrist interposition arthroplasty with the Amandys® implant (i.e. index revision surgery). The indication for this procedure was persisting wrist pain after proximal row carpectomy (PRC) in three patients, scapholunate advance collapse (SLAC Stage III) in one patient, and Kienböck’s disease (Stage IIIb) in the last patient. All patients underwent clinical and radiographic examinations to determine total range of motion, improvement in the level of pain and carpal bone alignment after 6 weeks, 3, 6 and 12 months post-surgery. Results Due to persisting postoperative wrist pain in two patients, we had to remove the Amandys® implant and perform wrist fusion after 12 and 23 months respectively. These patients had undergone PRC prior to the index revision surgery. Of these two patients, one required an additional intervention before the wrist fusion to excise the proximal part of the hamate bone due to osseous impingement (as detected by SPECT/CT scan). The patient with Kienböck’s disease is scheduled to undergo revision surgery because of persisting pain and loss of strength. The last two patients (with a SLAC and PRC wrist, respectively) were satisfied with their hand function. The 6-month postoperative mean wrist flexion was 21° (range: 0 - 45°) and mean wrist extension was 37° (range: 20 - 50°). Conclusions Based on our small patient series, we could not confirm the results from previously published studies. Our failure rate after interposition arthroplasty with the Amandys® implant is high, particularly for PRC patients. We hypothesize that PRC, in conjunction with a certain degree of intrinsic ligament destabilization, may primarily lead to proximalization of the hamate. This process could provoke an impingement with the implant, resulting in subsequent pain and failure of this procedure. In cases of obvious distal carpal row instability, additional stabilization may therefore be considered. More patients are needed to find the optimum indication for this implant, and we encourage further reports on this issue.

Magne Røkkum, Trygve Holm Glad, Rasmus Thorkildsen, Ole Reigstad

Oslo University Hospital, Norway

Arthrodesis has been the final treatment of destroyed and painful wrists. Pain relief may be good, although several patients complain of residual pain and complications that require reoperation. In addition, many people experience that stiffness reduces hand function. We have rearticulated 8 fused wrists with the Motec cement-free total wrist prosthesis with metal-on-metal articulation. There were 4 women and 4 men of median age 53 (41-67) years. The causes of arthrodeses were SLAC (3) and SNAC (1) wrist, seq. radius fracture (2), Madelung’s deformity and hand replantation (1). The indication for rearticulation was impaired function in all, as well as significant pain in 5 wrists. The rearticulation took place median 5 (2-13) years after arthrodesis. Mobile CMC 3-joints were fused simultaneously. The patients were followed up median 2 (2-11) years after rearticulation. No peroperative complication was seen. In one patient, X-ray showed radiolucent lines developing between the distal fixation screw and the diaphysis of the third metacarpal, where a part of a screw was left. No lucencies were found in the capitate and no migration of the component was seen. Radiologically, excellent bone integration of all components was observed. At the last check, median flexion/extension was 60 (45-90) degrees divided on 20 (10-32) degrees of flexion and 40 (30-60) degrees of extension. Median ulnar/radial deviation was 25 (20-40) degrees. Six wrists were painless, while two had some tenderness. All patients were very pleased with the improved function, the mobility and the reduced pain. Although the follow-up is short, the results of rearticulation of fused wrists with the Motec prosthesis are promising. Fixation of the prosthesis is not more difficult than in the primary situation. All patients achieved enough wrist mobility to get close to normal hand function. The surprising pain relief may be explained elimination intercarpal and CMC 3 joints. Patients with functional problems and pain following wrist fusion should be considered for rearticulation.

Stéphane Barbary 1, Thomas Apard 2, Jean-louis Bovet 3, Jacques Teissier 4

1 Centre Chirurgicale ADR, Nancy, France; 2 Center of Echo Handsurgery, Versailles, France; 3 Orthopole, Bruges, France; 4 Orthosud, Montpellier, France

It’s a prospective study. 50 Maia prosthesis has been implanted between January and July 2015 for the treatment of thumb arthritis Dell stage 2 or 3. The implant is a ball and socket dual mobility prosthesis with hemispherical cup and press-fit fixation and hydroxy-apatite coated. The surgical technique (dorso-radial approach) and the average duration of intervention (40 minutes) was the same as for the placement of a conventional trapezio-metacarpal prosthesis. The thumb column was immobilized for 3 weeks then rehabilitation was gently encouraged. At the minimal 2 years follow up, we observed : one early dislocation ( 2 months) because of a surgical error (cam effect) solve by the excision of the palmar horn of the first metacarpal, no trapezial/metacarpal fracture, no infection and no failure of the implants. The score pain VAS decrease from 7/10 to 1,5/10, the mobility was similar or increase in any direction after surgery, the most of unfixed Z deformations were corrected, the pinch grap increase of 30% and the rate of patient satisfaction was very high. In conclusion, at 2 years follow-up, the pain release, the mobility, the pinch grap, the patient satisfaction, was comparable as the assess of the classical single mobility Maia prosthesis. However, with 1 dislocation on 50 patients, because of a technical error, the dual mobility seems to be better than single mobility in short outcome. A prospective comparative study with more patient should be conducted.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne – Franche-Comte, Bd. Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in patient who have been operated on both sides. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 12 patients who underwent 36 Isis TMC prosthesis implantations from June 2007 to September 2016, and who had a minimum of 12 months’ follow-up. Indications for the procedure were painful bilateral TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independent operator). We compared the means of the Kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, ADL, QDash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: we included 36 prostheses in the survival analysis with a mean follow-up of 48.2 months (range, 12-111 months). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 32 bilateral arthroplasties from 12 patients were included in the clinical analysis. The mean age at surgery was 60.4 years (range, 42-80 years) and the median follow-up was 48.2 months (range, 12-111 months). At 5 years' follow-up, the mean Quick Disabilities of the arm, shoulder, and hand score improved from 75.6± 3.5 to 8.8 ± 0.5. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the Kapandji score, was almost normal (9.6 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 25% and 44%, respectively. CONCLUSIONS: In our series, the bilateral procedure for Isis prosthesis in TMC osteoarthritis has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in males patients only. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 13 males patients who underwent 17 Isis TMC prosthesis implantations from December 2010 to September 2015, and who had a minimum of 14 months’ follow-up. Indications for the procedure were painful TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independent operator). We compared the means of the Kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, ADL, QDash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 17 prostheses in the survival analysis with a mean follow-up of 36.7 months (range, 14-69 months). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 17 arthroplasties from 13 males patients were included in the clinical analysis. The mean age at surgery was 65.4 years (range, 54-80 years) and the median follow-up was 36.7 months (range, 14-69 months). At 5 years' follow-up, the mean Quick Disabilities of the arm, shoulder, and hand score improved from 78.7 ± 501 to 8 ± 1.2. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. opposition, defined by the Kapandji score, was almost normal (8.5 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 32% and 45%, respectively. CONCLUSIONS: In our series, the Isis prosthesis of the thumb TMC joint has proven to be a reliable and effective implant in males patients. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: The new generation of ISIS TMC total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 24 patients who underwent 29 Isis TMC prosthesis implantations from November 2006 to July 2009, and who had a minimum of 5 years' follow-up. Indications for the procedure were painful TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independant operator). We compared the means of the kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, adl, qdash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 29 prostheses in the survival analysis with a mean follow-up of months. No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 29 arthroplasties from 24 patients were included in the clinical analysis. The mean age at surgery was 63 years (range, 42-84 years) and the median follow-up was 80 months (range, 60-120 months). At 5 years' follow-up, the mean quick disabilities of the arm, shoulder, and hand score improved from 77.2 ± 2.5 to 11.9 ± 1.4. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the kapandji score, was almost normal (9.6 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 25% and 42%, respectively. CONCLUSIONS: In our series, the Isis prosthesis of the thumb TMC joint has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Gauthier Menu, Etienne Boyer, François Loisel, Daniel Lepage, Laurent Obert

Orthopedic, Traumatology, and Hand Surgery Unit, CHRU Besancon - University of Bourgogne - Franche Comte, Bd Fleming, 25030 Besancon, France

PURPOSE: the new generation of ISIS tmc total joint arthroplasty is a modular, semi retentive, uncemented ball-and-socket hydroxyapatite-coated implant. It was introduced in 2007 for the treatment of symptomatic trapeziometacarpal (TMC) osteoarthritis. The primary outcome of this retrospective study is to report the medium- to long-term joint survival of this prosthesis in patients with scaphotrapeziotrapezoid osteoarthritis. Our secondary outcomes are the clinical and functional results. METHODS: This multicenter retrospective study involved 20 patients who underwent 21 Isis TMC prosthesis implantations from September 2010 to march 2016, and who had a minimum of 18 months follow-up. Indications for the procedure were painful scaphotrapeziotrapezoid joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Clinical and radiological assessment was recorded prospectively: before surgery and in the first year by the surgeon, and at 5 years or more after surgery by an independant operator). We compared the means of the kapandji index (assessing the thumb range of motion and opposition), the grip strength, the pinch strength, adl, qdash, before surgery and at the latest follow-up. Clinical and radiological complications were registered. RESULTS: We included 21 prostheses in the survival analysis with a mean follow-up of 46.9 months (range 18-111). No prostheses required revision surgery and no implant failed. No dislocation was pointed. A total of 21 arthroplasties from 20 patients were included in the clinical analysis. The mean age at surgery was 66.4 years (range, 54-84 years) and the median follow-up was 46.9 months (range, 18-111 months). At 5 years' follow-up, the mean quick disabilities of the arm, shoulder, and hand score improved from 70.3 ± 3.2 to 13.2 ± 1.5 the mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the Kapandji score, was almost normal (9.45 of 10; range, 5-10), as was the final mean key pinch and grip strength, which improved by 30% and 46%, respectively. CONCLUSIONS: In our series, the Isis prosthesis in patients with scaphotrapeziotrapezoid osteoarthritis has proven to be a reliable and effective implant. Mean motion and strength increased whereas pain decreased after surgery and these results remained constant within the follow-up period.

Infection / Arthritis (13 abstracts)

Gavrielle Kang 1, Mabel Leow 2, Tay Shian Chao 2

1 Tan Tock Seng Hospital, Singapore; 2 Singapore General Hospital, Singapore

This study aims to identify differences in demographics, clinical and laboratory data between wrist septic arthritis and other non-septic arthritides in patients admitted for wrist inflammation. A retrospective review of inpatients managed by the Hand Surgery Service from May 2012 – April 2015 was conducted. 77 patients were included. Non-septic arthritis patients were more likely to have chronic kidney disease, pre-existing gout, or both. All septic arthritis patients had normal serum uric acid levels, and two or more raised inflammatory markers (white cell count, C-reactive protein, and erythrocyte sedimentation rate). In patients with isolated wrist inflammation, the mean C-reactive protein in the septic arthritis group was significantly higher compared to the non-septic arthritis group (mean difference 132 mg/L, 95% CI 30.9 – 234).

Clara Vella, Samuel George, Zahid Hassan

Whiston Hospital, Liverpool, UK

Hypothesis: To evaluate practice and recurrence rates of surgically treated DMC in a single-centre where DMC excision is performed by both plastic and orthopaedic surgeons; comparing practice to the suggested operative-triad outlined by Shin and Jupiter(1). Methods: A retrospective review of all patients with surgically treated DMC, under the care of plastics or orthopaedic surgery, from April 2012-April 2016 was performed. Data was collected from an online database of operative records, outpatient follow-up letters and histology reports. The areas that were analysed were patient demographics, grade of surgeon, documentation of osteophyte debridement and synovectomy, methods of closure, follow-up period, recurrence and complications. Results: A total of 136 cases were included; 66.2% were female patients with an average age of 58.9 (range 16-90). 73 (53.7%) were treated by plastic surgeons and 63 (46.3%) by orthopaedic surgeons. There was a total 14 (10.3%) documented recurrences; the average recurrence rates for plastic surgery were 13.7%, compared to the orthopaedic surgery recurrence rate of 6.4%. All three of the suggested triad were documented as performed in 4(2.9%) cases – with a 100% cure rate. Debridement of osteophytes was documented in 39 (28.7%) cases, 31 (79.5%) of which were under the care of the plastic surgeons. Synovectomy was documented in 13 (9.6%) cases, 9 (69.2%) of which were under the care of the plastic surgeons. 114(83.8%) cases underwent direct closure and 16(11.8%) had local flaps. Plastic surgeons sent more samples for histology at 84.9% when compared to orthopaedic surgeons, 36.5%. The follow up period ranged from 1 week to 12 months but on average plastic surgeons followed their patients up for longer, with a mean follow-up period of 8.6 weeks, while orthopaedic surgery had a mean follow-up of 3.6 weeks. The complication rate for plastic surgeons was 23.3% while orthopaedic surgeons had a complication rate of 19%. Conclusion: The study has shown discrepancies in practice and outcomes between plastic and orthopaedic surgeons. The difference in complications and recurrence rates cannot be commented on due to the large difference in follow-up periods between the two groups. Discussions regarding the introduction of a universal proforma to be used by both plastic and orthopaedic surgeons ensuring all surgeons are performing Shin and Jupiter’s triad of skin excision, osteophyte debridement and synovectomy which have a 100% reported cure rate(1) will promote treatment consistency and pave the way for further research into the optimal technique for digital mucous cyst excision. References: 1. Shin EK, Jupiter JB. Flap advancement coverage after excision of large mucous cysts. Tech Hand Up Extrem Surg. 2007 Jun;11(2):159-62.

Isidro Jiménez 1, Pedro J. Delgado 2, Ricardo Kaempf de Oliveira 3

1 Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain; 2 Hospital Universitario HM Montepríncipe, Madrid, Spain; 3 Instituto da Mão, Complexo Hospitalar Santa Casa and Hospital Mãe de Deus, Porto Alegre, Brazil

Our purpose was to study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cyst using the Zitelli modified bilobed flap. Thirty-three cases were surgically treated from January 2006 to June 2015. Demographic data, comorbidities, location and size of the cyst, time to wound healing and complications were assessed. No punctures or injections were performed prior to surgery. The surgery was performed under a digital nerve block using 1% mepivacaine and a digital tourniquet was applied as described by Salem. The first dressing was performed five to seven days after surgery placing a non-adherent dressing and an aluminum DIP immobilization splint was used for two weeks. The mean mucous cyst size was 7.1 x 5.8 mm and the most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. In one case donor area skin necrosis on the very distal part of the first lobe occurred but healed by secondary intention. In two of cases a superficial infection was diagnosed and treated successfully by oral antibiotics. There were no major complications. The mucous cyst recurred in one of 33 cases The Zitelli bilobed flap is an exceptional flap to provide good quality skin coverage over the DIP joint in a short time period. Its geometrics landmarks facilitate the technique learning curve for young surgeons. The Zitelli bilobed flap can provide good quality skin coverage over the DIP joint in a short time period.

P. Martínez-Galarza 1, A. Toro-Aguilera 1, V. Arcediano 2, H. Alfaro 3, M. Pascasio 4, E. Povedano 5, I. Dot 6

1 Hand and wrist unit, Fundació Sanitària Mollet, Barcelona, Spain; 2 Vascular Surgery Department, Fundació Sanitària Mollet, Barcelona, Spain; 3 Socio-Sanitary Hospital, Fundació Sanitària Mollet, Barcelona, Spain; 4 Physical Therapy Department, Fundació Sanitària Mollet, Barcelona, Spain; 5 Occupational Therapist, Hospital Sant Joan de Deu, Barcelona, Spain; 6 Intensive Care Unit, Hospital del Mar, Barcelona, Spain

Purpose: We would like to expose the multidisciplinary approach after this rare and devastating situation in two different patients: a 73 and 52 years old woman. Methods: Challenges of managing people with multimorbidity in today’s healthcare systems force professionals to face patients under multiple considerations as previous quality of life, patient expectations and family support. We present a 73 years old lady type 2 diabetes insulin-dependent with a severe peripheral neuropathy and nephropathy, allergic to penicillin, who suffered a septic shock after an acute 7mm obstructive pyelonephritis. After pigtail ureteral stent placement and imipenem/linezolid intravenous treatment the patient didn’t improve and evolved to a multiorgan collapse because of E.coli bacteraemia. She was treated by noradrenaline up to 14 mcg/kg/min, dialysis and mechanical ventilation. The patient survived but unfortunately presented a symmetrical peripheral gangrene. The second case is a 52 years old lady with a Chron disease, who also suffered a septic shock after an intestinal resection surgery. After a suture failure and a polymicrobial infection she developed a septicaemia and was started on broad-spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. A peripheral four limbs dry gangrene was established. Results: The first case got a 4 limb amputation. Lower limbs were resected by vascular surgery in a transtibial short below knee amputation. After 2 months, hand and wrist unit proceed with a bilateral wrist disarticulation. Due to her medical conditions, the patient is in a wheelchair and uses hand external cosmetic prosthesis. The 52 years old lady was treated by a transtibial short below knee amputation of both legs. After 6 weeks she had a transmetacarpal amputation of the left hand and a multidigital amputation of the right hand. At present time, the patient is able to walk with prosthesis and she was protetized from the dominant hand. Conclusions: This is an extremely rare side effect from inotropic use in a septic shock. A multidisciplinary approach has to be done to manage this anecdotal situation. Four limb amputations is a reasonable treatment once the gangrene is well established.

Thomas Henne

Kreiskrankenhaus Osterholz-Scharmbeck, Germany

Introduction: About 35.000 people are victims of animal bites in Germany every year. 80% of them never see or need a doctor. Nevertheless specially cat bites are a therapeutic problem, because they are like inoculation injuries and are in up to 50 % infected. Though the clinical course without intervention cannot be predicted due to multiple variables ( microbiological settlement of cat`s oral cavity, immunbiological state of the patient ). The therapeutic range starts with watchful waiting and raise up to operative revision in every case. We present a seton drainage as a new tool for treatment of cat bites. Method: A monofile non resorbable seton is led through the cat bite in the subcutaneous tissue, stitched out one inch proximally and fixed by a false knot, though that the cat bite wound cannot close. After a wound dressing soaked with an alcoholic desinfection solution the related upper extremity is immobilized by a splint. Moxifloxacin is given as antibiotic. The wound is controlled day by day. After clinical recovery of inflammation the setons were removed, antibiotics run 2 days longer. Return to work is possible 2 days later. Results: Up to now 22 patients with hand or forearm bite injuries ( cat 19, dog 1, Degu ( southamerican hamster ) 1, rat 1 ) were treated according to the procedure described above. The patients came to hospital between 6 and 48 hours after injury ( rat bite after 2 weeks ). Clinical findings were pain ( 22 ), local swelling ( 22 ), local inflammation ( 22 ), lymphangitis ( 6 ) and fever ( 3 ). In 20 patients wounds healed without complications. One patient, presenting himself 48 hours after cat bite, required operative intervention 24 hours later and one patient developed an abscess of the related finger 6 weeks later. A definitive evaluation of the method needs greater numbers of patients.

Deepak Samson, Matthew Jones, Andrew Mahon

University Hospital Coventry and Warwickshire, Coventry, UK

Objectives: Fractures of the trapezium are rare and easily missed. . As these injuries are often imperceptible on plain radiographs, diagnosis in the ED setting is challenging. We report a case of an isolated fracture of the Trapezium which was picked up as a non-union five months after the injury following persistence of symptoms. To our knowledge successful fixation of a non union of the trapezium has not been reported in the literature. This case highlights the importance of a high index of suspicion in the face of continuing symptoms and the judicious use of cross sectional imaging . Methods: A 49 year old man fell from his mountain bike at speed and presented to his local secondary care hospital with an injury to the base of his left thumb. There was pain and swelling at the base of the thumb with painful restriction of movements. Initial radiographs were deemed to be normal and he was treated as a soft tissue injury with a period of immobilisation followed by physiotherapy. The patient was referred to us four months later as the pain and weakness were persisting. A thorough retrospective perusal of his history and imaging to date was carried out. A review of his initial plain radiographs and MRI scans indicated a fracture of the left trapezium and a CT scan was obtained to further characterise the anatomy of the fracture. We performed a open reduction and internal fixation through a Wagner approach with headless compression screws. Results: At three months from injury, the patient had complete resolution of his symptoms and had gone back to mountain biking. Range of movement had improved remarkably and he was pain free. Plain radiographs confirmed union across the fracture site. Conclusion: These are rare and challenging injuries to diagnose and can often be missed. Open reduction and internal fixation, even after delayed diagnosis and late surgery, can result in good functional outcome.

Mateus Saito, Renata Gregorio Paulos, Priscila Rosalba Domingos de Oliveira, Thiago Felipe dos Santos Barros, So Yeon Kim, Marcelo Rosa de Rezende, Rames Mattar Junior

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: Report the first case of infectious tenosynovitis caused by bacteria from the genus Paenibacillus Methods (CLINICAL CASE) Female patient, 23 years old, professional Judo athlete. At the time of infection she was in her second month rehabilitation from an left knee anterior cruciate ligament reconstruction. Her main complaint was pain and edema of her right hand for the past 10 days. She denied any type of trauma, fever or chills. When she came into the our service she had already been seen in two different hospitals and was treated as inflammatory tendinitis caused by overuse. She had clear Kanavel signs in her middle, annular, and small finger of her right hand. She had intense pain when palpated on the volar side of the distal third of the forearm. Her neurological exam was normal. An incision was made at the distal palmar crease of the anular and small finger, with another incision at the distal interphalangeal joint level of the same fingers. We observed intense synovitis in the pulleys of the flexor tendons but did not observe purulent drainage, even after a irrigation catheter was placed and the tendon sheath irrigated. The tissue in the A1 pulley and the proximal portion of the A2 pulley of the small finger, was friable, as well as the subcutaneous tissue around them. Samples of these tissues were sent for culture analysis. Another 4cm longitudinal incision was made over the flexor radialis carpus, proximal to the palmar crease at the wrist and the Parona’s space was explored. We found clear serous liquid. Results:Leucocyte count: 8390; C reactive protein: 57.2 mg/ L. The culture analysis of the tissue was positive for Paenibacillus spp. The patient was admitted for ten days, was prescribed Oxacillin and Ceftriaxone. At discharge, she was prescribed oral Levofloxacin and had good clinical remission of the signs and symptoms. Conclusion: This is the first case report on pyogenic tenosynovitis caused by Paenibacillus. Even though it was an isolated case, it alerts health professionals of the fact that this can be an agent that causes pyogenic tenosynovitis in the hand in healthy patients.

Marco Borsetti, Federica Bergamin, Claudia Cerato, Alessandra Clemente, Ezio Gangemi, Silvia Germano

Departement of Plastic Surgery, Hand Surgery and Microsurgery

Objective Osteomyelitis of the hand is uncommon, but prompt diagnosis and treatment are important, because hand stiffness, contractures, and even amputation can result from missed diagnoses or delayed treatment. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. The principles of management are good surgical debridement and culture-guided antimicrobial therapy but in the hand, duration and mode of antibiotic administration are still uclear and evidence is lacking to guide the decision whether to send atypical cultures during surgical debridement. Our purpose was to validate a protocol of treatment. Methods We retrospectively identified 28 adult patients undergoing surgical debridement of bone infections of the upper extremity in which cultures were sent. Descriptive statistics were used to describe patient characteristics, infection diagnoses, number of cultures sent with corresponding rates of positivity. The treatment involves a combination of: surgical debridment with tissue coltures, antibiotic treatment of 4weeks' duration (intravenous and/or oral) first and guided by swabs results after and flaps to cover or to fill the defect. Patient were evaluated at one year with x-ray to esclude persistence of infection. Results The most common bacteria implicated remains Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent. The protocol adopted was able to eradicate the infection in all cases. The functional result depends on duration of the disease before surgery and on type of bone involved (metacarpal, phalanx). Conclusion The continued emergence of antibiotic-resistant bacteria and the development of only a few new classes of antibiotics over the past 50 years have made the treatment of acute hand infections problematic. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. We have introduced a protocol of treatment with optimal cure rate e good funcional preservation.

Alberto Castellón, Matías Núnez, Ignacio Fernández

Instituto de Seguridad del Trabajo, Viña del Mar, Chile

Acute osteomyelitis is a diagnostic and therapeutic emergency, whose Early diagnosis and timely treatment improve prognosis and minimize the risk of progression to chronicity and complications. Knowledge about the use of bone grafts has demonstrated clinical success in musculoskeletal surgery. The clinical achievements and the ability to solve highly complex pathologies are directly related to the possibility of having allografts or bone autografts. The surgeon who faces a reconstructive and rescue problem must choose the graft to use that has the greatest integration potential, according to local conditions and minimize the risk of complications, especially in thumb injuries where the fist and clamp maneuver are of vital importance for activities of daily living. The following case correspond to a 63-years-old male, with no known morbid history or allergies. Smoker +. Two weeks of evolution of pain in the right thumb plus volume increase and erythema, secondary to a puncture wound in the kitchen area while on board. Physical exam, right thumb with erythema, increased phlegmonous volume, associated with functional impotence. Radiological studies were requested to complement the study, where an osteolytic lesion involving the entire distal phalanx is observed. Patient is hospitalized for surgery and intravenous antibiotic treatment. Surgical cleanliness was performed with dorsal approach to proximal, with loss of almost the entire distal phalanx and almost complete infectious involvement of the extensor tendon. As well as commitment of the capsule and the joint. 3 cultures samples and 2 biopsies of perilesional and bony tissue are taken. It is left in treatment with intravenous Clindamycin, with poor response. Antibiotic treatment is adjusted according to the result of cultures (Proteus vulgaris and Enterobacter), to Moxifloxacin 400 mg every 24 hours and new surgical toilets Confirmed the infectious etiology with cultures and biopsy (nonspecific acute osteomyelitis, suppurative associated with an acute nonspecific acute peritendinitis), it was decided to leave cement spacer with antibiotic COPAL G + C, debriding devitalized tissue and removing remnants of base of distal phalanx. On the fourth day after the last procedure, discharge and ambulatory control were decided in 9 days, continuing with antibiotic treatment orally. In medical control, it was decided to perform phalangisation by means of a structural bone graft technique of the anterior iliac crest, in addition to sample taking of secretion and tissue culture. Graft is carved and fixed with transient axial Kirschner wire, and 28 mm trimed compression screw step. He is immobilized with Jackson splint. It evolves favorably and it is decided high with ambulatory control. The following week, the last culture is rescued, being positive for negative coagulase staphylococcus, being evaluated by an infectious agent, who suggests maintaining behavior without antimicrobials. Two weeks after structural bone grafting, the patient is referred to Occupational Therapy and physical therapy. At 9 weeks postoperatively, he presented advanced signs of consolidation, with a well-tolerated grip and grip maneuver. It is decided to register as a patient together with a multidisciplinary team, reintegrating to differentiated tasks in their work.

Mihaela Perţea 1,2, Sorinel Luncă 1,3, Oxana-Mădălina Grosu 2

1 University of Medicine and Pharmacy “Gr. T. Popa” Iași, Romania; 2 Clinic of Plastic and Reconstructive Microsurgery, “Sf. Spiridon” Emergency Hospital Iași, Romania; 3 Surgery II Department, Regional Institute of Oncology Iași, Romania

Objectives Septic arthritis is not a very common pathology. The incidence of septic arthritis is 5-10 cases per 100000 inhabitants. It occurs as a result of a pathogenic agent contamination in one of the joints, most often a bacterial one. The etiology may be various: wounds, neglected fractures, vicious treated or unrecognized due to an atypical clinical picture that a septic arthritis can take. Symptoms occur later enough, so the disease is detected when tissue destruction is massive. Methods Our study is based on a group of 4 patients: a woman and three men, aged between 45 and 76 years old, all with a recent history (between 3 weeks and 1 month) of closed fracture of distal radius. The treatment in all four cases was cast immobilization. It should be noted that all the patients were diagnosed with insulin-requiring diabetes. Clinically, the onset of the septic arthritis is with very intense pain, erythema and swelling in the wrist, symptoms which did not remit under conservative treatment with anti-inflammatory. Paraclinical tests showed important leukocytosis (maximum of 40.000), thrombocytosis (maximum of 1.100.000) and a moderate anemia (up to 7.1). Ultrasound exam showed, in all four cases, fluid collection in the wrist (left wrist of the woman and right wrist of all the men). Operatively, we found a purulent content (a quantity between 50 and 300 ml), extended in the carpal tunnel and palm in two cases. The bacteriological exam found the presence of Methicillin-resistant Staphylococcus aureus in all four cases. Targeted antibiotics were administered. Local treatment was difficult and long-standing in two cases, using negative pressure therapy (VAC therapy) associated with continuous lavage. Only in one case we managed to obtain a quality granular bed which allowed the coverage with a split-thickness skin graft. In the other one, due to the associated diseases, the general status of the patient worsened, so the amputation was necessary. In the last two cases, we managed to close the wounds by direct suture. Results The results were relatively good only in three cases. The physiotherapy after the complete healing was mandatory and the patients remained with wrist flexion deficits betwwen 10 and 30 degrees and limited wrist extension between 15 and 35 degrees. In one case (the youngest patient) the diabetes mellitus and associated diseases exacerbated the patient’s condition in the infectious general status, so that the amputation was necessary from the upper third of the forearm. Conclusions Although quite rare, the septic arthritis must be a well-known condition and considered in the differential diagnosis with other diseases. Neglected, it can lead to serious complications with long-suffering period of hospitalisation and, in the extreme cases, with loss of limb segment. Key-words: arthritis, VAC, infection.

Torbjörn Vedung

1 Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; 2 Department of Orthopedic and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden

Objectives Mycobacterium Senuense is a newly described previously unknown species, closely related to the Mycobacterium terrae complex. It was isolated 2008 from a Korean patient with a symptomatic pulmonary infection. It is an arbitrary name formed from the initial letters of Seoul National University, the organization that carried out the taxonomic investigation of the type strain. Mycobacterium Senuense has recently been found in slaughter pigs in Uganda, but has never been reported as a soft tissue infection in humans. Mycobacterium infections in the hand are rare but may occur. Methods A 40-year-old female chef accidently cut her long finger while preparing pork tenderloin. The wound healed but the long finger developed a relatively fast-growing tumour along the flexor tendon sheath. When she was admitted to the hospital six months later, the whole volar aspect of the finger was engaged by the tumour. MRI showed massive synovitis along the flexor tendons with multiple rice bodies. There were no signs of malignancy, and she went on to surgery. Results Despite meticulous dissection, it was impossible to find any remnants of the flexor tendon sheath. Only parts of the A5 pulley remained intact. The underlying tendons were almost unaffected, although a bit rugged on their surface. As soon as the skin had healed, two external plastic rings were placed over the proximal and middle phalanx respectively, to prevent bowstringing. Histology showed unspecific granulomatosis and synovitis. Special cultures found Mycobacterium Senuense. A six months treatment with Klaritromycin and Etambutol followed. The resulting bowstringing was very mild, probably due to subcutaneous scarring. Conclusions Mycobacterium Senuense can cause soft tissue infection in humans. Bacteria in pigs may be transmitted to humans through wounds. The infection seems to destruct the flexor tendon sheath. Early postoperative mobilisation and treatment with external rings over the proximal and the middle phalanx can prevent most of the expected bowstringing after a complete loss of the flexor tendon sheath.

Bismark Adjjei, Hazem Alfeky, Irfan Khan, Chris West, David Bell

Whiston Hospital, Liverpool, UK

Introduction and Aims The World Health Organisation recently raised an alarm concerning moving towards a world without effective antibiotics (The post-antibiotic era) urging medical specialities to review their practice and, where appropriate, change them to stem the tide. Prophylactic antibiotics are frequently used by plastic surgeons in hand trauma as a prophylaxis. However, there is no solid evidence for that. The aim of this audit is to review the current practise and measure it to the guidelines. Material and Methods A review of 300 hand soft tissue laceration cases were included. All open fractures and complex soft tissue injury were excluded. The antibiotics prescription was measured against the guidelines and the recommendations of a two recent meta-analysis studies to define the role of prophylactic antibiotics in upper limb lacerations. Results In two recent meta-analyses, Jennifer Lane et al. and Murphy et al, showed that prophylactic antimicrobial use has no significant effect on the infection rate compared to placebo or no antibiotics in patients with small soft hand lacerations. Our current practise shows that there is a trend to prescribe prophylactic antibiotics where there is no clear indication. Conclusion Not withstanding current evidence, there is a trend to routinely supply simple hand laceration patients with prophylactic antibiotics. There is a need to review our practise and define a clear guidance on the role of antibiotic prophylaxis in hand trauma patients.

Judit Réka Hetthéssy, Noémi Szakács

Semmelweis University, Department of Orthopedics, Budapest, Hungary

Introduction, backround: Synovial chondromatosis is a rare disorder characterized by the development of multiple cartilaginous nodules in the synovial membrane of joints, bursae or tendon sheaths as a result of subsynovial connective tissue metaplasia. It usually affects larger joints (knee, hip, elbow and shoulder), the wrist and hand is an exceptionally rare localization. Because of its low prevalence and nonspecific symptoms, synovial chondromatosis may pose differential diagnostic difficulties for the treating clinician, which may lead to a delay in treatment. As synovial chondromatosis is rare in the pisotriquetral joint, other diseases including infection, tenosynovitis, autoimmune disease, triangular fibrocartilage pathology may be suspected at first. Based on imaging studies, the differential diagnoses include rheumatoid disease, osteochondritis dissecans, crystal arthropathy, tuberculous arthritis, trauma-related osteochondral proliferations, periosteal chondroma, synovial sarcoma, psoriatic arthropathy, pigmented villonodular synovitis and degenerative joint disease. A misdiagnosis may lead to complications down the line as over time the presence of intraarticular bodies may lead to degenerative arthritis with associated pain and loss of function. Spontaneous regression is rare in this disorder, and is not to be expected. There have also been a very small number of reported cases of sarcomatous transformation of synovial chondromatosis. For these reasons, recommended treatment is synovectomy and removal of loose bodies by open surgery. Objective: Our objective was to call attention to this rare disorder, and to aid both the diagnostic and differential diagnostic process of clinicians to avoid the above complications. Case Report: We present a case of synovial chondromatosis arising from the pisotriquetral joint. A 56-year-old female patient was referred to our department with persistent ulnar sided wrist pain on the left side, two years following minor trauma and chronic overuse. She complained of increasing swelling over the pisotriquetral joint and flexor carpi ulnaris tendon, she noticed the apperance of a mass which had become increasingly painful over the previous 3 months and there was a limitation in the range of motion also (F/E 20/40). Radiographs demonstrated calcification over the pisiform and the ulnar styloid process, MRI and CT scan suggested synovial proliferation with calcification or atypical pigmented villonodular synovitis. Surgical excision revealed numerous loose bodies surrounded by a 25x15x10 mm area of soft tissue. Histological examination demonstrated mature hyaline cartilage surrounded by fibrous tissue and partly lined by synovium, which was consistent with synovial chondromatosis. 9 months after the excision there was no recurrence, the pain decreased immediately after surgery and the range of motion increased continuously. Conclusion: Synovial chondromatosis is a rare disorder, and misdiagnosis may lead to complications down the line. Clinicians should keep this disorder in their mind when faced with an atypical chondromatous lesion.

Kienböck (5 abstracts)

Michio Sano 1, Tomokazu Sawada 1, Kazuhiro Hagiwara 1, Takao Omura 2, Ryo Okabayashi 3

1 Department of Orthopaedic Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan; 2 Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan; 3 Department of Orthopaedic Surgery, JA Enshu Hospital, Shizuoka, Japan

Hypothesis Whether dynamic compression plate (JMM-KYOCERA OSR plate) could hasten bone union after radius osteotomy for Kienbock’s disease in comparison with locking plate. Methods During 2011 and 2016, We performed radius shortening wedge osteotomy for Kienbock’s disease in 8 hands of 8 patients. The patients consisted of 4 males and 4 females. Their average age was 46.1 years old. The follow up period ranged from 6 to 39 months. The Lichtman classification revealed five Stage3a cases and 3 were 3b. After the shortening wedge osteotomy, the radius was fixed with locking plate in 5 patients (Synthes LCP-T plate;3, Japan Unitec Stellar I plate;2) and dynamic compression plate in 3 patients. The bone union was evaluated using plain X ray film, when bridging callus was comfirmed both sides of radial cortex in both A-P view and lateral view. The statistical analysis was performed using non-parametric method (Mann-Whitney U test). Result The bone union was confirmed at 5.9 ± 1.9 months after surgery with locking plates, while it was 2.5 ± 0.5 with compression plates.(p<0.05) Four patients treated with locking plates required LIPUS application for promoting bone union, in contrast to no patients requiring additional treatment in compression plate group. We considered that dynamic compression plate was more useful than the ordinary locking plates because of the accelerated bone union and for no LIPUS necessity. Discussion Various operative methods have been performed for Kienbock’s disease. Osteotomy of radius is one of the established methods. At first, we used locking plate until 2012. We changed the locking plate to OSR dynamic compression plate in 2012. As a fixation method after osteotomy, sufficient fixing force can be obtained even with locking plates, but OSR plate was more useful for crimping osteotomy site during operation. Since crimping force can be applied by the osteotomy site, we consider that we could shorten the period until bone union. Summary Dynamic compression plate (JMM OSR plate) is very useful for the fixation of radius after osteotomy for Kienbock’s disease.

Young Ho Shin 1, Jae Kwang Kim 1, Joo-Yul Bae 2, Shin Woo Choi 1

1 Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; 2 Gangneung Asan Medical Center, University of Ulsan College of Medicine, Gangneung, South Korea

Objective: The purpose of this study was to compare radial osteotomy with non-operative treatment in terms of radiologic and clinical long-term outcomes in Kienböck's disease. Methods: We systematically reviewed long-term follow-up (more than average 10 years) retrospective studies of radial osteotomy and non-operative treatment in Kienböck's disease. A systematic search was conducted across 3 databases (CENTRAL, PubMed, and Embase) and relevant articles were selected. Data regarding patient demographics, treatment details, and radiologic and clinical outcome were abstracted from the selected studies. Results: Seventeen studies (five studies of non-operative treatment and 12 studies of radial osteotomy) were included. Before treatment, the mean age of patients and mean proportions of wrists with Lichtman stage III or higher were not significantly different between the two groups. The mean proportions of wrists which showed aggravation and no change of the Lichtman stage after treatment were not significantly different between the two groups. However, the mean proportion of wrists which had pain more than moderate degree at final follow-up was significantly lower in radial osteotomy group (5.7% (range, 0.0% to 18.2%)) than in non-operative treatment group (23.2% (range, 17.4% to 35.3%)). In addition, the total arc of wrist motion at final follow-up was significantly higher in radial osteotomy group (107.4° ± 10.0° (range, 93.0° to 126.0°)) than in non-operative treatment group (88.8° ± 13.2° (range, 68.5° to 103.5°)). Conclusions: Systematic review of long-term follow-up studies showed that radial osteotomy was not superior to non-operative treatment in terms of disease progression according to Lichtman stage. Nevertheless, radial osteotomy was reported to have better outcomes with respect to the extent of pain and range of wrist motion.

Ki-tae Na, Sang-uk Lee, Do-yeol Kim, Jong-yoon Lee, Won-woo Kang

Incheon St. Mary's Hospital, The Cathlic University of Korea, Incheon, South Korea

Objective It has been known that treating early stage Kienbock's disease with vascularized bone graft inhibits disease progression and prevents collapse of lunate. Various modified techniques are used, but the possibility of damage to the blood vessels and the availability of sufficient blood flow have always been a problem. Here, we present the surgical technique of fourth and fifth extensor compartment artery & ulnar artery dorsal branch vascularized bone graft. Methods The surgical procedure At first, fifth extensor compartment artery was found in the dorsal aspect of distal radius. Then the distal aspect of the fourth extensor compartment artery & ulnar artery dorsal branch was found. After identify feeding vessel, vascularized bone from radius were harvested by the saw. Sufficiently dissected around the dorsal branch of ulnar artery to avoid compression of the ulnar artery dorsal branch during the insertion of vascularized grafting bone in the bone defect of lunate. After bone grafting, the tourniquet was released to check viability of graft. At last, scaphoid and capitate were temporary fixed by K-wire to avoid weight bearing on lunate during the period of revascularization. Results Case 1 73 year old female patient with kienbock disease (Lichtman stage IIIA) were treated with this technique. Preoperatively, her wrist range of motion was decreased, and she complained wrist joint pain. Radiographic examination showed sclerotic change and collapse of lunate. VAS score improved seven to three, and range of motion improved after surgery. Case 2 48 year old female patient with kienbock disease were treated. She has complained wrist pain for two years without trauma history. She had tenderness over the dorsal wrist, but range of motion of affected wrist was nearly normal during physical examination. Radiography showed Lichtman stage IIIA kienbock disease. After surgery, VAS score improved five to three. And DASH score was improved. Case 3 50 year old male patient, who have a history of ipsilateral wrist extensor tenorrhaphy at local hospital two years ago, visited the clinic to evaluate signal change on MR images. He complained wrist pain. Simple X-ray showed necrotic change and diffuse bone marrow edema for lunate. After surgery, patient improved range of motion. However, pain was unchanged after 6 month follow-up. Conclusion Fourth and fifth extensor compartment artery & Ulnar artery dorsal branch vascularized bone grafting technique provide multiple feeding vessels and lesser variations, and enough length of attached vessel. As a result, this technique provide safe and easy technique for kienbock disease.

Ryogo Nakamura 1, Hirofusa Ichinose 2, Etsuhiro Nakao 1, Takaaki Shinohara 1, Masahiro Tatebe 3

1 Nagoya Hand Center, Nagoya, Japan; 2 Fujita Health University, Aichi, Japan; 3 Nagoya University, Nagoya, Japan

Wrist swelling is a frequent clinical manifestation of Kienböck’s disease but no study has reported the site and pathology of wrist swelling in this disease. The aim of this study is to elucidate the site and pathology of wrist swelling in Kienböck’s disease. Dorsal and palmar soft tissue thickness of the wrist were measured on standard lateral radiographs of the wrist in 26 patients with Kienböck’s and 30 subjects without intraarticular lesion. Axial MRI views were examined to detect the site of swelling. The dorsal capsular ligament in three patients with Kienböck’s disease underwent histological examination. X-ray Measurements could not detect a difference in the average thickness of the dorsal and palmar soft tissue thickness in the control group. Radiographic study confirmed dorsal wrist swelling in 24 of 26 (92%) patients examined comparted to the contralateral unaffected wrists. However, the average palmar sogt tissue thickness of affected wrists was similar to that of unaffected wrist. MRI demonstrated thickening of the dorsal capsular ligament and extensor layer with synovial proliferation. Histological examination revealed non-specific chronic inflammation. Dorsal wrist swelling in Kienböck’s disease is a common manifestation and constitute a part of pathology of Kienböck’s disease, although further study is required to clarify the relation between wrist swelling and etiology of Kienböck’s disease.

Johanne Korslund 1, Rasmus Thorkildsen 1, Ole Reigstad 1, Magne Røkkum 1,2

1 Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Norway; 2 Institute Of Clinical Medicine, University of Oslo, Norway

Triscaphoid arthrodesis for advanced Mb Kienböck, follow up after 7 years Objective: Patients with grade IIIA Mb Kienböck/lunate malacia is a therapeutical challenge. To postpone more extensive surgery we have offered these patients a triscaphoid arthrodesis. We present our long term results after a partial wrist fusion. Material and method: Since 2004, 15 (11 male) patients, median 33 (19-44) years with Mb Kienböck and minimum 3 year follow-up were treated with a triscaphoid arthrodesis. They were all grade IIIA and preoperative radiographs showed no radioscaphoid arthritis. We used a dorsoradial incision, and cartilage was removed in the scapho-trapezial-trapezoidal joint and bone was transplanted from the radius (12) or iliac crest (3) and the fusion was secured by 1.1 mm K-wires. Postoperative the patients wore a cast for 8 weeks, K-wires were routinely removed after 12 weeks, and the patients were then encouraged to use the wrist without any restrictions. All patients had unilateral disease. 9 had surgery done in non-dominant wrist (9 left). At final follow-up AROM, grip strength and key pinch was measured and compared to the uninjured side. The patients completed the Q-DASH, PRWHE and graded pain (VAS) at rest and activity. New radiographs of both wrists and a CT of the affected wrist were taken. Results: There were no per- or post-operative complications. All arthrodesis healed. 1 patient emigrated and one patient was satisfied, but did not attend follow-up. During the follow-up period 3 of 15 received a wrist arthroplasty due to increasing pain and progression of wrist arthritis. At final follow-up 7 (3-13) years after surgery the patients reported a median Q-DASH and PRWHE = 10 (0-52) and 14 (2-68) and median VAS pain score = 0 (0-6) at rest and 1 (0-6) at activity. AROM was 50% of AROM in their healthy wrist. Grip strength was reduced by approximately 20% compared to their healthy wrist. Key pinch was similar to the healthy side. New radiographs demonstrated intercarpal degenerative changes in 4 patients, whilst CT scans showed degenerative changes (intercarpal and radioscaphoid) in 8. The patients were satisfied with the procedure and felt it had improved both hand function and pain level compared to their preoperative status. Conclusion: Advanced lunate malacia/Mb Keinböck is not easily treated. A triscaphoid arthrodesis can be an alternative, at the expense of wrist motion and strength. The procedure has postponed total wrist fusions or arthroplasty surgery in the majority of the patients in our study, and might slow the degerenative prosess in the wrist. CT scans revealed more degenerative changes and should be included in the follow-up of this complicated disease.

Measurement (15 abstracts)

Ronit Wollstein 1,2, Yahav Levy 1, Raviv Allon 1, Idit Lavi 3, Aviv Kramer 1

1 Technion, Israel Institute of Technology, Haifa Israel; 2 New York University, NY NY USA; 3Department of Community Medicine and Epidemiology, Carmel Medical Center, Israel

Purpose: Fragility fractures of the distal radius are commonly treated by the hand surgeon, and constitute a risk factor for a subsequent fragility fracture. In general osteoporosis and its main complication -fractures have an enormous impact on global health systems. It is therefore imperative to be able to screen for fragility fractures. Prevention includes treatment of osteoporosis and fall prevention. Currently, screening uses dual-energy X-ray absorptiometry (DXA), which has limited ability to predict fractures. Our purpose was to evaluate the current literature for a method that may form a screening test better able to predict fragility fractures. Methods: A review of studies evaluating osteoporosis and fragility fractures was performed. Multiple modalities were reviewed. Ultrasound (US) had sufficient data on fracture prediction to perform a meta-analysis, therefore prospective US cohort studies were analysed. Six study populations, with 29,299 individuals, 87,296 person-years of observation and including nine hundred and ninety-two fractures were analysed. Results: US was a good predictor of any fracture occurrence with an increased risk of 1.45 (95% CI 1.21-1.73) to fracture. The ability to predict a hip fracture was 1.52 (95% CI 0.94-2.48). MRI is sensitive and specific for osteoporosis but its use for screening has not been sufficiently evaluated. Computed tomography seems to have the ability to predict fracture occurrence. Conclusions: US has not taken the place of DXA as a screening tool for osteoporosis, perhaps due to operator dependency and difficulty in standardization of testing. CT has been shown to have the potential for fracture prediction, however may be problematic as a screening tool due to cost, radiation and availability. MRI has not yet been thoroughly evaluated. More study taking into account cost, accessibility, technical challenges and sensitivity and specificity of the tool is needed.

Antonio García-Jiménez 1, Àlex Grau 2, Laura Noguera 2, Santiago Castañeda 1, Bernardo Uran 1, Javier Ochoa 1, Ignacio Proubasta 2, Ignasi Gich 2, Judit Martínez 2

1 SSIBE - Hospital de Palamós, Palamós, Spain; 2 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Perilunate dislocation is a severe and disabling injury that necessitates urgent emergency reduction and stabilization to prevent late complications such as vascular necrosis, chronic instability and arthritis. Acute perilunate injuries may be misdiagnosed and treated conservatively in 25% of cases. The recognition of the three arcs or lines of Gilula in the posteroanterior projection (PA) x-ray is crucial for a correct diagnosis. The objetive of our study was to evaluate the intraobserver and interobserver reliability of Gilula lines in the diagnostic of perilunate dislocation. Six observers evaluated 30 carpal x-rays (15 with a diagnosed perilunate dislocation and 15 without carpal injuries). There were 2 orthopedic residents, 2 orthopedic surgeons and 2 hand surgeons. They all had to classify that x-rays as pathological or normal, attending only to Gilula's lines. A statistical calculation of the interobserver and intraobserver variability was performed using the Kappa coefficient. The intraobserver agreement was very good (Kappa 0,867-1,000) in residents and in hand surgeons, and moderate or good (Kappa 0,553-0,795) in orthopedic surgeons. The interobserver agreement was very good (Kappa 0.875) among the hand surgeons, while it was good among orthopedic surgeons and residents (Kappa 0.679 and 0.751 respectively). The interobserver agreement was greater among residents and hand surgeons (Kappa 0.875, very good agreement) than among residents and orthopedic surgeons (Kappa 0.702, good agreement). We can conclude that the observation of Gilula's lines is a good diagnostic method in case of suspicion of perilunar dislocation, with good intraobserver and interobserver agreement in orthopedic residents, hand surgeons and orthopedic surgeons.

Shohei Omokawa 1, Iida akio 1, Kenji Kawamura 2, Takamasa Shimizu 2, Tadanobu Onishi 2, Yasuhito Tanaka 2

1 Department of Hand Surgery, Nara Medical University; 2 Department of Orthopedic Surgery, Nara Medical University

Objective: Although standardized criteria for evaluating the distal radioulnar joint (DRUJ) instability have not been established, DRUJ ballottement test remains a key component of diagnosing peripheral tears of the triangular fibrocartilage complex (TFCC) at the ulnar foveal insertion. This prospective cohort study investigated the reliability and diagnostic accuracy of the DRUJ ballottement test in detecting the TFCC foveal tears. Methods: The study enrolled 50 consecutive patients with ulnar wrist pain (25 with foveal tears and 25 without tears, 27 men and 23 women, mean age was 41 years) and 25 healthy volunteers (mean age 36 years). Two observers independently performed the DRUJ ballottement test; the test was repeated by one observer. These data were used for reliability analysis. Interobserver and intraobserver reliability were analysed with Cohen’s kappa statistics. First time assessments during the initial hospital visit were used for analysis of diagnostic accuracy of the DRUJ ballottement test. DRUJ instability grade was assessed with Nakamura’s criteria (grade 0: stable DRUJ; grade 1: less stable than intact contralateral side; grade 2: absence of an endpoint in either the dorsal or palmar direction; grade 3: no endpoint in either direction). Results: Regarding the DRUJ instability grade, there were 18 of the 25 patients with foveal tears had grade 2 instability, and 19 of the 25 patients without foveal tears had grade 0 or grade 1 instability. There were 23 volunteers in grade 0. Kappa values for intraobserver and interobserver reliability of the instability grade were 0.85 and 0.8, respectively. Regarding the accuracy analysis by comparing the test results between the 25 patients with and without TFCC foveal tears, the sensitivity and specificity of the DRUJ ballottement test were 96% and 40%, respectively, when a positive result was defined as grade 1. When a positive result was defined as grade 2 (absence of endpoint in either the dorsal or palmar direction), the sensitivity and accuracy specificity were 76% and 76% respectively. The comparison between the 25 foveal tears patients and 25 healthy volunteers revealed that the sensitivity and specificity were 96% and 88%, respectively, when a positive result was defined as grade 1. When a positive result was defined as grade 2, the sensitivity and specificity were 76% and 100%, respectively. Conclusions: Comparing injured and contralateral wrists provided reasonable reliability and high sensitivity in detecting TFCC foveal tears. When the test result is grade 1 in a clinical setting, acquisition of imaging techniques would be recommended to diagnose tears of the radioulnar ligaments. We found perfect specificity when comparing patients with healthy volunteers, but the test was not specific in a population of patients with ulnar wrist pain. Because absence of endpoint alone is not a specific finding to diagnose radioulnar ligament tears, exclusion of other disorders with DRUJ instability such as ulnocarpal abutment syndrome is needed to confirm the foveal tears in patients with ulnar wrist pain.

Lisa Reissner, Gabriella Fischer, Pietro Giovanoli, Maurizio Calcagni

Division of Hand and Plastic Surgery, University Hospital Zurich, Switzerland

Objective: The human hand is used in a great range of activities of daily living. In recent years, researchers and clinicians increasingly focused attention towards the assessment of hand movements. However, there is still very little knowledge about hand and finger kinematics during ADL. The aim of the study was to analyse the motion patterns during the task of opening a yoghurt in healthy volunteers. Method: Twenty healthy volunteers (10 male, 10 female), mean age 28 (SD 4.7), years were performing a set of basic motion tasks and the functional task “opening a yoghurt”. Each volunteer was assessed twice on two different measurement days. The active range of motion (AROM) and the mean angle during the opening phase were calculated for the wrist, the radioulnar joint and the joints of the small finger. Furthermore, the AROM of a joint during the functional task was expressed in percentage of its maximum range of motion calculated from the basic motion tasks. Results: There was a wide range of joint angles among different volunteers. The AROM ranged between 17°-85° / 21°-58° and 17-79° for flexion angle of the MCP of the small finger, the wrist and the pronation-supination of the radioulnar joint, respectively. Some individuals had the wrist, metacarpophalangeal (MCP) 5 or proximal interphalangeal (PIP) 5 joint in extended position, while others preferred in the same joints in flexed position with a mean angle up to 60°. The exploitation of the maximum range of motion was between 5-84%. A significant higher AROM in wrist flexion of 44° (p<0.001) was found for the female group compared to 32° of the male subjects. Furthermore, the female group had a mean flexion angle of 30° (p=0.043) in the MCP of the small finger during the opening phase, while the male group had the corresponding joint in a more flexed position of 41°. Conclusion: Individuals seem to use different strategies to fulfil the analysed task. In the group, that performed the functional task without contact of the small finger to the object (extended/abducted small finger), five out of six cases were women whereas mostly male subjects tended to “roll” the hand over the small finger to open the yoghurt. This study reveals that gender differences might influence motion pattern during the analysed ADL. The individual preference has to be considered for the determination of the required range of motion of this daily activity.

Angela Reger, Marion Mühldorfer-Fodor, Karl-Josef Prommersberger, Jörg van Schoonhoven

Klinik für Handchirurgie Bad Neustadt, Bad Neustadt / Saale, Germany

Objective: This study investigates in vivo if an isolated fusion of a single DIP-joint influences the grip force and the load distribution of the hand when gripping a clylindrical object. Methods: Ten patients who had one single DIP joint fused due to posttraumatic joint destruction, but without other structural lesions of the Hand, were included in this study. On average 55 (17-121) months postoperatively, patients returned for a manugraphy analysis. Patients performed grip force tests, using three clyinders covered with a pressure sensor matrix and with 100 mm, 150 mm and 200 mm circumferences to measure the total grip force and the load distribution pattern of both hands. The grip force and the load distribution applied by each of the four fingers were compared for the affected and the healthy hand. Due to the small number of patients, only descriptive statistics were provided. Results: Two patients had the index finger involved; both omitted the affected finger during gripping evidently. Their total grip force was 57%, 62% and 60% of the healthy opposite side, for the small, middle and large cylinder resepctively. Eight patients had a Fusion of the middle finger DIP. All of them had an apparent load Peak at the finger tip III while using the 150 mm cylinder, six patients had such load peaks additionally on at least a second cylinder size. Their total grip force was 94%, 101% and 94% compared to the healthy side. If the dominant hand was affected, the hand was even stronger than the healthy, non-dominant hand. Analyzing the load applied exclusively by each finger, there was a different pattern apparent for the DIP joint II and DIP joint III fusions: the operated index finger showed a considerable force loss, but also the other fingers were weaker than those of the healthy side. Patients with a DIP joint fusion of the middle finger applied considerable less force with the middle and ring finger, but the index and small finger performed with the same or even higher finger force compared to the healthy side. Conclusion: Although this study investigated a small study group, DIP joint fusion of the index finger seems to affect the total grip force more than DIP joint fusion of the middle finger. This confirms the results of some previous experimental studies and might be contributed to the "Quadriga-effect" of the finger flexors.

Ali Arnaout 1, Paul Caine 1, Elizabeth Mawby 2, Christopher Powell 1

1 Department of Plastic, Burns and Reconstructive Surgery, Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK; 2 Department of Physiotherapy, Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK

Objective: Extensor Pollicis Longus (EPL) division is a common injury that is routinely managed in hand surgery. The literature on the subject, despite this, is limited and rarely discussed in isolation from finger extensors injuries. There are two accepted rehabilitation regimes accepted for EPL mobilisation, post repair. 1) The utilisation of early active movement regimes, 2) the most commonly practised regime in European units, is splinting, EPL repairs in a static splint or mobilising in a dynamic extension outrigger for 4 to 6 weeks followed by active mobilisation for further 2-4 weeks. We decided to assess the outcome of our EPL repairs in zone 1 and 2, through an intra-patient controlled range of movement outcome measures. Methods: Prospective data was collected by the departmental hand specialist physiotherapists, between February 2013 and September 2015 for anyone identified as a complete zone 1 or zone 2 EPL ruptures that were repaired. Total Active Movement (TAM), which calculates the active range of movement as a percentage of movement of the unoperated thumb at the metacarpophalangeal joint (MCPJ) and the interphalangeal joint (IPJ) and White’s criteria (1956) was used to compare the range of movement outcome post repair. All therapists within the department were taught how to measure thumb range of movement (ROM) according to department guidelines using standardised positioning and equipment. Results: Total sample size N=20 patients, followed through to discharge at 8-weeks post mobilisation. ROM started 25-35 days after surgery 90% (N=18). Excellent ROM [=TAM] on discharge 25% (N=5), Good ROM [>75% TAM] 30% (N=6), Fair [50-75% TAM] 40% (N=8), Poor ROM [<50% TAM] 5% (N=1) Over half (55%) of cases therefore, achieved 75% ROM of the control thumb on discharge, and 95% achieved over >50% ROM on discharge. 66% of patients required less than 3 sessions, and 80% of patients were discharged after fewer than 8 treatment sessions. Conclusions: Over half of the patients regained >75% of the ROM of the unoperated thumb within only 2 or 3 physiotherapy sessions. Stuart el al 1965, and Mowlavi et al 2005 both reported no long-term superiority of mobilization protocols over immobilization. The reported NHS tariff for a physiotherapy session is £81(€91.37) for the initial session followed by £40(€45)/session; extrapolating this data, immobilising post EPL repair and discharge in 66% will cost £161(€181.61) 3 sessions, while for early active, it’s suggested they will have between 8-12 weeks of physiotherapy costing between £361-521(€407-587.45) leading to an increased cost of 124-224% per patient without any long-term benefit. Although greater ROM represents restoration closer to pre-injury movement, it does not necessarily reflect the restoration of function. However, it has been reported in literature the versatility of the thumb in adapting to a reduced range of movement in one joint by increasing range in another joint, preventing functional loss. It will be useful for future projects, to assess the time of returning to work post-injury, and any difficulty with function or pain, using PRWHE (Patient Related Wrist and Hand Evaluation), ideally with a larger sample size.

Abby Choke 1, Ou Yang You Heng 3, Alyssa Toh LiYu 2, Wong Yoke Rung 2, Muntasir Choudhary 1, Duncan Angus McGrouther 1,2

1 Department of Hand Surgery, Singapore General Hospital, Singapore; 2 Biomechanics Laboratory, Singapore General Hospital, Singapore; 3 Department of Orthopedics Surgery, Singapore General Hospital, Singapore

Objectives Spiral fractures of the metacarpal are common and indicated for surgical fixation due to its unstable nature. We aim to study the fracture pattern and characteristics following a biomechanically induced torsional force on a chicken humerus model. We hypothesize that the speed of the torsional force is related to the length of the spiral, and that secondary fracture lines always propagate along the ‘spiral component’ of the fracture. Methods 30 fresh frozen chicken humerus bone were dissected and divided into three groups of 10. The bones were mounted onto a customized jig and subjected to torsional load using the Instron 3343 Mechanical Tester. The bones were tested at 3 different speeds (2,3 and 4 seconds) based on their group. The fracture pattern, angle, length, and degree of comminution were analyzed. Results 24 bones failed in a spiral pattern along the shaft of the bone. 6 bones that failed at the metaphysis were excluded. For the first observation, we noticed that all spiral fractures have two components: a helical line that traverses the circumference of the bone and another longitudinal line that connects both ends of the helical. This creates the characteristic spikes at two bony ends. A linear pattern was observed for the different torsional rate applied - the faster the torque, the smaller the fracture angle (R2=0.9957) and the longer the fracture length (R2=0.9778). The appearance of secondary fracture lines was not related to the torsional rate and always propagate at a sharp angle to the original fracture line. Conclusion A thorough understanding of fracture characteristics is important for the surgeon to plan the fracture fixation. As spiral fractures of the metacarpal have a broad and irregular configuration, anatomical reduction by screws and plates should be well planned to prevent fracture propagation or comminution.

Thea Birch Ransby 1, Lisa Bay Johansen 2, Helene Nørgaard 2, Nanna Rolving 3

1 Faculty of Health, Aarhus University, Aarhus, Denmark; 2 Department of Physical and Occupational Therapy, Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark; 3 University Clinic of Innovative Patient Pathways, Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark

Objective: The aim of the study was to assess the responsiveness of the Assessment of Motor and Process Skills (AMPS) in a population of patients undergoing rehabilitation following finger or hand surgery, as this has not previously been investigated.   Methods: Patients are included from the Department of Physical and Occupational therapy at Silkeborg Regional Hospital in the period October 2017 to March 2018. A total of 50 patients, who have been referred for specialized occupational therapy rehabilitation following finger or hand surgery, will be included. At baseline and follow-up (after 8-10 weeks) all patients are assessed with AMPS, Canadian Occupational Performance Measure (COPM), hand grip strength and joint range of motion using standardized methods. Responsiveness to change is evaluated using an anchor-based method, comparing AMPS scores with the scores on the Global Rating Scale. The area under the ROC curve will be calculated, and an area under the curve of 0.7 is considered acceptable. Convergent and discriminative validity of the AMPS will be assessed across the different instruments used. Thus we expect a higher correlation between AMPS and COPM and lower correlation between AMPS and hand grip strength and range of motion.   Results: Patient inclusion was initiated as planned in October 2017. We expect the last follow-up to be completed in May 2018. Results will be presented at the FESSH conference.   Conclusions: Rehabilitation following finger or hand surgery is often evaluated using only instruments assessing bodily function, e.g. hand grip strength and joint range of motion. However, considering the ICF rehabilitation framework, outcome measures should focus more on activity and participation. Furthermore, many patients requiring finger or hand surgery are still at the labor market, which underlines the importance of a valid assessment of their abilities in terms of activity and participation. This study will provide valuable knowledge in terms of whether AMPS is a valid tool for measuring improvement on these parameters in a population for which AMPS has not traditionally been used.

Shingo Abe 1,3, Kunihiro Oka 1, Yoshihito Ootake 2, Yuusuke Tennma 2, Yuuta Hiasa 2, Yoshinobu Sato 2, Satoshi Miyamura 1, Atsuo Shigi 1, Tsuyoshi Murase 1

1 Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Japan; 2 Nara Institute of Science and Technology, Ikoma, Japan, 3 Toyonaka Municipital Hospital, Toyonaka, Japan

Objective It is important to analyze dynamic forearm rotational motion for the patient with forearm rotational restriction or instability during forearm rotation; however, in-vivo three dimensional (3D) forearm rotational analysis is difficult to obtain. We have conventionally performed forearm computed tomography (CT) in three rotational position (full supination/ pronation, and neutral rotation) and created virtual dynamic forearm rotation using the computer software (CT method). The purpose of this study was to create a new intensity-based 2D-3D registration (2D-3D method) to measure real forearm rotational motion and validate the accuracy of this method. Methods We performed biplane fluorography for forearm dynamic rotation and acquired 2D dynamic image data; the forearm CT was performed and created 3D static image data. Digital reconstructed radiograph (DRR), which was projected image of 3D CT data in arbitrary direction containing intensity information of radiolucency, was created for each the radius and ulna. The DRR of the radius and ulna was registered on the corresponding bone on fluoroscopy images for each frame based on similarity metric which calculated intensity information. All the registration procedure was implemented through an automatic matching algorithm written by MATLAB software. Consequently, 6 degree-of-freedom (DOF) of rotation and translation for each the radius and the ulna during forearm rotation were calculated and visualized. For validation study, we manufactured the upper arm phantom (Kyoto Kagaku, Japan) composed of bones, soft-tissue, and 8 stainless spheres with diameter 1.5mm implanted on the radius and the ulna. We manually rotated the phantom for 10 seconds and performed biplane fluorography with 12.5 frame/sec, acquiring total 125 frames of biplane fluorography. We defined the radiostereometric analysis (RSA method), which calculated 3D bone position based on 3D position of stainless spheres, as ground truth. Because the density of spheres on the images help to increase the accuracy of registration, we removed the density of spheres from the images using the impainting technique which replace the density of the spheres to average density of surroundings. We executed 2D-3D method using the images without the stainless spheres. To assess accuracy of 2D3D method, we compared 6 DOF of rotation and translation for the radius and ulna between 2D-3D method and RSA method. One healthy male volunteer performed forearm rotation and analyzed by both the 2D-3D method and the conventional CT method. We compared radiation dose between the 2D-3D method and CT method. Results The absolute value of rotation error were 0.36 ± 0.59° for the radius, and 0.55 ± 0.73° for the ulna. The absolute value of translation error were 0.26 ± 0.28 mm for the radius, and 0.18 ± 0.18 mm for the ulna. Radiation dose was 1.58 mGy for 2D-3D method, which was lower than conventional CT method (4.05 mGy). Conclusion We achieved highly accurate in-vivo forearm rotational analysis using intensity-based biplane 2D-3D registration technique with high temporal and special resolution. In addition, the radiation dose of the current 2D-3D method was lower than conventional CT method.

Stefanie Hensler 1, Pascal Behm 3, Stephen J. Ferguson 3, Daniel B. Herren 2, Stephan Schindele 2

1 Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland; 2 Department of Hand Surgery, Schulthess Klinik, Zurich, Switzerland; 3 Swiss Federal Institute of Technology (ETH), Zurich, Switzerland

Objective Many activities of daily living are dependent on sufficient motion and good stability of the proximal interphalangeal (PIP) joint. However, there is no well-established, objective and adequately precise method for measuring full three-dimensional finger joint kinematics, including lateral stability of the PIP joint. There are associated technical challenges including the limited space for marker localization, ensuring visibility of all markers during the entire motion task, and the processing of large data volumes. Therefore, our objective was to adapt a three-dimensional motion capture system for measuring lateral stability of the PIP joint, and conduct pilot trials with this system in healthy volunteers as well as in a patient after surface-replacing arthroplasty to establish its reliability. Methods A machine-vision optical tracking system (CamBar B2 C4, Axios 3D GmbH, Oldenburg, Germany) was used for motion analysis measurements. Four retroreflective markers (3 mm diameter) were clustered on each of two rigid plates, which were mounted onto the proximal and intermediate phalanx by compression cuffs to limit relative skin motion. A frame was constructed to fix the proximal phalanx during the measurement. A lateral bending moment in the PIP joint was generated by a pulley system with free hanging weights of 40, 90 and 170 grams. Lateral deflection of the intermediate phalanx provides a relative quantitative measure of radial and ulnar instability of the PIP joint. Data were analysed using MATLAB R2016b (The MathWorks Inc., Massachusetts, USA). Measurement reliability was evaluated with a test-retest (intraclass correlation coefficient (ICC)) method in ten healthy volunteers. Initial measurements of lateral stability were also performed in a 68-year-old PIP osteoarthritis patient who underwent surface-replacing arthroplasty (CapFlex-PIP, KLS Martin Group, Tuttlingen, Germany) five years ago. Results Reliability measurements demonstrated stable and continuous motion data recording of the PIP joint and adjacent segments, which allowed the calculation of representative deflection angles. The test-retest repeatability was high with an ICC of 0.83. System handling was easy and the measurement time of approximately 20 minutes per subject was short. The first patient test confirmed these observations; the patient had a stable PIP joint with both radial and ulnar deflection angles of less than 2 degrees, which corresponded to the subjective clinical assessment of lateral stability. Conclusions The current system provides a simple, fast and precise measurement of PIP joint lateral stability as well as reliable and repeatable kinematic data. It will be used in a comparative study to test the hypothesis that a surface-replacing implant leads to higher 1-year postoperative PIP joint stability compared to silicone arthroplasty.

Per Linnertz 1, Johanna Prieto Ek 2, Birgitta Rosén 1

1 Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Lund University, Malmö Sweden; 2 Department of Health Sciences, Lund University, Sweden

Background:The STI™- test (shape-texture-identification) is used to evaluate one aspect of tactile gnosis in nerve disorders, and it has proven good methodological properties. Aim: A new version of the STI™-test was recently introduced. The aim of this study was to test the concurrent validity in STI²™ in patients with affected sensibility and in a population with uninjured hands. Method: Using a cross sectional design this study compared STI²™ to the original version based on 20 persons (40 tested fingers) with subjectively affected sensibility following hand injuries and one healthy group including 20 persons (80 tested fingers). The agreement between the two versions of the instrument was calculated. Results: Of the 112 tested fingers there was a complete agreement between the versions in 74 % (n=83) of the cases. The measurements showing complete agreement including the accepted 1.2 points margin of error of the instrument was 92 % (n=103). The result showed that there is no significant deviation between the two versions of the STI™ test. Conclusion. Since STI²™ proved good concurrent validity we conclude there is enough evidence to implement the new instrument in the hand therapy tool box.

Spyridon Gigourtakis 2, Zacharias Christoforakis 1, Petros Kapsetakis 1, Anastasia Pitikaki 2, Georgios Koumantakis 3, Antonia Baxevani 2, Tzagkarakis Eustratios4 , Bounakis Nikolaos 5

1 Orthopaedic Department, University Hospital of Heraklio, Heraklio, Crete, Greece; 2 Physiotherapy Private Practice, Heraklio, Crete, Greece; 3 Physiotherapy Department, 401 General Military Hospital of Athens, Athens, Greece, 4 Orthopaedic Surgeon, Private Practice, Heraklio, Crete, Greece 5 Orthopaedic Department, General Hospital of Irakleion Venizeleio - Pananeio, Heraklio, Crete, Greece

Objective: Dynamometric assessment of muscle groups with tendon disorders is performed to interpret their mechanical profile and to assess treatment effects. Accurate functional assessment of muscular strength is fundamental. A same-day test-retest reliability study, for the muscle groups of elbow flexion, extension, forearm pronation, supination and grip strength, following distal biceps tendon rupture was performed. Methods: A sample of 16 male patients, who underwent the same technique surgery, from the same surgeon, for the repair of rapture on the distal biceps tendon, where assessed one year plus postoperatively. The assessment included the use of an isokinetic device, "Humac Norm Isokinetic Extremity System", CSMi and a "Digital Hand Held Dynamometer", “Biometrics Ltd“. The protocol of isokinetic device assessment included: isometric flexion, at 90° elbow flexion, 3 reps; isometric extension, at 90° elbow flexion, 3 reps; isometric supination, at 0° and 45° of pronation, 3 reps for each position; concentric flexion-extension, speed test 60°/sec, 5 reps; concentric flexion-extension, speed test 120°/sec, 5 reps; concentric pronation-supination, speed test 60°/sec, 3 reps; concentric pronation-supination, speed test 120°/sec, 3 reps. The protocol of grip strength assessment included the isometric maximum grip strength measurement, 3 reps. The assessment included both right and left upper limbs, with random side selection. The selection of isokinetic speeds were based on the characteristics of the sample. The slow speed (60°/sec) was selected for the purpose of gaining highest torque without the fatigue of a slower speed. The more rapid speed was selected for best representing functionality. Eccentric testing was not performed, to ensure the safety of the re-attached tendon. Lastly, the grip strength evaluation was performed to assess whether surgery affected the total capability of hand grip. Results: Patient mean (range) age at the time of surgery was 47 (24-60) years and measurements were conducted 62 months (range 12-174) postoperatively. The protocol included reliability measurements for 26 contractions: 10 isometric and 16 isokinetic concentric, involving both upper limbs. The proposed method was found to be equally reliable for both the isometric and isokinetic concentric contractions. Intraclass Correlation Coefficients (ICCs Model 3,1) ranged between 0.92-0.98 for the isometric and between 0.87-0.98 for the isokinetic assessments. Standard Error of the Measurement (SEM) % values ranged between 3.79-13.56 % for the isometric and between 4.68-14.06 % for the isokinetic assessments. All testing has been successfully completed by all subjects and the procedures involved in the assessment protocol were easy to comprehend. Better stabilization and isolation of the assessed muscle groups, with elimination of the effect of gravity was achieved with the isokinetic dynamometer. Conclusions: The application of a dynamometric evaluation of elbow and hand muscles has been tested in a population of subjects with distal biceps tendon rupture. Contrary to what has been done so far, all muscle groups involved were evaluated under both static and dynamic contractions. We believe it has a clinical applicability in assessing the muscle changes that occur in people undergoing surgery that affect upper limb strength. These are the preliminary results of a project in progress.

Harry Belcher

Independent Hand Surgeon

Outline: the assessment of power is an important part of the assessment of a hand in medicolegal practice. The most widely used method is the measurement of grip-strength using a Jamar dynamometer, which is an adjustable hand-held device that measures grip strength over five widths. The power that can be applied over the five settings of the dynamometer usually exhibits a skewed bell-shaped curve; the maximum power being almost always achieved at either setting 2 or 3. It has been observed that the performance of patients is variable and inconsistent due to the effects of injury as well as anxiety about the assessment. An extended test protocol has been developed to mitigate these effects whilst retaining the ability to detect submaximal effort. Methods: the extended protocol was undertaken in 100 consecutive patients who had suffered unilateral upper limb injuries undergoing medicolegal assessment at a median interval of 26 months from injury. Information collected included demographic data and a quick-DASH score (QDASH). The whole limb impairment (WLI) was calculated from the examination findings. The dynamometry test protocol comprised two tests at each Jamar position. The sequence starts from the first and narrowest position on the uninjured hand, followed by the first position on the injured hand, the second position on the uninjured hand, etc. Following the 5th test on the injured hand at the widest handle setting, the sequence is reversed. The largest value for the two attempts at any given side and position was used for the purposes of analysis. The data is analysed for consistency of performance, variation over the five settings and deviation from the expected curve pattern derived from a normal population. Results: The population had a median age of 42 years, WLI of 4% and QDASH score of 42. The median difference in maximum power between injured and uninjured sides was 25%. This difference was correlated with the WLI (R=0.43, p<0.001) and QDASH (R=0.53, p<0.001). Maximum power was exerted at postion-2 in 81% of uninjured hands compared with 65% in injured hands (p<0.05) Patients were less consistent in test performance with their injured compared with uninjured hands (median values of 9.4% vs 6.7%, p<0.001). The curves achieved by injured hands were significantly albeit slightly more dynamic (20.1% vs 18.2%, p<0.01) and deviated more from the expected curves than the injured hands (9.8% vs 6.9%, p<0.001). Conclusion: injury causes loss of power and changes in dynamometry performance. Analysis of curve physiology allows the identification of statistical outliers. Whilst some results can be explained on the basis of the injury sustained, others cannot, suggesting that these test results cannot be relied upon as a true reflection of capacity.

Spyridon Gigourtakis 1, Antonia Baxevani 1, Anastasia Pitikaki 1, Georgios Koumantakis 2, Georgios Manolarakis 3, Matthaios Matthaiakis 4, Constantinos Koutsojannis 5

1 Physiotherapy Private Practice, Heraklion, Crete, Greece; 2 401 General Military Hospital of Athens, Athens, Greece; 3 Orthopaedic & Ortho-Trauma Surgeon Private Practice, Heraklio, Crete, Greece; 4 Orthopaedic Surgeon Private Practice, Heraklio, Crete, Greece; 5 University of Patras, Computer Engineering and Informatics Department, Patras, Greece

Abstract Purpose: The purpose of the study was to establish the concurrent validity and test-retest reliability of the Grip Force Measurement System (GFMS), as a specialized system of the grip force of the palm and its individual fingers. Methods: Grip strength testing was performed on 12 injured participants. Three trials were completed for the right and left hand on the Biometrics E-LINK EP 9, using a repeated measures design. The maximal voluntary grip force perpendicular to the surface of the handle was estimated immediately afterwards, using a glove with 349 sensors (Tekscan, USA-Grip Force Measurement System), while holding the digital biometrics dynamometer at the same time. Six more trials (three for each hand) were tested using GFMS, during holding a cylindrical handle. Individual digit and palm forces were studied. Each subject was properly positioned and the same verbal orders were given. Six participants repeated the testing later, for test-retest reliability of the Grip Force Measurement System. Main Findings: The study presents initial evidence on the test-retest reliability of the Grip Force Measurement System. In addition, a repeated measures analysis of variance (ANOVA) with one within participants factor of systems (Biometrics versus Grip), was conducted to determine whether differences in strength scores existed between systems. Differences were considered significant at the 0.05 level of significance. Conclusion: The results indicate that the Grip Force Measurement System is reliable and comparable to the Biometrics E-LINK EP 9, when used for measuring grip strength. The human hand grip force is commonly assessed using hydraulic or tensometric hand dynamometers, but the Grip Force Measurement System allowed identification and analysis of the force of the palm and its individual fingers. The total hand grip force was measured by 349 resistive sensors located in a glove. Fourteen sensing areas were placed on the phalanges of the hand, and the remaining ones on the palm. Ηowever, due to small sample, future studies into the reliability and validity of the Grip Force Measurement System should be conducted

Özge Buket Cesim, Başak Karadağ, Elif Cimilli, Burcu Semin Akel, Çiğdem Öksüz

Hacettepe University, Ankara, Turkey

Purpose: DASH is an useful questionnaire for measuring functional disability in upper extremity disorders of Turkish patients and is used to determine functional activity profile of patients with different upper extremity injuries. The aim of the study is to investigate activity profile with DASH questionnaire thereby determining the distribution of items in Turkish population with distal radius fractures. Methods: Forty five patients (32 females, 13 males) with distal radius fractures completed the Turkish version of Disability of the Arm, Shoulder and Hand (DASH) questionnaire which response options are range from 1 to 5 (1: no difficulty; 2: mild difficulty; 3: moderate difficulty; 4: severe difficulty; 5: unable). The DASH scores are between 0 and 100 in which a high DASH score indicates severe disability. Assessments were done at the first session of the patients by authors. Incomplete DASH questionnaires (more than three items missing) were excluded from the study. To determine the distribution of items and most unanswered questions, frequency analysis was done with SPSS 21 programme. Results: The age interval of the patients were between 21 and 65 years with the mean age of 49,17 ± 13,75 years. The mean score of DASH questionnaire was 45,84 ± 24,35 (minimum 6,89, maximum 87,03). Most unanswered items were ‘garden or yard work’ (by 10 female patiens), ‘sexual activities’ (by 6 female and 2 male patients), ‘prepare a meal’ (by 4 female and 2 male patients) and ‘make a bed’ (by 1 female and 5 male patiens). ‘Open a tight or new jar’ (by 44 patients), ‘do heavy household chores (e.g. wash walls, wash floors)’ (by 41 patients) and ‘carry a heavy object (over 10 lbs)’ (by 40 patients) items were considered difficult for these patients. Not at all difficult items were ‘manage transportation needs’ (by 30 patients), ‘use a knife to cut food’ (by 22 patients) and ‘sexual activities’ (by 20 patients) for these patients. Conclusions: Our results showed that patients with distal radius fractures have specifically difficulties in bilateral activities which require strength. On the contrary, these patients have no difficulties in activities which is not specific to the upper extremities. Unanswered items may be the reflection of culturel and physical environment. In Turkish population most males do not perform activities related home management such as making a bed. Due to the majority of females patients, we may found that unanswered acitivities mostly indicated by female patients. Nevertheless we think that unanswered questions -except questions which include home management activities- such as sexual activities or garden or yard work, reflect both genders in Turkish population. We believe that identifying activity profiles which are specific to patient groups guide treatment programmes.

Microsurgery and Flaps (37 abstracts)

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background: A Morel-Lavallée lesion is a closed degloving injury associated with severe trauma. The lesions classically occur over the greater trochanter of the femur. Occasionally over the lumbar, scapula, or knee can result in identical lesions. Once these lesions became established and encapsulated, then conservative management is rarely successful. In that case, surgical intervention such as open drainage, repeated debridement, and vacuum sealing drainage may be required. However, this surgical treatment could be insufficient. Herein, we describe good results of fasciocutaneous rotation flap for the intractable Morel-Lavallée lesion. Methods: Since 2012, 6 patients underwent fasciocutaneous rotation flap for intractable Morel-Lavallée lesion over the greater trochanter (n=2), lumbar (n=1), and buttock (n=3). The patients' age, sex, the cause of the defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results: All the flaps survived completely without the additional procedure. The mean operative time was 48minutes(range 35 to 58). The dimension of the defects ranged from 3cm×5 cm to as large as 5cm×8 cm. There was no significant complication in any of the patients. Conclusion: The fasciocutaneous rotation flap for Morel-Lavallée lesion has the advantages of reliable, easy to perform and fast operation times. Therefore we recommend this flap for the reconstruction of an intractable Morel-Lavallée lesion.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background and aims. The sacral region is one of the most frequent sites of a pressure sore. Sacral pressure sores remain challenging to orthopedic surgeons who are unfamiliar with microsurgical techniques. Herein, we present our experience in reconstruction of sacral defects with the use of fasciocutaneous rotational and parasacral perforator flaps. Methods. 15 sacral pressure sores, patients underwent surgical reconstruction of sacral defects with a fasciocutaneous rotational (n=7) and parasacral perforator flaps (n=8). The patients' age, sex, the cause of the sacral defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results. All the flaps survived completely except for one patient who had partial necrosis of the flap, which necessitated another rotation flap for coverage. There was no significant operation related mortality in our study. The average follow-up period was 12.6 months (range, 3-18 months). The dimension of the sacral defects ranged from 3cm×4 cm to as large as 7 cm×12 cm. The mean operative time was 62minutes (range 48 to 75). The overall flap survival rate was 93% (14/15). There was no recurrence of sacral pressure sores during the follow-up period. Conclusions. In our experience, fasciocutaneous rotational and parasacral perforator flaps are easy and reliable in reconstructing sacral pressure sores. Therefore, we recommend these flaps for orthopedic surgeons who are unfamiliar with microsurgical techniques.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background: Soft tissue coverage of lower extremity defects is a challenging for an orthopedic surgeon. Perforator flaps are widely used in reconstructive surgery. Herein, we describe our experience with the use of medial sural artery perforator (MSAP) based propeller flap for reconstruction of defects of the upper one-third of the leg and around the knee. Methods: Since 2012, six patients have undergone MSAP based propeller flap reconstruction. The patients' age, sex, the cause of the defect, wound dimensions, the timing of flap coverage, operative time, and postoperative complications were recorded. Results: All the flaps survived completely except one who had developed marginal necrosis of the flap, which was managed with secondary intention healing. The defect site was upper one-third of the leg in 4 cases and around the knee in 2 cases. The mean operative time was 65minutes (range 55 to 90). The dimension of the defects ranged from 4cm×5 cm to as large as 5 cm×12 cm. There was no significant complication in any of the patients. Conclusion: MSAP based propeller flap has the advantages of relatively constant perforator anatomy, faster operation times, without sacrifice gastrocnemius muscle and sural nerve. Furthermore, this flap is reliable and easy to perform. Therefore, we recommend this flap in selected cases for reconstruction of defects of the upper one-third of the leg and around the knee.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Background and aims. Perforator flaps increasingly use in orthopedic reconstructive surgery. Freestyle local perforator flaps allow flap harvesting in any anatomical region. Although an advantage of Freestyle local perforator flaps, it is difficult to identify the location of the perforators. We report our clinical experience with Freestyle local perforator flaps in various orthopedic reconstructive surgery and describe how to use a preoperative handheld Doppler and color Doppler ultrasound for the detection of the perforator. Methods. From March 2011 to December 2016, 46 patients underwent the reconstruction of soft tissue defects using freestyle local perforator flaps. The defect area included the elbow (4), sacral/gluteal (11), trochanteric (2) thigh (6), knee/popliteal (6), leg (8), ankle (8) and plantar foot (1). Preoperatively, we used a handheld Doppler and color Doppler ultrasound to locate the perforators. The mean age of patients was 48.6 years. The mean follow-up period was 6.5months. Results. Except for 5 cases (thigh: 1, leg: 2, ankle: 2), all remaining flaps survived. The donor sites were closed primarily in 33 of 46 patients, and 13 patients required skin grafts (elbow: 1, knee/popliteal: 2, leg: 4, ankle: 5 and plantar: 1). All the perforators except two (leg: 1, ankle: 1) were found intraoperatively. Handheld Doppler and color Doppler ultrasound assessment had a 92% true-positive rate. The time required to complete the procedure varied from 0.5 to 2.5h depending on each case. There was no complication at the donor site in any patient. Conclusions. By using handheld Doppler and color Doppler ultrasound, we could easily identify the perforators. Freestyle local perforator flaps have the advantages of using similar tissues in reconstruction, not damaging another area, not sacrifice main vessels, and the donor site can be primary closed. Freestyle local perforator flaps provide a useful option for the reconstruction of various orthopedic soft tissue defects.

Satoshi Usami, Kohei Inami

Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, Tokyo, Japan

Objective: A posterior interosseous artery perforator flap is used for small defects, leaving no functional disturbance at the flap donor site. The purpose of this study is to describe our experience with the transfer of this flap for fingertip defects and the evaluation of postoperative function. Methods: Thirteen flaps were used for 16 fingertip reconstructions in 13 patients from April 2014 to December 2016. All patients were men without one female, and their mean age was 45.2 years. Of the 16 digits, two were thumbs, three were index fingers, seven were middle, three were ring, and one was little. Three patients had two finger defects covered at a time with one bridge flap, and five flaps were harvested in true perforator flap style. As the postoperative flap evaluations, Semmes-Weinstein and two point discrimination was used for sensory recovery, and numbness, hypersensitivity and cold intolerance for peripheral nerve disturbance. Moreover, patient’s satisfaction (excellent, good, fair, poor) and the time for return to work was assessed as the item of patient-based outcomes. Results: Flap size was from 2.5×2.0 cm to 7.5×3.0 cm with mean 10.4cm2. Two flaps were congested postoperatively, but bloodletting for two days improved flap congestion. Eventually, all flaps were survived without two flaps. Partial necrosis were observed in these flaps, but they eventually became epithelialized after conservative treatment using ointment. Over the mean follow-up of 10.6 months, static and moving two-point discrimination were 9.4 and 6.8 mm, and in Semmes-Weinstein, blue were six, purple were six and red were four. In the sensory disturbance, numbness was remained in 31% patient, hypersensitivity in 38% and cold intolerance in 44%. Patients returned to work approximately two months after surgery. There were no complications at the donor sites. As conclusive satisfaction, excellent was 38%, good was 62%, and there was no patient who complained about treatment by this flap. Conclusions: A posterior interosseous artery perforator flap was a useful choice for fingertip reconstruction without donor site morbidity, and the patients were able to return to daily living quickly. This flap consists of thin skin and subcutaneous tissue not of glabrous skin, but offers an acceptable sensory recovery and a desired patient’s satisfaction.

Rosana Raquel Endo 1, Flavio Faloppa 2, João Baptista Gomes dos Santos 2, Carlos Henrique Fernandes 2, Luiz Carlos Angelini 1, Luis Renato Nakachima 2, Marcela Fernandes 2

1 Hospital do Servidor Público Municipal de São Paulo, Brazil; 2 Hospital São Paulo UNIFESP/Orthopedic Surgery Department, Hand Surgery Department, Brazil

Due to the scarcity of data in the Brazilian literature regarding the hand surgeon's performance in microvascular surgeries, we performed a statistical analysis with the data obtained through an anonymous questionnaire carried out during a specialty congress. Through it we approach technical, demographic, epidemiological and financial aspects to obtain pertinent conclusions. 143 brazilians hand surgeons answered the questionnaire. Only 10 (7%) did not receive microsurgery training during medical residency. 90 (72.6%) stated that they already performed reimplants 67 (49.6%) performed microsurgical flaps. 65 (63,1%) relataram que os dedos amputados chegam ao hospital em condições inadequadas. Quanto ao tempo o qual os dedos amputados chegam ao hospital, 53 (53,0%) responderam receber em tempo hábil.We did not find in the medical literature data regarding the hand surgeon's performance in microvascular surgeries in Brazil, but the results obtained were similar to those found in the North American literature with drawings similar to ours.

Renata Gregorio Paulos, Bruno Alves Rudelli, Renee Zon Filippe, Gustavo Bispo dos Santos, Ana Abarca Herrera, Andre Araujo Ribeiro, Marcelo Rosa de Rezende, Teng Hsiang Wei, Rames Mattar Jr

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

OBJECTIVE: To analyze the histological changes observed in venous grafts subjected to arterial blood flow as function of the duration of the postoperative period to optimize their use in free flap reconstructions. METHODS: Twenty-five rats (7 females and 18 males) underwent surgery. Surgeries were performed on one animal per week. Five weeks after the first surgery, the same five animals were subjected to an additional surgery to assess the presence or absence of blood flow through the vascular loop, and samples were collected for histological analysis. This cycle was performed five times. RESULTS: Of the rats euthanized four to five weeks after the first surgery, no blood flow was observed through the graft in 80% of the cases. In the group euthanized three weeks after the first surgery, no blood flow was observed in 20% of the cases. In the groups euthanized one to two weeks after the first surgery, blood flow through the vascular loop was observed in all animals. Moreover, intimal proliferation tended to increase with the duration of the postoperative period. Two weeks after surgery, intimal proliferation increased slightly, whereas strong intimal proliferation was observed in all rats evaluated five weeks after surgery. CONCLUSION: Intimal proliferation was the most significant change noted in venous grafts as a function of the duration of the postoperative period and was directly correlated with graft occlusion. In cases in which vascular loops are required during free flap reconstruction, both procedures should preferably be performed during the same surgery.

Marcelo Rosa de Rezende, Mateus Saito, Renata Paulos, Samuel Ribak, Ana Abarca Herrera, Alvaro Baik Cho, Rames Mattar Jr

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: The reverse sural flap has often been used for cutaneous coverage of the distal region of the leg and ankle. When the flap is performed in 2 stages, the vascular pedicle is exteriorized and later resected. Our goal was to assess the reverse sural flap performed in 2 stages regarding its viability and lower morbidity along the flap-donor area. Methods: Eleven patients with cutaneous coverage loss found in the area between the distal third of the leg and ankle were subjected to cutaneous coverage surgery with reverse-flow sural flap with exteriorized pedicle, without violation of the skin between the base of the flap pedicle until the margin of the wound. After a minimum period of 15 days with flap autonomy, the pedicle was resected. The flap dimensions, its viability before and after the pedicle ligature, and the distance from the intact skin between the flap base and the margin of the wound were evaluated. Any losses were measured as a percentage of the total flap size. Results: The respective length and width of the flap were, on average, 7.45 cm x 4.18 cm. All flaps survived. There was partial loss of flap in 3 cases ranging from 20 to 30%. The average distance of the intact skin between the pedicle base and the margin of the wound was 5.59 cm (min: 4 cm/max: 8 cm). Conclusion: Our results show that the 2-stage reverse sural flap ensures good flap survival and a lower morbidity.

Miguel Moron, Thuan Ly, Claudia Meuli-Simmen, Itai Pasternak

Clinic for Hand, Reconstructive and Peripheral Nerve Surgery, Cantonal Hospital of Aarau, Switzerland

Introduction Soft tissue defects over the posterior aspect of the elbow can result from various causes, bursitis olecrani being one of the most common. There is a large variety of treatment strategies to address this problem, ranging from secondary wound healing to coverage with a flap. We report six selected cases, all of which were treated with a different flap. Methods We chose exemplary cases from our institution which warranted different sorts of soft tissue coverage due to defects over the posterior aspect of the elbow. Results Six patients whose ages ranged from 49 to 70 years were selected (4 male, 2 female). All defects could be closed by a flap. The flaps we used were; perforator flap and split skin graft (n=1), local bridging perforator flap (n=1), pedicle radialis flap (n=2), local bridge flap (n=1), reverse lateral upper arm flap (n=1). We observed no flap loss and all defects could be covered. Complications were one split skin graft loss and one postoperative hematoma. Conclusions Depending on the size of the defect, general medical condition and comorbidities treatment strategies are modified. There are numerous possibilities when choosing the ideal flap in each individual case, each comprising its own advantages and disadvantages. Decision pathways, operative technique, advantages and disadvantages are presented and discussed for each of these exemplary cases.

J Braga Silva

PUCRS University, Porto Alegre, Brazil

Hypothesis: The perforator pattern of vascularization of the dorsal forearm is a subject that is well studied, and based in these anatomic features non-debilitating flaps can be performed successfully in this region with good results in cases of complex injuries to the dorsum of the hand. We describe here our option for reconstruction of these kind of lesions, presenting our cases and results. Methods: Twenty patients underwent reconstruction of defects in their distal forearm, wrist or hand, using a dorsal forearm adipofascial turnover flap. Twelve males and eight females, with ages ranging from 26 to 80 years were treated. Regarding etiology, eight patients suffered trauma (including 4 crushing injuries), nine had a tumor, and three had burns. One half of patients showed bone exposure and the other half showed tendon exposure. In 18 patients, the lesion occupied the entire length of the back of the hand, and the other two were associated with more than 50% involvement of its surface. Radial artery injury was observed in six patients and ulnar artery injury in two (7%). Results: The flaps survived in all patients. In one case, there was necrosis in less than 25% of the length of the flap. In all patients, the normal gliding motion of the involved tendons and joints was gained, and the cosmetic result in the donor site was quite acceptable.

Andrzej Zyluk

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Degloving injury consists in tearing out the soft-tissue integument from skeleton of the hand, with accompanied nerves and vessels. The whole hand degloving has bad reputation and one of worst prognosis, even worse than total hand amputation. The range of possible salvage procedures in these cases is limited and their outcomes are unsatisfactory. One of the suitable methods is wrapping the skinned hand with pedicled or free greater omentum flap, retrieved from the abdominal cavity. The article reports outcomes of the treatment of 5 patients at a mean of 8 years after total degloving of their hands and coverage with omental flaps. All flaps healed uneventfully, but in none of the patients the whole length of the fingers was preserved. Division of stumps of 3 fingers was possible in one patient, two others had three-digital hands and remaining two had only separated thumb. Dexterity of injured hands was limited with a mean of score DASH questionnaire of 43 points. Quality of life as measured by SF-36 questionnaire was fair (58 and 53 points in physical and mental domain, respectively). Regardless this, all patients were satisfied with achieved outcomes and all returned to work, which was a confirmation of the effectiveness of the method used in their treatment.

Panai Laohaprasitiporn, Saichol Wongtrakul, Roongsak Limthongthang, Panupan Songcharoen, Torpon Vathana

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University Bangkok, Thailand

Background: Free functioning muscle transfer (FFMT) is a standard treatment in late brachial plexus injury (BPI) and failed primary nerve surgery. FFMT procedure required good donor arterial flow for arterial anastomosis. However, concomitant BPI and subclavian artery injury are not uncommon which required alternative method to restore sufficient arterial flow for FFMT. Objective: To preliminarily report results of arterio-venous loop (AV-loop) graft for FFMT in BPI patients with subclavian artery injury Material and Method: We performed a longitudinal descriptive study in adult BPI patients with concomitant subclavian artery injury proven by computed tomography angiogram. We excluded patients with good intraoperative thoraco-acromial and/or thoracodorsal arterial flow, which could perform FFMT without AV-loop graft. Results: Ten patients were enrolled into study. Three patients were excluded due to good intraoperative thoraco-acromial arterial flow in two patients and large amount of adhesion around external jugular vein in one patient, which couldn’t proceed to the index surgery. Seven patients with an average age of 39 years were included in this study. Most of the patients were male who sustained total arm type BPI from motorcycle accident. Four patients underwent one-stage operation (arterio-venous loop graft and free gracilis muscle transfer in the same operation) and three patients underwent two-stage operation. The success rate was 100% and 33% in one-stage and two-stage operation, respectively. There were increased in operative time, blood loss, blood transfusion rate and length of hospital stay in two-stage operation. All successful cases regained gracilis motor power grade I-III within 10-13 months. Conclusions: Arterio-venous loop graft with free functioning muscle transfer could be an option for late reconstructive surgery in BPI patients with insufficient donor arterial flow.

Hiroyuki Gotani, Hirohisa Yagi

Department of Hand and Microsurgery, Osaka Hospital of Sea Affairs and Relief Association, Japan

(Introduction) We recently have used dorsal ulnar artery perforator flaps (DUAPF) or fascial flaps to cover the tendons and nerves during initial treatment as well as to repair soft tissue defects after elimination of scars during secondary tendon or nerve release in cases of incomplete amputation of forearm and wrist laceration. The flap was first reported by Becker and Gilbert et al. and uses the dorsal ulnar artery as the pedicle. Our clinical experience with the flap is reported. (Materials and Methods) Fifteen patients of complex hand injuries were studied. The injury was caused by an electric saw in five patient, a press in eight, and so-called “spaghetti wrist” by self-laceration in two. The patients ranged in age from 16 to 47 years old (mean: 30 years). The DUAPF was used during the initial surgery in 6 patients and during secondary tenolysis or neurolysis in 9. The DUAPF was prepared as follows. First, a small skin incision, about 2 cm long, was made over the ulnar axis 2 cm proximal to the pisiform bone, and the flexor carpi ulnaris muscle was pulled with a retractor. The dorsal ulnar artery, which serves as the vascular pedicle, was then identified. Ideally, the ulnar axis should be at the center of the flap, and the flap should reach the palmaris longus muscle tendon on the palmar side and the ring finger extensor muscle on the dorsal side. Its length should be determined on the basis of its positional relationship with the site of the defect, taking into consideration that the length of the rotatable vascular pedicle is 2 to 4 cm with the pisiform bone at the center. (Results) The vascular pedicle could be identified in all cases. In six cases, a DUAPF was used in the initial treatment because as a result of debridement, etc., associated with the crush injury and contamination, the skin remaining immediately above the tendon and nerves had poor circulation. A DUAF was used as the pedicle flap in all cases, and as the fascial flap in three of them. Severe adhesion of the flap to the underlying tissues was not observed postoperatively, and none of the patients required secondary neurolysis or tenolysis. The postoperative results assessed according to Chen’s classification were Grade 4 in one patient, Grade 3 in three, Grade 2 in seven, and Grade 1 in four. (Discussion) Treatment of forearm injuries becomes difficult if severe scar tissue occurs at the site of the injury on the palmar side and the tendons or nerves adhere to the skin. It therefore seems best to use a flap with good circulation to cover the site in the early stage whenever possible. Our approach is considered useful because the soft tissue defect around the hand joint, including the carpal canal and the dorsum of the hand, can be covered with a pedicle flap, the main artery can be spared, and the operation itself is easier than with other flaps.

Iva Neshkova, Michael Jakubietz, Silvia Bernuth, Karsten Schmidt, Rainer Meffert, Rafael Jakubietz

Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Clinic Wuerzburg, Wuerzburg, Germany

Objective Soft tissue reconstruction of the hand is often challenging to the reconstructive surgeon. The intricate anatomy of the hand requires a durable soft-tissue -envelope to with gliding capacity crucial for tendon excursion . Commonly used fascial flaps for the dorsum of the hand are free flaps – e.g. temporal fascia flap, ALT fascia flap. We report on a modification as a “fascia only “ distally based interosseus posterior flap (PIA flap). Methods The distally based PIA flap was used in 7 patients to reconstruct soft tissue defects of the hand. In one patient the flap was pulled through the metacarpal gap to cover a palmar defect at the MCP level. Contrary to the standard technique only the deep fascia was included in the flap. A split thickness skin graft was transferred primarily. The donor site was closed in a straight line scar. Results 6 flaps survived completely. In one patient a distal tip necrosis required repeated debridement and a split thickness skin graft. In 3 patients secondary procedures such as bone grafting and tenolysis were carried out. No thinning was required. Conclusions This study reports on the use of a fascial flap without including a skin paddle. As only vascularized fascia is transferred, this flap is very thin and thus allows an aesthetically pleasing reconstruction of dorsal hand defects. Although the series is small we have not found an increased rate of complication. In comparison to the temporal artery fascia flap or the lateral arm fascia flap, harvesting the PIA flap is technically easier and can be done under plexus anesthesia only. The straight forearm scar is aesthetically more pleasing than a large skin grafted area over the extensor muscles. The thin and pliable nature of this pedicled flap is beneficial for reconstructing dorsal hand defects.

Luciano Ruiz Torres, Renata Gregorio Paulos, Luiz Sorrenti, Marcos Leonhardt, Teng Hsiang Wei, Tulio Diniz Fernandes, Marcelo Rosa de Rezende, Rames Mattar Junior.

Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objective: Distal third of leg and foot coverage was in the 1980’s a strong indication for microsurgical reconstruction with free flaps. After perforator arteries concept better understanding, many new and reappraised flaps were developed and applied to this particular area on avoiding microvascular flaps application: propellers and high reverse sural flaps are examples. As these series progresses in many centers, their assessment showed that failure rates are significant. The authors applied the pedicle medial plantar artery flap in other areas than plantar one and the purpose of this study was to analyze its use in non weight-bearing areas of lower limb. Methods: From 1995 to 2017 we have operated 21 patients with soft tissue defects of posterior heel, medial lower tibia, ankle, Achilles tendon surgery dehiscence and one proximal tibia. Age varies from 21 to 85. Sixteen patients were men. Most patients were operated due to trauma, except for two patient by pressure sores, two patients due sarcoma and two due osteomyelitis. We assessed viability of the flap, complications in donor area and patient satisfaction. Results: All the flaps healed uneventfully. There was no flap necrosis (total or partial). In 5 patients, partial width skin graft over the donor area didn't take completely. They were treated only by dressing changes with complete wound healing. There was no need for secondary surgery except for two patients: one that extruded active bioglass and needed debridement and another one that had problems after debulking (only one in this series). All patients are satisfied. The unaesthetic grafted donor site was hidden under the foot. Only one of them asked for a flap debulking. Conclusions: In these case series anatomy was constant, flap was reliable with no failure and there was reasonable donor site morbidity on medium term follow-up. To our understanding this is a rare series on non-weightbearing area coverage with MPA flap.The authors consider MPA as option on small to moderate defects of posterior heel, medial ankle and medial distal tibia. It worked well as a unique flap, as a rescue of other partial flap failures and in association to other pedicled local flaps when microvascular surgery was not best option due to clinical or local considerations.

Andrea Marchesini, P. Pugliese, P. P. Pangrazi, L. Senesi, Michele Riccio

A.O.U. Ospedali Riuniti di Ancona, Department of Reconstructive Plastic Surgery, Hand Surgery, Ancona, Italy

Objective: The loss of substance in the hand dorsum, both due to traumas and soft tissue cancer, can be classified as simple or complex. In the first case only the skin is involved while two or more tissues are involved in the second case. Such tissutal losses are likely to impose severe deficit to patients as they limit the ability of wrist and fingers extension which is a biomechanically essential functional task in order to grant a proper hand’s grip. Due to the importance of such functional area various authors proposed and largely employed a ‘one stage functional reconstruction’ in the multi-tissutal loss of substance by means free or pedicled composite flap [1-3]. Such treatments have been integrated, in the last years, by the use of dermal substituted and more recently by new methods of regenerative surgery [4]. Authors propose a review of their cases which reveals a treatment flowchart allowing for a reduction of the costs associated to the reconstruction for the patients involved. Materials and method: Authors provide a review of hand dorsum and wrist trauma cases treated at their unit from 2006 to 2016. The sample is made of 40 patients of which 14 received a one-stage reconstruction of the hand dorsum by means of a radial forearm composite free flap, 2 were treated with free ALT flap, 8 were treated with pedicled radial forearm flap and the remaining 16 had their hand dorsum reconstructed with dermal substituted and regenerative surgery. Valuations are based on the number of surgical procedures that patients received, the numbers of days they were at hospital, and the quality of their functional recovery in terms of TAM, sensitivity, Quick-Dash e Posas score. Results: From our preliminary results all patients were satisfied with their reconstruction and recovered a good or excellent function a part from two cases of poor recovery. Conclusions: Based on the results a treatment flowchart will be proposed which merges traditional and innovative reconstructive techniques depending on the specific tissue involved in the loss of substance. [1]Reid CD, Moss LH. One-stage flap repair with vascularized tendon grafts in a dorsal hand injury using the “Chinese” forearm flap. Br J Plast Surg 1983;36:473–9. [2] Yajima H, Inada Y, Shono M, Tamai S. Radical forearm flap with vascularized tendons for hand reconstruction. Plast Reconstr Surg 1996;98:328–33. [3] Caroli A, Adani R, Castagnetti C, et al. Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction. Plast Reconstr Surg 1993;92:1326–30. [4] Adani R, Rossati L, Tarallo L, Corain M. Use of integra artificial dermis to reduce donor site morbidity after pedicle flaps in hand surgery. J Hand Surg Am. 2014 Nov;39(11):2228-34. doi: 10.1016/j.jhsa.2014.08.014. Epub 2014 Sep 26.

Horst Zajonc, David Braig, Jan R. Thiele, Vincenzo Penna, G. Björn Stark, Steffen U. Eisenhardt

Clinic for Plastic and Hand Surgery, University Clinic of Freiburg, Freiburg, Germany

Background: There are only relative indications for distal digital replantation in zones 1 and 2 according to Tamai. In contrast to primary closure for fingertip amputations, replantation is a complex procedure that requires skills in supermicrosurgical techniques, as vessels with diameters between 0.3–0.8 mm are connected. In addition the time spent in hospital and the time off from work are longer. Distal digital replantation is thus only indicated, if the expected functional and aesthetic benefits surmount those of primary closure. Patients and Methods We retrospectively analysed all fingertip amputations in zone 1 and 2 according to Tamai between 9/2009 and 7/2014 where we attempted distal digital replantation. The success of replantation, wound healing and functional results were evaluated according to Yamano. Results We performed 11 distal digital replantations in the study period. There were 6 total amputations, 4 subtotal amputations and 1 avulsion of the digital pulp. Revascularisation with long-term reattachment of the amputated tissues was possible in 8 cases (73%). In 3 cases (27%) secondary amputation closure was necessary. The mean operating time was 3 h 56 min. 6 patients, which had a successful replantation, were available for follow-up examinations after a mean period of 19 months. 5 patients were satisfied with the result and would again prefer replantation over primary amputation closure. 4 patients reported a good function of the replanted digits and did not complain about any limitations in their use. 2 patients complained about restricted function. All patients could return to their previous places of employment and were free of pain. Of the 12 affected digital nerves 11 nerves had a 2-point discrimination (2-PD) of ≤15 mm, 3 of them had a 2-PD between 7 and 10 mm and 4 of them of <6 mm. Soft tissue atrophy was obvious in 3 replanted digits and nail deformities in 2 patients. Conculsions Distal digital replantation is complex and technically challenging. It leads to high patient satisfaction with only minimal functional limitations, if successful. Due to the good results that can be obtained by these procedures, fingertip replantation should be attempted, if operative risks are minimal and if requested by the patient.

Jin Yong Shin, Jung Hoon Lee, Si-gyun Roh, Suk-Choo Chang, Nae-Ho Lee

Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, South Korea

Introduction Traumatic injuries and soft tissue defects in the fingertips are challenging problems for hand surgeons. Many surgical techniques for the reconstruction of fingertip injuries have been described depending on the type of injuries. The most frequently considered procedure is the reverse digital island flap, which is useful for the repair of various fingertip injuries. Although usually surgical detachment procedures have been performed about 14 postoperative days (POD), we introduce early detachment technique as a effective surgical method. Methods 15 patients undergone a heterodigital island flap from 2013 to 2017 were included in this study. We performed 15 reconstructive procedures using a heterodigital island flap to cover the defects. Through our medical charts, we investigated the patient's medical history, vector, level of injury, severity, hospitalization period and time to surgery after injury. In all patients who had heterodigital island flap surgery, we performed surgical delay about 3 POD and detatchment between 7 to 10 POD. Result The 15 patients included 10 males and 5 females, with an average age of 44.87 years. They have undergone surgical delay about 3 POD and detachments on 7 to 10 day after surgery. 15 flaps completely survived and there were no severe complications. Patient’s mean hospital days from day of surgery to discharge were 10 days. Conclusion Early detachment of heterodigital island flap is effective technique for defect of fingertip. All patients who underwent early detachment techniques returned their activities of daily living earlier.

SangHyun Lee, SungJin An, HeeJin Lee

Department of Orthopaedic Surgery, Medical Research Institute, Pusan National University Hospital, Pusan, South Korea

In cases of multi-level amputation of the hand, unsuccessful replantation leads to severe loss of hand function, as well as psychological sequelae resulting from the physical appearance. We report the outcomes of replantation in eight patients with multi-level amputations of the hand between June 2006 and December 2016. In four of the eight patients, all injured fingers survived. The average finger motion recovery was 40.6%. Mean static two-point discrimination was 3.0 cm at finger level and 4.9 cm at palm level. The average grip strength in the affected hand was 65.6% of that of the contralateral hand. According to Chen’s criteria, four patients had good results, three had fair results, and one had poor results. The replantation of multi-level amputations of the hand is challenging, but a good understanding of the surgical procedure can produce good results.

Hyeonwoo Kim, Ji Ung Park, Jun Ho Choi, Julong Hu, Sung Tack Kwon, Byungjun Kim

Seoul National University Hospital, Seoul, South Korea

Background: Fascia free flaps have been widely used in the soft tissue reconstruction of the hands. Fascia flaps are thin, pliable, and provide gliding surface. We have achieved good postoperative results using serratus anterior fascia free flaps (SAFF) in patients with skin malignancy in the nail units, hands, and forearms. Methods: Seven patients with skin malignancy had wide local excision followed by reconstruction with SAFF and skin graft between April 2017 and November 2017 by a single surgeon. All patients were operated in semi-lateral position with vertical incision on their upper lateral flanks. Flaps were harvested with great caution to prevent long thoracic nerve injury. The fascia was anastomosed with recipient vessels under microscope, then covered with skin graft. . Results: Five patients had subungual type of malignant melanoma. Two patients had squamous cell carcinoma on their wrist and forearm, respectively. The serratus anterior fascia flaps were successfully harvested on each donor site in all seven cases. There were no identifiable injury of long thoracic nerve during the operation. The lack of skin paddles made monitoring of the flaps difficult but all the flaps survived without major complications. Conclusions: SAFF is a reliable option in the soft tissue reconstruction of the nail unit and hand, especially when a thin and pliable flap is required. Donor site complications like injury of long thoracic nerve can be minimized with careful dissection during harvest of serratus anterior fascia flap.

Hugo Maschino 1, Germain Pomares 2, François Dap 1, Gilles Dautel 1

1 Centre Chirurgical Emile Gallé, Nancy, France; 2 Institut Européen de la Main, Luxembourg

Objective : -The aim of this presentation is to report the technique applied to reconstruct a metaphysiary-shaft defect of the 4th metacarpal bone in a 22 years old women after tumoral resection. Methods : -Xray and IRM showed typical aspect of aneurysmal cyst of the left 4th metacarpal bone, with typical septa and formation of fluids levels. The lesion concerned metacarpal shaft preserving articular surface proximally and distally. -After submission of patient’s disease history and imaging in oncologic consultation meeting, decision was made to perform a resection and reconstruction in a one stage surgery program. -Preoperative status asked the question of preservation of distal epiphysis in this particular case and in order to determine metacarpophalangeal joint preservation or reconstruction in one surgical approach, we chose to perform free medial femoral condyle flap. This choice was emphasized by intermetacarpal space invasion leading to possible poor revascularization possibilities, justifying the use of a vascularized bone transfer. Results : -After resection distal articular surface was preserved, the length of the defect and the orientation of articular surface was first maintained by intermetacarpal Kirschner wire fixation. -Flap harvesting was made on the contralateral side and measured 4x1 cm, the length enabled to preserve epiphyseal structure and bone anatomy and length. One artery and two veins were found, pedicle length was sufficient to perform terminolateral anastomosis on radial artery and terminoterminal anastomosis of the two veins on venae comitans of radial artery into anatomical snuffbox. -Bone fixation used multiple wire and this solution allowed early active motion, after 2 weeks. Donor site was reconstructed by fitted bone allograft without fixation. -Good results and quite complete flexion-extension range were observed during the follow-up, except minor intrinsic muscles deficit in progress of recovery. At 2 months bone consolidation was complete. Conclusion : -Free medial femoral condyle flap in its extra-articular version seems to offer an alternative to other bone vascularized transfer, minimizing donor site morbidity in cases of metacarpal reconstruction, it also offers an on demand solution when we have to decide peroperatively between articular conservation or reconstruction.

Roderick Dunn 1, Alexandra Crick 2, Stuart Watson 2

1 Odstock Centre for Burns and Plastic Surgery, Salisbury, UK; 2 Canniesburn Plastic Surgery Unit, Glasgow, UK

Objectives This is a case series of 20 free thinned extended lateral arm flaps to the hand and wrist. This paper describes the technique, planning and modifications to the standard lateral arm flap which enable skin distal to the lateral epicondyle to be included in the flap safely. Method This is a prospective case series from 2005 to date. All cases were performed by the author. The method for raising the flap, particularly the inclusion of skin distal to the lateral epicondyle, is described, along with lessons learned. Results Twenty free thinned extended lateral arm flaps were used in 20 patients, 12 primary and 8 secondary. Eleven flaps were performed for trauma, 2 for burns reconstruction, 3 in blast injuries and 4 for infection. All flaps survived completely. No secondary thinning was required, and all flaps tolerated further secondary procedures under the flap when required. All patents regained a high level of function post-operatively. Conclusions The free thinned distal lateral arm flap is very useful small flap for hand and wrist reconstruction, both primary and secondary. The skin is suitably thin for the hand, is a good colour match for normal hand skin, and it can be raised again safely for secondary procedures such as tendon, nerve or joint reconstruction. It is robust enough withstand early use in non-compliant patients. Lessons learned and the evolution of the technique are described, including how to include the much thinner skin distal to the lateral epicondyle safely, flap planning, pedicle length, and selection of appropriate recipient vessels. It is a reliable flap, is easier to thin than alternative fasciocutaneous flaps, and provides a very good skin and colour match for hand reconstruction with an acceptable donor site.

Cheng-Hung Lin, Chew-Wei Chong, Yu-Te Lin, Chung-Chen Hsu, Shih-Heng Chen

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taipei, Taiwan

Introduction: Fingertip injuries constitute a significant portion of cases that present to Hand Surgery service. These injuries are commonly associated with soft tissue loss. Conventional cross-finger flap is the workhorse flap for resurfacing of pulp loss. The authors described a laterally based cross-finger flap for reconstruction of soft tissue defect of the fingers. This modification enables coverage of volar or dorsal soft tissue defect at the distal, middle or proximal phalanx. Patients and Methods: From March 2015 to January 2017, a total of 10 patients (11 fingers) underwent laterally based cross-finger flaps and two patient (two fingers) underwent extended laterally based cross-finger flap. There were 10 men and two women, and the age of the patients ranged from 24 to 46 years. Results: The flap dimensions ranged from 13 x 7 mm to 43 x 13 mm. Eleven of the 13 flaps survived completely. The two flap failures were attributed to injury of the donor fingers, rendering the blood supply of the flaps unreliable. All donor sites were closed primarily without the need for skin grafting, negating the problem of donor site morbidity associated with harvesting of skin graft. Conclusion: The laterally based cross-finger flap is a versatile flap with less donor site morbidity and better aesthetics than conventional cross-finger flap. The authors described the design of the flap, as well as the pearls and the pitfalls, in doing a laterally based cross-finger flap.

Alexandru Georgescu, Ileana Matei, Irina Capota, Marius Pruna, Maria Nedu

University of Medicine Iuliu Hatieganu Cluj Napoca, Romania

Objective Coverage of complex tissue loss in the hand after severe traumas by crushing or avulsion is very challenging. These defects involve generally all the anatomical structures. The difficulties in repairing such a compromise hand are primarily related to the necessity to obtain an as good as possible functionality. The key of obtaining a good functional rehabilitation is to perform, whenever is possible, both the reconstruction and coverage as an all-in-one procedure. Material and Methods We take into account the cases with very complex injuries involving all the structures of the hand. In 70% of our cases we used local or regional perforator flaps, and in 30% of cases free flaps. In case of need to cover soft tissue defects over repaired fractures, vessels, nerves and tendon lesions, we prefer to use-whenever is possible-local or regional perforator flaps; if the skin defect is to big, a free flap is preferred. For composite skin and bone defects we use generally composite flaps including bone. For amputations or devascularized segments with skin defects, a free flow-through flap is used. For amputations of different segments, and especially of the thumb accompanied by skin defects, we cover the defect with a free flow-through-flap which is used in mean time to revascularize one or more toe transfers. Results All the hands treated by this protocol survived. The failure rate of the flaps was comparable with the one in the literature. By using local/regional perforator flaps we experienced no complete necrosis, but only a transitory venous congestion (20%) followed by a superficial necrosis in 5% of cases. We lost 2 free flaps out of 45 (4.4%). We obtained a satisfactory functional rehabilitation of the reconstructed hand in 10% of cases, a good one in 40% of cases, and a very good one in the remaining 50%. Conclusions In complex injuries of the hand the modality of reconstruction is up to the team experience. The use of local/regional perforator flaps has a very good indication in small and medium skin defects, and only in the purpose of coverage. The use of free flaps remain the gold standard in solving big composite defects. The emergency all-in-one reconstruction and the beginning of kinetotherapy as soon as possible after surgery are the key stone of a good functional recovery

Alexandru Georgescu 1,2, Ileana Matei 1,2, Octavian Olaru 2

1 University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; 2 Rehabilitation Hospital Cluj Napoca, Romania

Objective The coverage of simple or complex tissue defects in hand and wrist is generally very challenging because of the complexity of the lesions, which involve not only the skin but also most of the anatomical structures. The repair as complete as possible of all the important functional structures and the beginning as soon as possible of the functional rehabilitation represent the keystone of obtaining a functional hand. Material We take into account the cases with very complex injuries involving all the structures of the hand, amputations in absence of amputated segments and complex tissue defects. In 70% of our cases we use local or regional perforator flaps, and in 30% of cases free flaps. In case of need to cover soft tissue defects over repaired fractures, vessels, nerves and tendon lesions, we prefer to use-whenever is possible-local or regional perforator flaps; if the skin defect is to big, a free flap is preferred, as for example the antero-lateral thigh (ALT) or toraco-dorsal (TD) perforator flap. For composite skin and bone defects we use generally composite flaps including bone; our preferred flap is serratus anterior or latissimus dorsi, or both, with rib. For amputations or devascularized segments with skin defects, a free Chinese or ALT flow-through flap is used. For amputations of different segments, and especially of the thumb, but in absence of the amputated segment/s, accompanied by skin defects, we prefer to do an all-in-one reconstruction, by covering the defect with a free flow-through-flap which is used in mean time to revascularize one or more toe transfers to reconstruct the missing fingers Results The failure rate of the flaps in our hands is comparable with the one in the literature, i.e. not more than 5%. By using local/regional perforator flaps we experienced no complete necrosis, but only a transitory venous congestion (20%) followed by a superficial necrosis in only 5% of cases. We lost only 2 free flaps out of 45 (4.4%). We obtained a satisfactory functional rehabilitation of the reconstructed hand in 10% of cases, a good one in 40% of cases, and a very good one in the remaining 50%. We consider that these good results are related to our strategy, i.e. the all-in-one reconstruction whenever is possible and the beginning of the kinetotherapy very early after surgery. Conclusion In complex injuries of the hand and wrist, the modality of reconstruction is up to the team’s experience. The use of local/regional perforator flaps has a very good indication in small and medium skin defects, and only in the purpose of coverage. The use of free flaps remains the gold standard in solving big composite defects.

María L Manzanares Retamosa, Pedro Bolado Gutiérrez, Luis Landín Jarillo, Aleksandar Lovic Jazbec

Hospital Universitario La Paz, Madrid, Spain

Objective: The prevalence of clavicle fractures ranges between 2.5 to 15% of all fractures and non-union rate ( bone shortening and defects) between 0.1 and 5.8%.The oncologic resections are another source of this type of injuries. Early, safe and effective reconstruction is a must in such a cases, in order to provide an adequate treatment and rehabilitation of any underlined condition as brachial plexus injury, spine injury or any direct upper limb lesion. Methods: Although the microsurgical reconstruction of the clavicle non-union is rarely indicated from the beginning of the treatment it could be the most efficient option for patients who’s upper limb function recovery is strongly conditioned by the proper shoulder stability. We present 8 cases with a free fibula flap carried out between 2011-2016. The analyzed data were: etiology of the defect, associated comorbidities, secondary surgeries, recipient of the anastomosis , osteosynthesis, recovery period and functional evaluation of the shoulder and upper extremity before and after the treatment. Results:Four cases were fracture sequelae with multiple previous surgeries, two tumor resections and two post-surgical clavicle excisions. All of the patients with the exception of the tumoral cases showed important comorbidity (five brachial plexus palsies and one trapezius palsy) that needed nerve transfers and tendon/muscle transfers as a part of the surgical treatment. ORIF was performed in all the cases using anatomical plates and screws. Two cases presented supraclavicular hematoma as postsurgical complication. All the patients started immediate physical therapy and reached bone consolidation within two months after the surgery. There was notorious improvement of pain and the shoulder stability permitted to apply an adequate surgical protocol of the nerve lesions without interfering with the rehabilitation. Screws and plate were removed in six cases for cosmetic reasons. All the patients were back to their original activities. Conclusions: The reconstruction of clavicular defects with a free fibula flap is reliable, straightforward procedure that transform the complex pseudoarthrosis of the clavicle into much “easier to heal”, “fracture-like” conditions, that immediately restore the original shape and stability of the shoulder. It is highly recommendable in the cases where other surgical procedures have to be done simultaneously or as secondary surgery in order to achieve satisfactory functional recovery.

Martina Greminger, Urs Hug, Elmar Fritsche

Luzerner Kantonsspital, Hand- und Plastische Chirurgie, Luzern, Switzerland

The Interossea posterior system is well known as a source for pedicled or even free flaps in hand surgery. In contrast, the Interossea anterior system is not established yet. There is only few literature, and many flap books do not even mention the use of Interosseous anterior flaps. Also the medline database includes only few publications regarding these flaps. In the past 8 years we performed 8 Interossea anterior flaps, 3 pedicled flaps and 5 free microvascular flaps. Flaps were performed in patients with traumatic hand injuries either immediately or early elective, or in a secondary intervention after hand trauma. We registered one partial loss of a free flap. In most cases, donor site could be primarly closed and donor site morbidity was generally low. There are various opportunities to cover small or medium sized defects of the hand. Up to date the Interosseous anterior flap is unreasonably unknown and rarely performed. We show the anatomy, the flap harvesting technique and point out advantages of these flaps in comparison with other flaps of the forearm.

Soo Joong Choi, Jinsoo Park, Seungjin Lee

Hallym University Sacred Heart Hoaspital, Anyang, South Korea

Objective The best form of reconstruction of the soft tissue defects of the hand is replacing like with like. However, small but not very small defect is difficult to be covered by local flap. We tried to cover them by various small free flaps and reporting the results. Methods We performed retrospective review of 12 hand trauma patients treated by small free flaps. There were 11 men and one woman,their ages ranged from 15 to 71 years(mean 46.3 years). The size of defects were from 1x2 to 3.5x9 cm(mean 10.0 cm2). 7 radial artery superficial palmar branch(RASP) flaps and one medialis pedis flap were used for volar defects of fingers and 3 partial big toe flaps for finger tips or side and one medial sural artery perforator (MSAP) flap for dorsum of fingers. Results All the flaps survived completely.The glabrous skins of RASP,medialis pedis and partial big toe flaps and pliable MSAP flap matched well in color and texture with the recipient sites with minimal donor site morbidity . Conclusion Appropriate selection of small free flap is very useful for functional and cosmetic restoration of the soft tissue loss of the hand.

Jorge G. Boretto, Javier Bennice, Gerardo L. Gallucci, Ignacio Rellan, Agustin Donndorff, Pablo De Carli

Hospital Italiano de Buenos Aires, Argentina

Objective The anterolateral thigh (ALT) free flap is currently one of the most useful options for the reconstruction of cutaneous defects in different locations. A long pedicle, reliable anatomy, suitable vessel diameter, the availability of different tissues with large amounts of skin, make this flap versatile with the possibility of customized its applications. The purpose of this study was to evaluate the versatility and customization of the ALT free flap in a series of patients with coverage defects in both, the upper and lower limbs. Methods A retrospective review from a single orthopedic service at a level I Hospital was performed. Inclusion criterion were: patients with defects in different locations of the extremities to whom this flap was made as a reconstructive treatment. All were treated by the same surgeon. In the preoperative period, demographic variables, causes of the defect, size and location of the defect and time between the defect and surgery were analyzed. From the surgical technique, the type of flap, the suture performed and the type of closure of the donor site were analyzed. Finally, during the postoperative period, the survival of the flaps and the complications of the flap and the donor site were evaluated. Results During a 6 years’ period, 12 ALT free flaps were performed. Seven men and five women with an average age of 44 years (range 13-78) were included. The defects were caused by oncological resection in 9 patients and trauma in 3. In 4 cases the defect was in the upper extremity and in 8 cases in the lower extremity. The average time between the defect and the reconstructive surgery was 8 days. Eight flaps were fascio-cutaneous, one flap was compound with fascia lata and 3 were cutaneous. Three out of twelve were thinned before insetting and two were inset as flow-through. In 5 cases the arterial anastomosis was end to end and in 8 end to side. Venous anastomosis was end to end in 10 cases and end to side in 2. The size of the flap varied from 6 to 20 cm in length and from 3 to 12 cm in width. The survival rate of the flap was 92%, presenting failure only in one case. One patient required revision of the pedicle for lack of Doppler signal and suffered partial necrosis. The donor site presented no complications and primary closure was performed in all cases except for 2 that required closure with skin graft. Conclusions The ALT free flap is a valid and very useful resource for the coverage of defects of different etiologies in the upper and lower limbs since its versatility allows it to customized it successfully in varied defects in both, location and size.

Hazem Alfeky 1, Paul McArthur 1, Yasser Helmy 2

1 Whiston Hospital, Liverpool, UK; 2 Alazhar University Hospitals, Cairo, Egypt

Background: Distal digital replantation remains one of the demanding microsurgical procedures due to the difficulty of vascular anastomosis. Venous congestion is the most commonly encountered problem after replantation due to the difficulty of venous anastomosis in traumatic injuries. Heparin, among other drugs, is commonly used to facilitate venous drainage and prevent thrombosis. However, systemic heparin can be contraindicated in some patients. The senior author has experience of subcutaneous heparin injection for venous congestion in thirteen patients Methods: An amount of 1 ml (25,000 U) of calcium heparin for subcutaneous injection was diluted with 2.4 ml of physiologic saline to prepare a solution containing 1000 U in each 0.1 ml. Initially, 1000 U (0.1 ml) of this calcium heparin solution was injected subcutaneously into the tip of congested replanted digits. This was repeated twice daily until venous congestion improved Results: all the congested replanted digits survived without systemic side effects. There were no local side effects of the treatment. The PT and APTT have shown slight increase but they remained within the normal range. Haemoglobin levels have dropped slightly but no patients were at any risk of developing anaemia or needed blood transfusion. Conclusions: Subcutaneous heparin injections can salvage the replanted digits when venous congestion is a warning flag for replantation failure. It is safe and very efficient in patients where systemic heparin cannot be administered. However, this article shows the results in only thirteen patients which is a small number to show the efficacy, safety and side effects. Keywords: Replantation, Heparin, Injection, Salvage

Ahmet Savran 1, Ozgun Gunturk 2

1 Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey; 2 Gaziantep Dr. Ersin Arslan Education and Research Hospital, Gaziantep, Turkey

26 years of male patient has administered our hospital with hypothenar mass and distal ulnar nerve symptoms. Previous penetrating injury at the wrist at the past medical history and scar is inspected at the dorsal side of the mass. Doppler US is reported as pseudo aneurism of ulnar artery. Resection of the mass and vein grafting is perform with Ulnar neurolysis is performed. Total relief of the symptoms is observed at the postoperative 3 months. Hypothenas hammer syndrome is a rare condition of the hand. Our aim is to share our experience in treatment of this diagnosis.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

We investigated the anti-adhesive effects of a temperature-sensitive poloxamer/alginate mixture (Guardix-SG®) through a prospective randomized controlled study for carpal tunnel release surgery. The 47 patients who received the infusion were classified as Group 1, and the 51 patients who did not were classified as Group 2. Basic demographic factors and preoperative clinical status were evaluated. At the postoperative 18 months, the degree of clinical recovery and adhesion around the median nerve for both groups were evaluated and compared using sonography. The clinical outcomes, which were assessed using the six-item carpal tunnel symptoms scale, were not significantly different between the groups. However, sonography showed that adhesions around the median nerve were significantly less common in the infusion group. Although the anti-adhesive effects of the temperature-sensitive Guardix-SG® were apparent upon radiological investigation, its use was not associated with a significant difference in clinical outcome on the short-term period follow-up.

Tomas Kubek 1,2, Pavel Novak 1, Libor Streit 1,2, Jiri Vesely 1,2

1 Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno, Czech Republic; 2 Faculty of Medicine, Masaryk University, Brno, Czech Republic

Objective: Authors present unique case report of combined amputation and burn injury of the hand. Methods: 48-years-old man suffered amputation injury to his left hand while working with circular saw. Unfortunately, amputated part fell into a fireplace, which resulted in second and third degree burns on dorsal aspect of the hand and fingers. Replantation was performed 5 hours after the accident. The procedure was supplemented by escharotomy. Gentle tangential necrectomy and debridement was performed in two steps during first two weeks. Defects after necrectomy were covered by skingrafts in third postoperative week. Patient started with active rehabilitation 3 weeks postoperatively. Results: Replantation of the hand with third degree burns was successful. No complications occurred during hospital stay, all wounds were healed within 40 days. Results of rehabilitation in early postoperative period were promising. Unfortunately, the patient failed to cooperate and did not come for follow up. Conclusions: Despite the initial concerns of the surgical team, third degree burns were not an obstacle to successful hand replantation.

Raquel Bernardelli Iamaguchi, Marco Aurélio de Moraes, Renan Lyuji Takemura, Gustavo Bersani Silva, Jairo Andre de Oliveira Alves, Alvaro Baik Cho, Teng Hsiang Wei, Marcelo Rosa de Rezende, Rames Mattar jr

University of Sao Paulo, Brazil

Objetive: Vascularized fibula flap is a standard technique for reconstruction of complex and long defects in lower and upper limbs, mostly in traumatic and oncologic defects. Although, the crescent knowledge in bone reconstruction with microsurgery, the fibula flap still remains one of the most difficult free flaps and complications, including the loss of viability of the vascularized bone and pseudarthrosis remains a challenge. This study evaluated the risk factors fof complications that can influence results in vascularized fibula flap. Methods: A cross-sectional study was conducted with consecutive inclusion of all patients undergoing vascularized fibula flap for upper and lower limb reconstruction at our institution, between July 2014 to July 2017. Patient demographics (age, gender and comorbidities), location and size of bone defect, operative technique, intraoperative and postoperative complications were studied. Statistical analysis were performed with SPSS 20.0 (SPSS Inc ®, Chicago, IL, EUA). All tests were two-tailed, and statistical significance was defined as p < 0.05. Qualitative data were analyzed by Pearson chi-square test or Fisher exact test. Mann-Whitney U-test was used for quantitative nonparametric data. Results: A total of 23 vascularized fibula flaps were performed in 23 patients. Of these, 14 patients were male and 9 female. The indications for bone reconstruction were defects cause by: trauma in 13 patients, tumor in 7 patients and congenital pseudarthrosis of the tibia in three patients. The type of bone tumor were: giant cell tumor in three cases, osteosarcoma in two cases, B-cell lymphoma in one case and adamantinoma in one case. The most common anatomical area of bone lesion was leg in eight cases, followed by forearm in six cases. Obese patients (BMI ≥ 30kg/m2) were significantly associated with an increase in early complications (p= 0,046). Although a high rate of complications, our overall success rates are similar to those in the literature, with 13% total flap loss. Conclusion: Obesity is a risk factor for complications in vascularized fibula flap in orthopedic surgery.

Sang Hyun Woo

W Institute for Hand and Reconstructive Microsurgery, W Hospital, Daegu, South Korea

We present 12 cases in which palmaris longus tendocutaneous arterialized venous free flaps were used for the reconstruction of the collateral ligament in compound defects of digits. There were nine cases involving the interphalangeal joint of the fingers and three of the interphalangeal joints of the thumb. The venous flaps survived completely in 10 of the 12 cases. In 11 cases, there were excellent functional results for joint stability, pain, total active motion and pinch power. In all 12 cases, a pain-free joint with excellent stability was achieved after surgery. The palmaris longus tendocutaneous arterialized venous free flap is a good option for reconstruction of composite defects of the collateral ligament of the interphalangeal joint.

Dong Geun Lee

Chungbuk National University Hospital, Cheongju, South Korea

Introduction Soft tissue defect of the heel is caused by several causes, such as trauma and tumor. Especially in traumatic case of the heel defect , the difficulty of the reconstructive problems is that composite tissue problems often present such as soft tissue and Achilles’ tendon defect. For example, a 54-year-old man with right tibiofibular open fractures had wide soft tissue defect and crushing injury on foot including posterior heel composite tissue defect. After undergoing closed reduction and external fixation of the fracture, there was substantial soft tissue defect on right lower leg area. The soft tissue defect except posterior heel defect was covered with split thickness skin mesh graft. The reason for exception of heel in coverage was that the heel defect included a necrosis of Achilles’ tendon. What should treatment be for this heel composite tissue defect? One month after the latest surgery, the surgical debridement was preformed on the heel wound. And Promptly, reconstruction was performed with anterolateral thigh perforator flap including strip of fascia lata. The purpose of this article is to address such complex problems and to provide a solution for complex soft tissue defect of the posterior heel. Methods and materials The patient was a 54-year-old man with right tibiofibular open fractures having a wide soft tissue defect and crushing injury on foot including posterior heel composite tissue defect. As the reconstruction method, I used microsurgical composite anterolateral thigh perforator flap with tendon transfer using fascia lata. The dimension of the flap was 4 X 6 centimeters sized. The dimension of the transferred fascia lata was 9 X 6 centimeters sized. Before the tendon transfer, the fascia lata was rolled to provide a more strength as a tendon. With a microscopic assistance, the vascular pedicles were anastomosed. Especially the artery was anastomosed with T-shaped pattern not to inhibit the orginal arterial flow of the foot. Results and conclusions The flap was survived without any problem. After 3 monthes following surgery, physical therapy was started for enhancing the power of the Achilles’ tendon. In soft tissue heel defect including the Achilles’ tendon loss, I believe that this method will be one of the best choice.

Hazem Alfeky 1, Esam Tamman 2

1: Whiston hospital, Liverpool, UK. 2: Alazhar University Hospitals, Damietta city ,Egypt.

Proximal hand and forearm amputations are devastating injuries. the prediction of the success is always uncertain due to multi factorial risk factors including the mode of injury, level of amputation, presence of contamination and the extent of the damage to the neuro-vascular tree. General patient status and co-morbidities affect the outcomes as well. There is not any reported algorithm or guidance that can help predict the outcomes of plantation. We present our experience of a series of 17 post traumatic proximal hand and forearm replantations over a 5 year period in 3 major trauma centres . A management guidance is proposed to help deciding whether the process will be successful regarding the immediate survival and the long term functional outcomes and cost effectiveness.

Miscellaneous (17 abstracts)

Nasa Fujihara 1, Yuki Fujihara 1, Jennifer M. Sterbenz 2, Melissa J. Shauver 2, Chung Ting-Ting 3, Kevin C. Chung 2

1 Department of Hand Surgery, Nagoya University, Nagoya, Japan; 2 Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI, USA; 3 Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan

Objective: Economic conditions affect surgical volumes, particularly for elective procedures. In this study, we aimed to identify the effects of the 2008 US economic downturn on hand surgery volumes to guide hand surgeons and managers when facing future economic crises. Methods: We used the California State Ambulatory Surgery and Services Databases from January 2005 to December 2011, which includes the entire period of the Great Recession (December 2007 to June 2009). We abstracted the monthly volume of five common hand procedures using ICD-9 and CPT codes. Pearson’s statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. Results: The total number of operative cases was 345,583 during the study period of seven years. Most common elective hand procedures, such as carpal tunnel release and trigger finger release had a negative correlation with the unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. Conclusions: The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. A strategy for mitigating this may be to take advantage of economies of scale, the principle that increased volume reduces unit cost. Consolidating hand surgery services at regional centers may make for a more “economy proof” environment.

Steven Roulet, Guillaume Bacle, Bertille Charruau, Charles Agout, Emilie Marteau, Jacky Laulan

Hand Surgery Unit, Department of Orthopedic Surgery 1, Trousseau University Hospital, Medical University François Rabelais of Tours, Tours, France

Objective : Carpal boss is a symptomatic bony protrusion on the dorsal surface of the wrist, at the base of the second and/or third metacarpal. The goal of this study is to assess reliability and safety of the simple resection of the exostosis. Methods: 29 carpal bosses have been operated. The surgical technique was consistent with Cuono and Watson's description : the bony abnormality was resected until the dorsal edge of normal cartilage. There were 16 females and 13 males. The mean age at surgery was 33 years. The chief complaint was: isolated pain in 13 cases; pain associated with aesthetic blemish in 13 cases; and isolated aesthetic blemish in 3 cases. A cyst was present in 10 cases. 25 patients were contacted for telephone interview by an independent investigator on average 8 years after surgery. Results : No recurrence was reported, seven patients (28%) reported a discrete persistent swollen scar. One patient reported daily pain and impairment 5 years post-surgery, in relation with carpometacarpal instability, requiring fusion. Sixteen of the 24 patients who did not undergo fusion (67%) were free of pain; the others reported episodic pain of a mean 2.3/10 on VAS (range, 1 to 4), which they all attributed to climatic factors. Twenty patients (83%) felt no functional impairment and 4 (17%) some impairment for unusual activities. None complained of metacarpal instability. Patients considered themselves cured in 15 cases (60%) and improved in 9 cases (36%) and unchanged for the patient treated by fusion. None considered their condition worsened by surgery. All patients would undergo the same surgery again. Conclusions : In this series, there was no recurrence of carpal boss, but 1 surgical complication with carpometacarpal instability, probably due to excessive bone resection. Other studies based on simple resection reported failure rates ranging from 4.7% to 50%. Doubts regarding simple resection include small series and short follow-up; the present series is one of only two in the literature to report at least 25 patients and is the only one with a mean follow-up of at least 8 years. Simple exostosis resection is sufficient to effectively treat carpal boss. Fusion should be reserved for the rare cases of secondary metacarpal instability.

Roberta Sartore, Filippo Zanotti, Vito Zanella, Leone Pangallo, Massimo Corain

Hand Surgery Department, Verona University Hospital, Verona, Italy

An aneurysm is as a progressive dilation of the normal diameter of a vessel in the amount of 50% or more. Aneurysms of the hand are rare lesions, caused mostly by recreational or occupational trauma, iatrogenic injury and atherosclerosis. Most of them are false aneurysms. Surgical treatment is suggested to treat symptoms and avoid possible complications like paresthesia, distal embolization, cold intolerance and rupture. We present here a general overview of this pathology and our clinical and surgical experience in its treatment. From October 2016 to September 2017, we treated five cases of arterial aneurysms of the hand. The patients were 3 men and 2 women, with a mean age of 68 year-old (38-84). Two cases involved ulnar artery at the palm (one of them was a recurrence), 1 case was a lesion in the superficial palmar arch, 1 case involved the 3rd common palmar digital artery and 1 case involved the artery in the 1st interdigital space. Two cases were traumatic and 2 spontaneous, whereas the fifth case was of unknown origin (probably post-traumatic, following omolateral wrist fracture). Every patient referred pain and a developing pulsating mass over the site of the lesion, but there was only one report of distal paresthesia in the III and IV fingers (last case). All patients were investigated with ultrasonography, in 2 cases an MRI with contrast was performed and in 1 case a CT with contrast was performed: in every case we found a complete arterial dilation and one case had a complete thrombosis of the vessel (3rd common palmar digital artery). Every patient underwent surgical treatment of aneurysmectomy. Three of them had a subsequent end-to-end anastomosis and 2 a vascular ligation.The mean follow-up was 8 months (2-13). The aneurysmectomy was performed without complications in every patient. We had no complications with the end-to-end anastomosis in terms of patency of the suture and distal ischemia; even in the 2 cases of vascular ligation there was no report of distal ischemia. We had no complications of wound healing or infection, in 1 case the patient lamented a scar pain problem, solved with skin massage. The number of arterial hand aneurysms, even though uncommon lesions, is increasing due to many factors, weather traumatic (working or recreational) or iatrogenic, causing direct or repetitive blows to the vessels. Surgery is the treatment of choice for hand and forearm aneurysms, but high microsurgical expertise is needed. Complete diagnostic assessment is mandatory before surgery to give patients the right surgical indications (avoiding misdiagnosis) and achieve good results.

Ellada Papadogeorgou, Nikolaos Daniilidis

Interbalkan Medical Center, Thessaloniki, Greece

Objective: To describe the rescue procedure of an amputated upper limb at the level of the wrist, prioritizing solely the revascularization of the hand during the first operation, because of the delayed admission of the patient. Methods: A 34 years old male with left hand amputation at the level of the wrist and the palm, caused by a severe crush injury at work, was admitted to our emergency department 6 hours after the accident and after having already had a failed operative attempt of the hand’s revascularization in another hospital. During surgery priority was given to the successful anastomosis of the ulnar and the radial arteries, which had been ligated and thrombosed after suturing retrospectively. After the successful revascularization of the hand, adequate numbers of veins were anastomosed, median and ulnar nerve stumps were tagged and flexor and extensor tendons were sutured en block. Multiple fractures and dislocations of the hand and the wrist were temporary stabilized with an ex-fix system and k-wires. Ten days later, a second operation took place during which all tendons were sutured, the ulnar and the median nerve were reconstructed with sural nerve grafting and the palmar skin defect was covered with local flaps and free skin grafts. The dorsal surface was left uncovered and VAC was applied. After one month, skeletal and extensor tendon reconstruction was performed. The dorsal skin defect was covered with groin flap, which was separated after three weeks. After this point the patient followed an intensive rehabilitation program. Defatting and refinement of the scars followed and two years later a rotational osteotomy of the thumb together with opposition tendon transfer was also performed. Results: Three years post-traumatic the patient has satisfying range of wrist motion and full ROM of the IP joints of the digits. He retains the extrinsic function of his injured hand, thumb’s opposition is functional and he has protective sensibility. He is completely independent in daily activities and very satisfied with the final result. Conclusions: Complex trauma often demands modification of the usual surgical practice, in order to obtain the best possible result. In this case the usual sequence of tissue reconstructions during replantation was modified according to the circumstances, based on critical thinking and experience.

Han-Vit Kang 1, Jin-Hyung Im 2, Myeong-Kyu Lee 3, Joo-Yup Lee 1

1 Department of Orthpedic Surgery, the Catholic University of Korea, South Korea; 2 Department of Orthpaedic Surgery, Gyeongsang National University Changwon Hospital, South Korea; 3 Korea Public Tissue Bank, South Korea

Objective Peripheral nerve injuries affect a large proportion of the global population, often causing significant morbidity and loss of function. Processed nerve allografts offer a promising alternative to nerve autografts in the surgical management of peripheral nerve injuries where short deficits exist. The aim of this study was to compare the effect of the detergent-processed nerve allografts by a novel protocol utilizing nuclease with another protocol in a rat model. Material and method Two established models of acellular nerve allograft produced by two different detergent-process were compared with each other in a 15-mm rat sciatic nerve defect. Twelve Adult male rats, weighing 225-250 g (Harlan Sprague-Dawley), were utilized as donors for two different detergent-processed nerve allografts. Twenty-four adult male rats were divided into two groups of 12 animals each. In group I, sciatic nerve defects were repaired with 15-mm detergent-processed nerve allografts which were conventionally processed and decellularized using a detergent as described by Hudson et al. In group II, newly developed detergent-processed nerve allografts described by Wilshaw et al utilizing nuclease were used. At 12 weeks postoperatively, we analyzed the muscle mass, evoked muscle force and ankle contracture angle as functional parameters and histomorphometric findings to compare the effect of nerve regeneration. Result No significant difference was observed in muscle mass(Group I ; 58.02±7.01%, Group II ; 57.99±4.85%, p=0.99), evoked muscle force(Group I ; 46.05±19.55%, Group II ; 58.89±16.15, p=0.1) and ankle contracture angle(Group I ; 28.82±4.96°, Group II ; 31.27±5.62°, p=0.29). Also, population of axons that successfully crossed interposed nerve graft was not significantly different. Conclusion A novel method for detergent-processed nerve allografts described by Wilshaw et al utilizing sodium dodecyl sulphate(SDS; Sigma) and nuclease was not inferior to conventional Hudson method and it could substitute existing method.

Woan-Yi Chan, Gabriel FIeraru

Royal Devon and Exeter Hospital, UK

Objective It is important to be aware of a junior doctor’s potential limitations and knowledge regarding hand injuries and relevant anatomy to ensure no injuries are missed. We developed rapid and easy methods to form a general idea about a new junior doctor’s knowledge about hand anatomy, hand trauma and initial management and identify potential pitfalls and learning needs. Methods Over a 9 month period, junior staff performing a rotation at our plastic surgery department were asked to complete a short questionnaire on three commonly presenting plastic surgery trauma scenarios: 1. laceration on the hand; 2. hand fracture; 3. pretibial leg injury. Each case was presented using a printed photo or X-ray followed by questions to elicit descriptions of taking a relevant medical history and performing a clinical examination as well as forming a management plan. Candidates were asked to provide written answers individually without the use of any books or internet resource. No time limit was given. On returning their questionnaires, all candidates were provided with a short individual session to discuss their answers. This was followed by another interactive session to test hand anatomy knowledge and practical skills. The candidates were asked to put on an examination glove from the ward and draw the nerve innervations areas and tendon zones on it. Results 8 people completed the questionnaires. Two 5th-year medical students, two locum doctors and four trainees. None had previous plastic surgery experience. However, the trainees ranged from no previous surgical experience to two years basic surgical training. Although some incomplete answers were given, no questions were answered completely incorrectly. The medical students and two most experienced trainees gave the most extensive answers. However, the latter provided answers with a more relevant clinical approach and gave a more thorough management plan. They were also fastest in returning their questionnaires. The examination glove was found to be readily available and versatile to test and teach hand anatomy and skills. As well as anatomical landmarks, trainees could advance their knowledge on local flaps, incision lines for wound explorations and carpal tunnel release. Moreover, they could keep the glove to remind oneself of the teaching. Informal feedback, in particular from the locum doctors and medical students, was good as it provided an opportunity to refresh and consolidate their knowledge and skills required for working in the department. Conclusion Using a short questionnaire and readily available examination glove can rapidly and inexpensively assess a new junior doctor’s basic knowledge and skills on hand trauma and identify potential learning needs to be addressed during their rotation.

Abbas Peymani 1,2, Samandar Dowlatshahi 1, Austin Chen 1, Sabine Egeler 1, Simon Strackee 2, Samuel Lin 1

1 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands

Objective. Both plastic surgeons and orthopedic surgeons operate on the hand. However, extensive differences in training exist between the services in terms of exposure, technique, and anatomical expertise. Comparable studies have shown significant differences in complication rates, operating time and length of stay of other specialties. In this study, the National Surgical Quality Improvement Program (NSQIP) was used to compare outcomes after surgical procedures of the hand. Methods. A retrospective analysis of the NSQIP database (2005-2015) was performed to identify all patients undergoing hand surgery. Relevant Current Procedural Terminology codes were used to categorize procedures into three groups: tendinoplasty, fracture repair, and amputation. Patient characteristics, operating time, length of hospital stay, and post-operative complications were examined and compared. Results. A total of 8723 hand procedures were identified, 5277 performed by orthopedic surgeons and 3446 by plastic surgeons. Total hospital length of stay after tendinoplasty and fracture repair was significantly lower for orthopedic surgery. After covariate adjustment, there were no significant differences in operative time, wound complications, unplanned readmissions, and unplanned reoperations. Conclusions. This study shows similar outcomes after tendinoplasty, fracture repair, and amputation when comparing orthopedic and plastic surgery. Future outcome comparison studies should investigate other anatomical regions and procedures for which overlap of services exists.

Abbas Peymani 1,2, Mahyar Foumani 1, Iwan Dobbe 2, Simon Strackee 1, Geert Streekstra 2

1 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands; 2 Department of Biomedical Engineering and Physics, University of Amsterdam, Amsterdam, The Netherlands

Objective. Proximal row carpectomy (PRC) is used in the treatment of various post-traumatic and degenerative disorders of the wrist. Previous studies have aimed to investigate the biomechanics of the wrist after PRC almost exclusively in static cadaveric models, bringing about several disadvantages, including the need to artificially load tendons and the disruption of ligaments. The purpose of our study was to investigate the effects of PRC on wrist joint kinematics in patients. Methods. We measured cartilage thickness, contact surface area, volume of the capitate and shape of the capitate during motion in the operated and unaffected wrists of 11 patients. Mean follow-up was 7.3 years after proximal row carpectomy. Results. Radiocapitate cartilage thickness in the operated wrists did not differ significantly from radiolunate cartilage thickness in the unaffected wrists. The radiolunate surface area was significantly less than the radiocapitate surface area. The volume of the capitate was significantly increased in the operated wrists. The shape of the capitate changed significantly in two of three orthogonal directions. Conclusion. The combination of remodelling of the capitate, increase in its surface area and intact cartilage thickness could help to explain the clinical success of proximal row carpectomy, highlighting the adaptive capacity of the wrist after major anatomical changes.

Thierry Dubert 1,2,3, Cedric Girault 3, Alexandre Kilink 1, Marc Rozenblat 3, Yves Lebelle 3,4, Emmanuel H. Masmejean 5, Christian Couturier 6, Julie Dorey 7, Gregory Katz 8

1 Ramsay Générale de Santé, Clinique Jouvenet, Paris, France; 2 Ramsay Générale de Santé, Hôpital Privé Paul d'Egine, Champigny sur Marne, France; 3 Groupement de Coopération Sanitaire du Réseau Prévention Main Ile de France, Paris, France; 4 Ramsay Générale de Santé, Clinique de l’Yvette, Longjumeau, France; 5 Hôpital européen Georges-Pompidou (HEGP) – APHP, Head of hand, upper limb & peripheral nerve surgery service, Paris, France; 6 Espace Médical Vauban, Paris, France; 7 School of Medicine, Chair of Innovation management & Healthcare Performance, Paris-Descartes University, Paris, France

Objective: There is growing evidence that a good doctor-patient relationship can increase patient’s ability to tolerate pain, facilitate recovery and reduce patient’s anxiety and depression. To date, there is no evidence of such correlation for surgeon- patient relationship. It is our hypothesis that, besides surgical expertise and skills, a positive patient-surgeon relationship may play a significant role in improving clinical outcomes, help return to work (RTW) and reduce time off work (TOW). If this hypothesis is confirmed, improving the quality of patient-surgeon relationships would have a significant economic impact by reducing costs for payers as well as for the patients themselves. This could be of paramount importance for hand and upper extremity surgery considering that hand injuries and musculoskeletal disorders (MSD) form a huge economic burden for both patients and society mostly because of temporary or definitive limitations to return to work (RTW). Methods: A total of 219 patients aged 18 to 55 years on sick-leave because of trauma or MSD of the upper limb were enrolled in a prospective longitudinal observational study conducted in eight Hand trauma centres in France. To measure the Patient’s health condition at enrolment we used 3 validated questionnaires: QuickDASH for disability, HADS for anxiety and depression, and the BICF-CS for hand lesions. To measure patient-surgeon relationship, we used the QPSR which is the only patient-reported questionnaire specifically designed to measure the impact of patient-surgeon relationship on return to work after surgery. The reliability of the QPSR was reported as satisfactory, with an intra-class Pearson’s correlation coefficient of 0.86, and good psychometric properties in patients with hand trauma and MSD. After 6 months, RTW and TOW data were collected. Statistics for all collected variables were computed and correlations between collected data and RTW were studied. Additionally, regression models were developed to identify the drivers of RTW and TOW. Results: Only two drivers of RTW and TOW where identified: Patients who had more severe lesions were 28% less likely to return to work (odds ratio [OR]=0.717, 95%CI=[0.549; 0.937]). More interestingly, patients with a low or middle-low QPSR score had 95% and 71% less chance to return to work, respectively. The quality of the patient-surgeon relationship was strongly correlated with RTW and TOW. Overall, 74% of patients who returned to work had a high or middle-high QPSR score, whereas 64% of patients who did not return to work had a low or middle-low QPSR score. All items of QPSR questionnaire were significantly correlated with RTW (all p-values <0.05). Conclusions: According to the present study, the quality of patient-surgeon relationship, as measured by the QPSR score, is strongly correlated with RTW and TOW. We believe that improving patient-surgeon relationship may play a significant role in improving clinical outcomes, help return to work (RTW) and reduce time off work (TOW) following hand trauma and MSD.

Mihaela Perţea 1,2, R. Issa 2, Oxana-Mădălina Grosu 2

1 University of Medicine and Pharmacy “Gr. T. Popa” Iași, Romania; 2 Clinic of Plastic and Reconstructive Microsurgery, “Sf. Spiridon” Emergency Hospital Iași, Romania

Objectives: Prof. Lalonde revolutionizes hand surgery by introducing local anesthesia without sedation and without tourniquet. Good results, safety technique and patient’s full satisfaction made us ask ourselves “what are the limits of this technique?” and try to reduce the amount of anesthetic recommended by the author on a number of hand surgical interventions. Material and method: Our personal experience is based on 96 patients, aged between 20 and 77 years, 38 women and 52 men with various pathologies of hand and fingers. The study included 36 patients (23 men and 13 women) with Dupuytren disease in different evolution stages, 27 patients (14 men and 13 women) with carpal tunnel syndrome, 17 patients (8 men and 9 women) with trigger finger and 10 patients (7 men and 3 women) with acute pathologies like zone 2 flexor tendonsand digital neurovascular bundles injuries.In all the cases we used local anesthesia with lidocaine 1% and epinephrine (1:100.000 concentration). In 60% of the cases we used the recommended doses in the literature and, in the other 40%, of the cases, we decreased the doses between 5% and 40%. The most important decrease was noticed in 20 out of the 27 cases of carpal tunnel syndrome. We always respected the injection points recommended in the literature. Results There were no operatively incidents or accidents, nor skin necrosis or other complications related to the effects of adrenaline. Patient’s satisfaction was highest in all the cases and the economies were large due to short-term (several hour) hospitalization. Only 10 cases required 24 hours hospitalization caused by associated diseases in some older patients. Conclusions Wallant technique is safe, easy, less expensive, assuring the necessary comfort for both the patient, as for the surgeon allowing a dissection in similar conditions of visibility as an exsanguinated surgical field obtained using a tourniquet. The possibility of decreasing the dose of used anesthetic will bring an additional advantage to this surgical technique. Key words: local anesthesia, hand, surgery

João Paulo Mussi, Christophe Camps, Alexandre Durand, Christophe Duysens, Rainer Andrea Falcone, Thomas Jager

Institut Européen de la Main, France

Objectives: The treatment of the pan-arthritic wrists in the young patients due to traumatic injuries is challenging even for experienced surgeons, especially when both lunate fossa and capitate head are committed with considerable arthritis being the most acceptable option is the total wrist fusion. We present a case report of an alternative technique of proximal row carpectomy associated with a bifocal osteochondral graft to treat a SNAC wrist type IV in a young patient. Methods: We performed in a 23 years-old male patient a proximal row carpectomy associated with a bifocal osteochondral graft from the lateral femoral condyle to resurface an important arthritic degeneration of both capitate head and lunate fossa due to a sequel of an open trans-styloid trans-scaphoid perilunate fracture-dissociation. Pre-operatively, he had 20kg of grip strength (50% compared with the contralateral side), 65 degrees of flexion-extension motion (35/30) and pain of intensity of 10/10 in the visual analogic scale. Results: At the 18-month follow-up, the patient is pain-free with the 60 degrees of flexion-extension motion (30/30), 22kg of grip strength (61% when compared with the contralateral side), completely integrated graft and no signs of degeneration of the resurfaced area at this follow-up period Conclusion: We conclude that, despite being only one case, the resurface of the capitate head and lunate fossa by osteochondral graft can be an alternative for young patients with advanced arthritis preserving some motion of the wrist.

Francisco Simões Deienno, Trajano Sardenberg, Raffaello de Freitas Miranda, Denis Varanda, Andréa Christina Cortopassi, Paulo Roberto de Almeida Silvares

Hospital das Clínica de Botucatu, São Paulo Estate University, UNESP, Brazil

Objective: Evaluate, through a systematic literature review, whether there is or not a need to suspend anticoagulants (warfarin, aspirin and clopidogrel) to perform elective procedures of wrist and hand surgeries. Methods: The search for articles was performed by using a combination of keywords in the databases available without scientific design restraints. A series of articles with five or more surgeries performed without suspending antithrombotic medication was selected and examined in terms of severity of the complications, serious (need for surgical treatment) and minor complications (no need for surgical treatment). Results: Six articles were identified and examined; 360 wrist and hand surgeries were performed in patients receiving warfarin or aspirin and clopidogrel, two serious (0.5%) and 24 minor complications (6.6%) were reported; 1973 surgeries were performed in patients who did not use antithrombotics, showing no serious complications and 13 minor complications (0.6%). Conclusions: The studies in this review allow us to suggest that there is no need for antithrombotic discontinuation in patients undergoing wrist and hand surgeries. However, further randomized studies are needed to properly elucidate this question

S. Rodríguez Paz 1, A. Oriol Segura 1, A. Rañé Tarragó 1, R. Galtés Fuertes 2, N.H. Sarma 3, P. Kumar 3, FJ. Peris Prat 1, G. Dargallo Carbonell 1

1 Parc Hospitalari Martí i Julià of Salt - St. Catherine Hospital, Girona, Spain; 2 Faculty of Health Sciencies at University of Vic-Central University of Catalonia, Manresa, Spain; 3 Rdt Hospital Bathalapalli, Anantapur, India

OBJECTIVE The surgical treatment for long-term sequelae after snake bite is not described at the scientific literature. We expose a surgical treatment based on fasciectomy, the macroscopic and microscopic features and the results of 2 cases of wrist fixed dorsiflexion contracture after indian cobra bites. METHODS A collaboration with the Bathalapalli Hospital in India through an international foundation is being developed for the last 8 years and the two patients were reported during this collaboration. Both were victims of a local cobra bite named Naja Naja at the dorsal area of the left wrist. The first patient is a 43-year-old woman with a 8-year history of 70 degrees dorsiflexion contracture. Opposition of the thumb was impossible. The second one is a 23-year-old woman with a 6-year history of 64 degrees dorsiflexion contracture and opposition of the thumb with only the index finger was possible. They didn’t developed systemic chronic affection but joint stiffness, muscle wasting and reduced muscle power were reported. Paresthesias or local pain were not documented. RESULTS Women underwent elective surgery with a dorsal wrist incision. A retraction of the soft tissue under skin was found, with fibrotic bundles but without infiltration of the rest of structures (extensor tendons were absolutely respected). The fibrotic tissue was excised and a dorsal capsulotomy was arranged. The histopathology reported bundles of fibro-collagenous tissue with degenerated and hyalinized areas, fibroblasts and occasional lymphocytes were seen between the collagen bundles. Women achieved a 70 and 64 degrees improvement in the range of motion respectively after the surgery and the rehabilitation programme. This allowed the thumb to touch the tips of the fingers in both patients and to grasp objects in the second pacient. CONCLUSIONS The treatment of the chronic musculoskeletal disability following a snakebite is not well known, whereas it’s widely described the acute treatment. Our work could be the first mention in the scientific literature. The snakebite in upper limbs causes a systemic and local response to the toxin and it developes a fibrotic contracture of the soft tissues near the bite area. This long-term sequelae can be treated with a fasciectomy of the fibrotic tissue and a dorsal capsulotomy with good results. Despite the limited number of cases, we believe thay his surgery provides an opportunity for disabled patients with this kind of affectation.

James D Bedford 1, Joseph J Dias 2, Vivien C Lees 3,4

1 Manchester University Foundation Trust, UK; 2 University of Leicester, UK; 3 Manchester Hand Institute, UK; 4 University of Manchester, UK

Objective The ultimate priority of all nations' healthcare systems is to prevent and treat the illnesses of their populations. Changes to health service provisions in high income countries aim to improve cost efficiency, productivity, and patient safety. In contrast in India, a low income country, a key governmental priority is to deliver universal, equitable healthcare, where the prevailing trend had been of worsening health inequalities. Hands for Life, a UK charity of hand surgeons, has visited a rural commune in central India for the last seventeen years, providing surgical care for patients with hand disabilities due to leprosy, burns, and congenital hand differences. We wanted to compare the economics of providing this surgical camp with the costs of performing the same work in our own system (the UK National Health Service). We also sought to reflect critically on the team working aspects of providing hand surgery in an austere environment, and consider what lessons can be brought back to practices in high-income countries in order to improve efficiency, clinical effectiveness, resource use and patient safety. Methods The activity undertaken at a week-long hand surgery camp in India in November 2015 was analysed. The surgical log was coded according to ICD-10 diagnosis and OPCS procedural codes. These are translated into HRG codes which determine remuneration within the English NHS. The economic “value” of the surgical work performed in India was appraised. Basic data was collected on the clinical outcomes of adult hand surgery patients by a local hand therapist trained by our visiting surgeons. The non-technical aspects of providing surgical care at the camp were qualitatively analysed. Results Forty-nine procedures were performed over four consecutive days by four hand surgeons, following a multidisciplinary pre-operative clinic. Procedures were split between those for leprosy (17), burn contracture (18), congenital hand difference (5) and other diagnoses (9). The overall cost of delivering the camp (including travel for the surgical team, theatre consumables, and infrastructure costs) was EUR 7350. If the camp workload had been delivered in the NHS, the income from the work would have been EUR 132 500. The non-technical aspects identified included: * Constant/ fixed team composition, eliminating errors due to handover and increasing role clarity and effectiveness of communication * Availability of senior surgeons for expert decision-making, surgical assistance, training and mentorship * Streamlining of administrative tasks to eliminate redundant and unnecessary steps, while preserving a “core” bundle of essential documentation, including consent, surgical notes, photography, and WHO safe surgery checklists * Clear briefings attended by all members of the surgical team, with emphasis on candour / contribution by the whole team to identify safety or logistical issues. Discussion Reflecting critically on the difference between high- and lower-income health systems allows lessons to be learned for practice in wealthier systems, which may have additional benefits in terms of increasing productivity and thus economic efficiency. Delivering such camps gives opportunity for teaching local professionals, appears to benefit the local community and also appears to be very good value for money.

Aurelio Portincasa, Liberato Roberto Cecchino, Luigi Annacontini, Fedele Lembo, Domenico Parisi

Plastic surgery Department, University of Foggia, Italy

Objective: Soft tissue deficiencies represent a challenge for the Reconstructive Surgeon if associated with exposed tendon and absent paratenon in order to select the proper procedure due to possible tendon adhesions, poor range of motion (ROM), poor cosmesis and donor site morbidity. The Integra Bilayer Dermal Regeneration Template (Integra Lifesciences, Plainsboro, NJ, USA) is a dermal inductor used in reconstructive surgery, including the incidental coverage of tendons. Integra dressing’s post-operative functionality of the tendons, anyway, has not been well documented yet. We present our results on the Integra use for soft tissue reconstruction overlying tendons with loss of paratenon in the upper extremity soft tissue defects. Methods: We reconstructed 52 patients (45 men and 7 women) with exposed tendons due to trauma (n = 47), cancer excision(n = 2) or chronic wounds (n = 3) using the Integra dressing. Results obtained in a prospective manner including age, gender, wound location, wound size, time to final closure, operative time, follow-up length, split-thickness skin graft percentage taking and active post-operative ROM. Medline engine was used for a literature research of current surgical techniques for the treatment of exposed tendons and the results compared with our results. Results: All 52 patients healed with an average split-thickness skin graft take rate of 92.5% (SD 6.1; range 80 - 100%). 10 patients dropped out of follow-up. 42 patients at the follow-up achieved an average ROM of 91.2% (SD 6.5; range, 80 - 100%). Conclusions: The Integra dermal regeneration template offers an ideal, efficient operative technique with minimal morbidity, assuring good morpho-functional results. Thus, the Integra dressing may offer an alternative, valid option for immediate tendon coverage in the upper extremities reconstruction.

Petros Mikalef, Manish Gupta, Rajive Jose, Mark Herron, Dominic Power

Birmingham Hand Centre, UK

Objectives: Cognitive simulation provides a readily accessible and low cost alternative to traditional methods of procedural skill acquisition that can supplement traditional experiential learning. The technique involves knowledge assessment, visualisation, sensory perception, and kinaesthetics supporting the development of psychomotor and decision making skills. OrthOracle is an on line training resource that provides a structured learning platform for complex surgical procedures. The aim of this study is to explore the use of OrthOracle as a model for wider development of cognitive simulation training in hand surgery. Methods: A complex surgical task was deconstructed to key component steps and a value assigned to each representing its importance. Consensus on the grading scale was reached by a committee of hand surgeons. Trainees in hand, orthopaedic and plastic surgery were recruited to undergo cognitive simulation training and assessment using standardised techniques. Baseline information regarding previous training and operative experience was recorded prior to simulation and trainees were asked to score themselves in key areas based on their experience. 50% were provided with free access to the OrthOracle training platform as prelude to assessment. All cognitive simulation assessments were undertaken by consultant hand surgeons and scores assigned using the approved grading scale. Results: Trainees performed better in the cognitive simulation tasks when they had higher levels of experiential learning. Trainees with OrthOracle priming performed better than their counterparts. Conclusion: Service pressures, shortened training hours and greater numbers of trainees have limited the effectiveness of the traditional cognitive apprenticeship model of surgical training where a trainer would scaffold the trainee allowing progressive autonomy and skill acquisition in a controlled and supervised environment. Alternative training methods include cadaveric training, computer simulations and virtual reality but are limited by cost and availability. Cognitive simulation is a cheap and effective alternative training tool. The high quality images and supplementary procedural training material on the OrthOracle platform can be developed for the purpose of cognitive simulation in hand and orthopaedic surgery.

Lorenza Caggiati, Henk P Giele

University of Oxford, UK

Background: Psycholgists and body language specialists explain that hand holding is determined by dominance in a relationship. However, we seek to determine the scientific basis of hand holding. Purpose: This study is aimed to study the scientific basis of holding hands. To determine if placing the hand in front is a mere consequence of physiological adjustment or relates to psychological dominance. Material and methods: Couple observations were performed in three cities (Oxford, Venice and Rome) as well as in magazines and web-sites. A total of 300 couples were analyzed by considering body height, sex and age. Couples with at least one subject obese or afflicted with evident neurologic or musculoskeletal disease were excluded. The study cohort included also couples of two adults, two children or one adult and one child. These preliminary findings were then correlated to those obtained in 30 couples of voluntaries by observing their holding hands in normal conditions and after putting the shorter one on a step (16-18 cm). Results: In 92% of cases, the taller person puts the hands in front. This was particularly evident when the difference in height was greater than 10 cm. In 26/30 couples, to move the shorter person on the step provoked the inversion of the hanging behaviour. Conclusion: our findings disagree with the common opinion that the position of the hands during hanging depends upon psychic dominance. Our findings suggest that in most cases the taller puts the hand in front of that of the shorter because he extends the arm and naturally he is taken to pronate it. In turn, the shorter has to flex the arm to reach the hand of the taller partner and he physiologically pronates it.

Nerve compression (49 abstracts)

Sze-Ryn Chung, Robert Yap Tze-Jin, Andrew Yam Kean Tuck

Department of Hand Surgery, Singapore General Hospital

Camitz abductorplasty is the most commonly used tendon transfer in patients with severe carpal tunnel syndrome with significant muscle wasting and loss of opposition. This procedure requires a long incision in the palm to harvest a strip of palmar aponeurosis to lengthen the palmaris longus tendon, allowing it to reach the abductor pollicis brevis insertion. Several complications have been attributed to this extensive dissection in the palm. We describe a minimally invasive palmaris longus abductorplasty using a strip of flexor carpi radialis tendon graft to achieve the necessary length. This can be done together with endoscopic carpal tunnel release in patients with severe carpal tunnel syndrome. In our experience, this operation achieves the same results as the Camitz transfer with less scarring and less risk of complications.

Karim Latrach Tlemsani, Sabeur Saadi, Khezami Mounira, Rafrafi Abderrazak, Lotfi Nouisri

The Main Training Military Hospital Tunis, Tunisia

Objective Ulnar neuropathy at elbow is the second most common peripheral nerve compression syndrome after the median nerve at the wrist. The surgical management of this affection proposes several procedures. The purpose of this study is to assess the long-term results of a series of 39 patients suffering of cubital tunnel syndrome exclusively treated with anterior subcutaneous transposition in order to provide predictive elements of outcome. Methods In a retrospective study, 39 patients with the diagnosis of cubital tunnel syndrome were submitted to anterior subcutaneous transposition, from January 1998 to December 2007. Preoperative clinical severity and postoperative assessment and satisfaction were appreciated using the British Medical Research Council scale after a mean follow-up duration of 18 months. All patients performed anterior subcutaneous transposition. Results According the British Medical Research Council scale, the patients were distributed into 3 groups: 18 patients had a beginning form with a mean scale of S2M4, 12 a medium form with a scale of S2M3 and 9 severe form with a mean scale of S2M2. Postoperative results were reported using Bishop rating system. Outcome was good in 18 patients (S4M5), fair in 15 (S3M4) and poor in 6 (S2M2). Neither surgical complications nor recurrences were recorded. The main finding was the significant correlation between preoperative neurological status and the postoperative outcome. Conclusion The nerve decompression, in the context of cubital tunnel syndrome, with anterior subcutaneous transposition have proven it efficiency in term of surgical safety and functional outcome even in advanced stage of the disease. A randomized prospective study, including several surgical techniques, could confirm our findings.

Ronit Wollstein, Duffield Ashmead, Lois Carlson,Haruko Okada, Jonathan Macknin, Steven Vantler Naalt

1 New York University, NY, USA: 2 The Hand Center, CT, USA

Purpose: Trigger finger (TF) and carpal tunnel syndrome (CTS) are common hand conditions that often occur together with an unclear relationship. While some studies conclude that trigger fingers occur as a result of carpal tunnel release (CTR), others found that they present concurrently. We believe that the reason trigger fingers tend to develop following CTR is due to an underlying tendency that is exacerbated by post-operative edema. It is possible that when a carpal tunnel release is done, the bursae within the carpal tunnel become edematous. This edema may extend distally and cause friction at the Al pulleys. The purpose of this study was to evaluate the prevalence and timing of trigger finger development after open CTR. Methods: Retrospective review of 497 patients who underwent open CTR by a single surgeon. Two hundred and twenty-nine charts were included in the study for analysis. Patients were further assessed for age, gender, handedness, BMI, workers compensation status and history of diabetes or hypothyroidism. We also analyzed the specific digit involved and the timing to the development of triggering after CTR. Results: Thirty-one patients developed triggering after carpal tunnel release (13.5%). Mean population age was 52.5 (14.0). Follow up ranged from 1-53 months with a median follow up of 6 months (IQR = 2,13). The thumb was the most common digit to trigger (42.22%). followed by the ring finger 24.44% (11 cases), middle finger 22.22% (10 cases), 8.89% little finger (4cases), and index finger 2.22% (1 case). Trigger thumb occurred at a median of 3.5 months (3,6 months) post-operative while other digits occurred at a median of 7.5 months (4,10.25) after surgery (p=0.022). No clear risk factors to trigger finger development after CTR were identified. Conclusions: 1) In tandem with recent literature, our results suggest that a trigger thumb develops more frequently and earlier than other trigger digits after an open carpal tunnel release. 2) Further study can reveal the mechanism of combined occurrence and may enable specific treatment such as local anti-inflammatory medication following carpal tunnel surgery. 3) We suggest educating prospective carpal tunnel surgery patients that the risk of trigger thumb and trigger digits following CTR is high.

Samuel George 1,2, Zahid Hassan 1,2

1 Whiston Hospital, Liverpool, UK; 2 Alder Hey Children's Hospital, Liverpool, UK

Introduction: Various anomalies of the palmaris longus have been described throughout history dating back to the 16th century. A well-known variation is agenesis which is prevalent in 12.8% of people. The muscle can also be digastric, duplicated, bifid or reversed. Symptomatic presentation of these variations are extremely rare and ee present a case of median nerve compression caused by a bifid reversed palmaris longus in a 9 year old girl which is the youngest reported case in the literature. Case Report: A 9-year old girl and active gymnast presented to us with an eight-month history of worsening left wrist pain and swelling with paraesthesia in the median nerve distribution, exacerbated by physical activity. She was a keen gymnast but there was no history of trauma to the affected limb. Clinically she had a bluish swelling on the distal volar wrist with very little active or passive wrist movement. After failure of conservative treatment, she was investigated with an ultrasound scan and Magnetic Resonance Imaging(MRI). The ultrasound scan and the MRI revealed an epifascial/reversed palmaris longus which was originating from the FDS perimysium and inserting in the flexor retinaculum and palmar aponeurosis. We present high resolution radiographic images and comparison with the contralateral limb demonstrating this. Surgical exploration revealed a bifid reversed palmaris longus as described causing displacement of the median nerve. The entire muscle was excised and the median nerve and carpal tunnel were released. At 3-month follow-up the patient had full resolution of symptoms, and now had full range of movement. She has gone back to full physical activity and gymnastics. Conclusions: Surgeons need to be aware of the possible variations of the palmaris longus muscle both when operating on a limb as well as when assessing patients in clinic as they’re appearances can mimic vascular malformations while the symptoms can be mistaken for chronic compartment syndrome. A good history identifying exacerbating factors and appropriate investigations as well as awareness of anomalies can ensure these patients are treated quickly and effectively.

Takakazu Hirayama, Masaaki Shindo

Department of Orthopedic Surgery, Shindo Hospital, Asahikawa City, Hokkaido, Japan

Objective: To report a new technique using the roof of the cubital tunnel as a ligamentofascial sling to maintain anterior position during ulnar nerve transposition. Methods: Operative Technique: The roof of the cubital tunnel is formed by a ligamentofascial band composed of the cubital tunnel retinaculum and antebrachial fascia that extends from the olecranon to the medial epicondyle. This technique creates a non-compressive ligamentofascial sling using the released band. An 8- to 10-cm curved, longitudinal incision is centred over the cubital tunnel. The medial antecubital cutaneous nerve is identified and preserved. The ulnar nerve and its vascular bundle are identified just proximal to the ligamentofascial band and dissected distally from the posterior aspect of the band. The band is incised medially to raise a 3-cm wide and 3-cm long flap based on the medial epicondyle, and tailored to wrap around the ulnar nerve and its vascular bundle. The origin of the flexor-pronator muscles is identified, and a 3-cm incision is made to the fascia overlying the muscles along this line. After the ulnar nerve and its vascular bundle are transposed anteriorly to the medial epicondyle, the band is loosely attached to the incised fascia overlying the flexor-pronator muscles to function as a sling. A bulky elbow dressing is maintained postoperatively and patients are encouraged to resume elbow motion immediately. Patients: Twenty-three elbows in 21 patients were assessed for primary chronic cubital tunnel syndrome without restriction of excursion or fixed deformity. Of the 23 elbows, 12 had no specific aetiology (idiopathic) and 11 showed ulnar nerve (sub)luxation. According to McGowan’s classification of severity, 6 elbows were grade I (minimal), 12 were grade II (intermediate), and 5 were grade III (severe). Results: Seventeen elbows were available for direct follow-up and 6 were contacted for a telephonic survey. The mean follow-up period was 3 years (range, 4 months to 9 years). According to the Messina grading system, 91% of the elbows had excellent or good results and only 9% had fair results. Pain was completely relieved in all 23 elbows, with improved sensation and motion. Patients with excellent or good results recovered sensitivity and muscular activity within several months. However, severely affected elbows showed little improvement. None of the cases required secondary surgery or had postoperative posterior nerve subluxation, and no injury to the medial antebrachial cutaneous nerve was observed. Conclusions: Posterior subluxation after anterior transposition is an uncommon but serious complication. Our new technique addresses this complication at the time of surgery. The ligamentofascial sling provides a wide, non-compressive flap, without tenting or kinking of the nerve. This prevents nerve instability, without restraining excursion during elbow motion. This procedure is indicated for primary chronic cubital tunnel syndrome, but is contraindicated in patients with an insufficient ligamentofascial band or an elbow with a severe fixed deformity.

Amaris Lim, Dawn Chia

Hand and Microsurgery Section, Department of Orthopaedics, Tan Tock Seng Hospital, Singapore

Objective: Distal radius fractures may distort carpal tunnel anatomy, and are a relative contraindication to endoscopic carpal tunnel release (eCTR). This study aims to evaluate the anatomical considerations of eCTR in patients with previous distal radius fractures, and compare the use of open release (OCTR) and eCTR in these patients. Methodology: This is a retrospective study conducted in a tertiary hospital in Singapore between May 2008 and February 2016. This study included all patients aged above 16, with a history of distal radius fractures, who underwent CTR. Parameters studied included patient biodata, risk factors for CTS, AO classification and treatment of the fractures, as well as CTR treatment outcome. Statistical analysis was conducted using the chi-squared test. Results: Among 5292 patients who had a history distal radius fractures, 40 had carpal tunnel syndrome requiring surgical release. Of these, 67.5% underwent OCTR, and 32.5% underwent eCTR. The eCTR patients most commonly had AO Type A fractures (66.7%), while the OCTR patients most commonly had Type C fractures (46.2%). 53.3% of the eCTR patients had their fractures treated conservatively, while 80.0% of the OCTR patients had undergone open reduction and internal fixation (ORIF). Within the eCTR cohort, radiological parameters post-fracture-healing were as follows: average volar tilt -2.6°, average radial height 8.49mm, average radial inclination 17.2°, and average ulnar variance -0.28°. The post-operative results of both the eCTR and OCTR patients were comparable. All patients experienced improvement in CTS symptoms at final follow-up. Conclusion: We recommend that eCTR can be used in the treatment of patients with previous distal radius fractures who now present with CTS.

Chul-Hyung Lee, Cheol-U Kim, Deuk-Hee Jung

Daejeon Sun Hospital, Daejeon, South Korea

Introduction Carpal tunnel syndrome is the most common nerve compression disorder in the upper extremities. Several variations of the thenar branch have been reported. Therefore, careful attention should be paid to the damage of the thenar branch when performing carpal tunnel release. There are few reports about iatrogenic thenar branch injury. We report a patient suffering from thenar branch injury after carpal tunnel release. The patient underwent delayed thenar branch repair at 138 days after carpal tunnel release, and the nerve function was restored. Case description A 49-year-old female patient with tingling of both hand in January 2016 underwent an electromyography with a positive Tinel and Phalen sign on physical examination. Electromyography showed bilateral carpal tunnel syndrome. Bilateral carpal tunnel release was performed with longitudinal incision. Symptoms improved but, the patient complained of discomfort in the left thumb at the 12 week follow-up. At the 16 week follow-up, the left thenar compartment showed weakness, and atrophy was observed. In electromyography abductor pollicis brevis innervated by thenar branch showed no motor conduction. On the 138th day after carpal tunnel release, median nerve exploration was performed. Adhesion of surgical site was not severe, and release was sufficient. The proximal part of the disconnected thenar branch was attached to the released transverse carpal ligament. The thenar branch was carefully detached from the transverse carpal ligament. The distal part of the disconnected thenar branch was searched in the thenar compartment and the adipose tissue between the muscle was observed and the adipose tissue was carefully removed to find the nerve tissue that entered the thenar compartment. The pathway of disconnected thenar branch was transligamentous variation. Both sides of the disconnected thenar branch had a contracture, so that direct repair was performed with tension slightly. At 6 months post-operative follow-up, the patient said that the power of the thumb was better and the electromyography showed motor conduction. At last follow-up, the patient had no atrophy and the electromyography was restored similar to that before carpal tunnel release. Discussion Several variations of the thenar branch have been reported. Our case is transligamentous variation. Especially in the case of this type of variation, care must be taken when releasing the carpal tunnel. If the branch is damaged, I think it’s better to repair it. There are some reports that delayed nerve repair has poor results. In our case, delayed repair was performed at 4 months after nerve injury, but motor function was restored. Even if the timing is delayed, I think it would be better to try repair. There was concern about slight tension on the repaired thenar branch, which might adversely affect the recovery, but the patient recovered normal function. If direct repair is not possible or if tension is predicted to be too strong during direct repair due to contracture, nerve graft may be considered. After nerve repair, the patient showed improvement after 6 months. In this case, it is good to observe the recovery of nerve function through electromyography every 3 months after surgery.

Shin Woo Choi 1, Jae Kwang Kim 1, Young Ho Shin 1, Joo-Yul Bae 2

1 Asan Medical Center,University of Ulsan College of Medicine, Seoul, South Korea; 2 Gangneung Asan Hospital,University of Ulsan College of Medicine, Gangneung-si, South Korea

Purpose: The purpose of this study was to investigate whether psychological status is associated with the symptom severity or functional disability of carpal tunnel syndrome (CTS) patients. Patients and Methods: Sixty patients diagnosed with CTS and treated with carpal tunnel release (CTR) were asked to complete a self-administered questionnaire consisting of three validated measures obtained before and 3 months after surgery. The Boston Carpal Tunnel Questionnaire (BCTQ) was administered to assess symptoms (BCTQ-S) and functional disabilities (BCTQ-F), and the Center for Epidemiologic Studies Depression Scale (CES-D) and Pain Anxiety Symptoms Scale (PASS) were administered to assess depression and pain anxiety. The preoperative scores obtained on the questionnaires and those obtained 3 months after CTR were compared. Bivariate and multivariable regression analyses were performed to determine whether the variance of CES-D and PASS scores are associated with the variance of symptom severity or functional disability of CTS patients. Results: The CES-D and PASS scores significantly improved after surgery. In a multivariable linear regression model, the CES-D and PASS scores were significantly associated with the BCTQ-S scores both before and 3 months after surgery. In addition, the changes in CES-D and PASS scores were significantly associated with the change in BCTQ-S scores. Conclusion: The depression level and pain anxiety of CTS patients were significantly improved at 3 months after CTR. The depression level and pain anxiety were significantly associated with the CTS symptoms both in preoperative and postoperative period. In addition, the improvement of depression and pain anxiety were associated with the improvement of CTS symptoms. Thus, our findings indicate that the depression and pain anxiety of CTS patients are associated with the symptom severity of CTS.

Takao Omura 1, Tomokazu Sawada 2, Michihito Miyagi 1, Yukihiro Matsuyama 1

1 Hamamatsu University School of Medicine; 2 Shizuoka City Shizuoka Hospital

Objective Cubital tunnel syndrome (CuTS) is symptomatic ulnar nerve dysfunction at the level of the elbow resulting from a combination of compression, traction, and friction. In Japan, the most common cause for CuTS is osteoarthritis (OA) with the prevalence rate of 64%, followed by Constriction of arcuate ligament of Osborne (9%). Due to this etiology, the prevalence of patients with female CuTS is much lower in comparison with female CTS patients. The purpose of this study is to identify the prevalence and the characteristics of female CuTS patients. Methods 99 patients who presented sensory disturbance of the little finger plus ulnar half of the ring finger and operated under the diagnosis of CuTS at Hamamatsu University School of Medicine were included in this study. All the patients were examined with a plain radiographic for the prevalence of OA of the elbow and all the subjects except one, who had a pace maker of the heart received motor conduction velocity (MCV) recordings. The prevalence of female patients, the cause, the initial severity of CuTS and MCV were analyzed in comparison with the male patients. Results There were 20 female and 79 males, and the prevalence of female patients was 20.2%. The average age was significantly higher in the female patients (64.8 ± 2.5) in comparison with the male patients (59.2 ± 1.5). The most common cause was OA in 11 females (prevalence rate 55%) and in 64 males (81%), followed by trauma of the elbow in 6 females (30%) and 7 males (12.7%) which was significantly different between the two groups. Interestingly, the average age of patients with OA was significantly higher in female patients in comparison with the male patients (70.4±3.03 vs 62.2±.52).According to McGowan’s classification, there was no significant difference in the severity of CuTS. Two females (10%) and 6 males (7.6%) were classified as grade I, 11 females (55%) and 75 males (41%) were classified as grade II and 7 females (35%) and 32 males (41%) were classified as grade III. There was also no significant difference in the preoperative MCV measured between the elbow which was 27.9±3.4m/s in females and 32.1±1.6m/s in males. Conclusions According to Adkinson et al, the prevalence of female patients operated for CuTS was 52% in Florida State, which could be reflecting the cultural or racial difference between the United States and Japan. Our results showed that the prevalence of female CuTS patients are much lower in Japan and that they are significantly older, with lower incidence of OA in comparison with male patients.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

BACKGROUND: Open carpal tunnel release (OCTR) and cubital tunnel release (OCTR) is a common procedure in nerve decompression surgery. This study aimed to compare the efficacy and patient satisfaction of wide-awake local anesthesia, no tourniquet (WALANT) technique versus traditional anesthesia method with the arm tourniquet in OCTR and OCTR MATERIAL AND METHOD: 46 patients (62 hands) underwent OCTR, and 38 patients (42 elbows) underwent OCuTR. Patients were divided into two groups (OCTR, OCuTR) and then each group was subdivided according to their anesthesia method and arm tourniquet use. 1. OCTR (n=46patients, 62hand): 20 hands were in wide-awake group (WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet, 22 hands were in the local anesthesia group (LA) who received lidocaine alone as a local anesthetic agent with a 250-mmHg tourniquet application and 20 hands were in the general anesthesia group (GA) and a 250-mmHg tourniquet application. 2. OCuTR(n=38patients,42elbows): 20 elbows were in the wide-awake group(WA), who received epinephrine-contained lidocaine as a local anesthetic agent, without tourniquet and 22 elbows were in the general anesthesia group(GA) and a 250-mmHg tourniquet application. Perioperative discomfort was assessed using a visual analog scale (V.A.S). The Michigan Hand Outcomes Questionnaire was used at OCTR to determine hand-specific disability. The subjective outcome was assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire at OCuTR. Adverse events during surgery were also recorded. Results: There were no perceived outcome differences at six weeks as evidenced by the Michigan Hand Outcomes Questionnaire between any of OCTR individual groups (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in OCTR(LA), (GA) group than OCTR (WA) group(p < 0.05). There were no perceived outcome differences at final follow up as evidenced by the quick DASH score between any of OCuTR individual groups (p > 0.05). The perioperative pain(preoperative surgical site injection, Intraoperative, postoperation) during the first 1week after surgery were higher in OCuTR (GA) group than OCuTR (WA) group(p < 0.05). Conclusions: a Wide-awake approach for open Carpal and Cubital tunnel release surgery offers better comfort for patients and reliable technique that eliminates the need for general anesthesia, removes the need for a tourniquet.

Ilka Anker 1, Gert S. Andersson 2, Malin Zimmerman 1, Helen Jacobsson 3, Lars B. Dahlin 1,4

1 Department of Translational Medicine – Hand Surgery, Lund University, Malmö, Sweden; 2 Department of Neurophysiology, Lund University, Skåne University Hospital, Lund; 3 R&D Centre Skåne, Skåne University Hospital, Lund; 4 Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden

Objective: Ulnar nerve entrapment at the elbow is common, but the knowledge about the outcome of revision surgery for recurrent or persistent entrapment is scarce. The outcome of subcutaneous (SCT) and submuscular (SMT) ulnar nerve transpositions, both primary and revision surgeries, due to ulnar nerve entrapment at the elbow was studied with the aim to identify predictors of revision surgery. Methods: All cases with an ulnar nerve entrapment at the elbow that were surgically treated at our department between 2004 and 2008 were retrospectively studied. Out of the 285 primary surgeries, 43 ulnar nerve transpositions (15 SCT and 28 SMT) and out of 52 revision surgeries, 44 ulnar nerve transpositions (7 SCT and 37 SMT), were identified. Medical records, including electrophysiological evaluations performed by a neurophysiologist, were reviewed and the postoperative outcome was graded as: 1) cured/improved and 2) unchanged/worsened symptoms, based on a simple patient-reported and surgeon-evaluated outcome, which correlates to patient-rated outcome measures, such as QuickDASH, at one year post-surgery. Results: Revision surgery cases had a high frequency of concomitant systemic diseases (p<0.001), musculoskeletal conditions (p=0.029) and carpal tunnel syndrome (p=0.048) compared to the primary surgery cases. Both primary (79%) and revision SMT (76%) cases had a high frequency of ulnar nerve subluxation. Primary SMT cases had a higher frequency of an ulnar nerve disorder observed through electrophysiological examination (p=0.045), while revision SMT cases had normal electrophysiological findings or a reduced ulnar nerve conduction velocity (not significant; p=0.10). The general satisfactory rate was 79-93% of the cases undergoing primary transposition surgery and the corresponding values after revision transposition surgery were 73-86%. Conclusions: Patients who have comorbidity with other systemic diseases, other musculoskeletal conditions or a concomitant carpal tunnel syndrome have a higher risk to be affected by ulnar nerve entrapment relapse needing revision surgery. Assessment should be made by the treating surgeon whether the ulnar nerve shows a tendency to perioperative subluxation at the primary surgery for ulnar nerve entrapment at the elbow. If such a subluxation is present, transposition of the ulnar nerve in the same surgical séance is suggested to minimize the need of revision surgery.

Sang Ho Kwak, Jung Yun Bae, Sang Woo Kang, Seung Jun Lee, Kuen Tak Suh

Pusan National University Yangsan Hospital, Korea

Objective Simple decompression, which is a treatment option for idiopathic cubital tunnel syndrome (ICTS), is an effective and safe procedure; however, nerve traction and instability are potential problems. Although several technical modifications have been developed for anterior transposition and medial epicondylectomy, few have been reported for simple decompression except for Osborne’s modification (the repair of Osborne’s ligament beneath the ulnar nerve after decompression). In this study, we compared Osborne’s modified simple decompression (MSD) with conventional simple decompression (CSD) and wanted to assess how the repair of Osborne’s ligament affects the ulnar nerve length (UNL), determine whether there are differences in the ultrasonographic grade of ulnar nerve instability (UNI) before and after each technique (MSD and CSD), and assess whether there are significant differences in the clinical outcome between the two techniques at 24 months postoperatively. Methods Between 2013 and 2015, we performed surgical treatment on 80 patients presenting with cubital tunnel syndrome. We excluded patients with previous trauma (n=8), limited range of motion (<90°, n=2), severe degenerative arthritis (n=5), revision surgery (n=2), and a systematic disorder (n=7). Patients treated conservatively (n=4) or followed for <24 months (n=6) were also excluded. Finally, 46 patients diagnosed with ICTS were included in the study. Twenty-eight patients (24 men, 4 women; mean age, 51.1 years) underwent MSD and 18 patients (11 men, 7 women; mean age, 55.9 years) underwent CSD. In the MSD group, UNL was measured from the intermuscular septum to the first motor branch intraoperatively. Measurements were performed during full elbow flexion and extension before and after the repair of Osborne’s ligament. UNI during elbow motion was classified using ultrasonography as Grade 0, Grade 1, and Grade 2 instability preoperatively and at 24 months postoperatively. Visual analogue scale (VAS) score; quick disability of the arm, shoulder, and hand score (quick DASH); grip power; pinch power; McGowan grade; and Wilson and Krout criteria were recorded preoperatively and at 24 months postoperatively. Results The UNL during full elbow flexion was significantly reduced after the repair of Osborne’s ligament, in the MSD group (after repair, 11.7 ± 1.7 cm; before repair, 12.4 ± 2.4 cm; p <0.001). At 24 months after the surgery, the MSD group had a lower grade of UNI than the CSD group (p=0.019). The VAS score, quick DASH score, grip power, pinch power, McGowan grade, and Wilson and Krout criteria were not significantly different at 24 months postoperatively. Conclusions UNL during elbow flexion was significantly reduced after the repair of Osborne’s ligament, and the MSD group had a lower grade of UNI compared to the CSD group. In addition, the clinical outcome was similar between the two groups through 24 months of follow-up. Therefore, considering the possibility of nerve traction and instability after CSD, MSD could be used as a possible surgical option to treat ICTS.

Myung Ho Lee, Hyun Sik Gong, Min Ho Lee, Seung Hoo Lee, Jihyeong Kim, Goo Hyun Baek

Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea

Objective: Studies suggest that vitamin D supplementation improves myelination and recovery after nerve injuries. The purpose of this study was to evaluate whether vitamin D supplementation could be helpful for better surgical outcomes in patients with both carpal tunnel syndrome (CTS) and vitamin D deficiency. Methods: We retrospectively reviewed 84 vitamin D deficient women with CTS who underwent carpal tunnel release and then received daily supplementation of 1000 IU vitamin D for 6 months. At baseline and 6 months postoperatively, serum vitamin D levels were measured as were symptom severity in terms of the Disabilities of the Arm, Shoulder and Hand (DASH) score, neurophysiologic severity with motor conduction velocity (MCV), and grip and pinch strengths. We evaluated whether improvement of vitamin D level at 6 months was associated with better surgical outcomes. Results: The mean vitamin D level improved from 12.0 to 24.5 ng/mL at 6 months postoperatively. Fifty-nine patients (70%) became vitamin D non-deficient (≥ 20 ng/mL) and 25 were still vitamin D deficient (< 20 ng/mL). Patients who were not deficient in vitamin D levels at 6 months had greater improvement of mean DASH score than patients who were still vitamin D deficient (-21 vs. -10, P = 0.023). There were no differences in MCV and grip and pinch strengths between the two groups. Vitamin D levels at 6 months were found to have significant correlation with the mean DASH score at 6 months (r = -0.349, P = 0.003) and also with the mean improvement of DASH score (r = -0.263, P = 0.041). Conclusions: This study suggests that correction of vitamin D deficiency is helpful for better surgical outcome in women with CTS and vitamin D deficiency. Further randomized comparative studies are necessary to determine whether vitamin D supplementation is helpful for vitamin D non-deficient patients.

Ema Onode 1, Takuya Uemura 1, Kosuke Shintani 1, Takuya Yokoi 1, Mitsuhiro Okada 1, Kiyohito Takamatsu 2, Hiroaki Nakamura 1

1 Osaka City University Graduate School of Medicine, Japan; 2 Yodogawa Christian Hospital, Japan

Objective: Adhesion neuropathy of the median nerve with persistent wrist pain can be a challenging problem. Current opinion dictates that coverage of the median nerve with well-vascularized soft tissue is important after secondary neurolysis. In the present study, we introduced a novel method using a radial artery perforator (RAP) adiposal flap for coverage of the neurolysed median nerve to minimize reformation of scar adhesion. Methods: Eight patients, who had previously undergone median nerve surgeries, repair of a median nerve laceration or primary open carpal tunnel release, were included. Because all had substantial median nerve hypersensitivity at the wrist, the secondary neurolysis with RAP adiposal flap was performed. In short, after careful neurolysis of the scared median nerve, the RAP adiposal flap was elevated and rotated to envelop the nerve without sacrificing of the radial artery. The average age was 65 years (range 42 - 89 years). The average interval between the prior nerve surgery and re-exploration was 19 months. The visual analogue pain scale score, presence of a positive tinel sign at the wrist, wrist range of motion, scores of the quick Disabilities of the Arm, Shoulder and Hand (DASH) were examined both preoperatively and at the final follow-up. The average follow-up was 13 months (range 4 – 28 months). Results: The RAP adiposal flap size ranged from 750 to 1200 mm2 (average 1088 mm2) and was enough to cover the exposed median nerve. After surgery, the positive tinel sign on the wrist disappeared in all patients and the mean visual analog pain scale score decreased. The fat pads remained beneath the skin and were detected in magnetic resonance imaging at the final follow up exam. Average arc of wrist motion and average score of the quick DASH improved postoperatively. There was no recurrence of median nerve adhesion neuropathy. There was a slight pigmentation of the skin and a mild surface infection but no major complications. Conclusions: This is the first report of the application of the RAP adiposal flap for the coverage of the neurolysed median nerve, modified to be thinner and softer than the RAP adipofascial flap. The results of interposing the RAP adiposal flap between dysesthetic volar wrist skin and the neurolysed median nerve have been successful in terms of both pain relief and restoration of hand function.

Carlos Henrique Fernandes 1, João Baptista Gomes dos Santos 1, Luis Renato Nakachima 1, Marcela Fernandes 1, Giana Giostri 2, Trajano Sardenberg 3, Henrique Ayzemberg 4, Jeffferson Braga Silva 5, Rodrigo Guerra Sabongi 1, Estevão Juliano Lopes 1, Jaime Piccaro Erazo 1, Thais Silva Barroso 1, Eduardo Murilo Novak 2, Suzilaine Ramos de Oliveira 2, Denis Varanda 3, Andrea Christina Cortopassi 3, Valdir Steglich 4, Tiago Salati Stangarlin 4, Flávio Hermano Bezerra Araujo 4

1 Hospital São Paulo/Universidade Federal de São Paulo, Brazil; 2 Hospital Universitário Cajuru/PUCPR, Brazil; 3 Hospital das Clinicas da Faculdade de Medicina de Botucatu – UNESP, Brazil; 4 Instituto de Ortopedia de Traumatologia de Joinville, Brazil

Objectives Traumatic lesions of the hand can correspond to 10 to 30% of all the services provided in the emergency room. Our objective was to study the characteristics of accidents involving trauma in the hand, wrist, forearm and elbow, performed during Carnival party in 2017. Method A questionnaire was drawn up in which data were collected on the patient's age and gender, whether or not there was use of licit or illicit drugs, characteristics of the trauma, type of agent causing the trauma, type and anatomical location of the lesion. The questionnaire was sent to all 31 Hand Surgery Training Centers accredited by the Brazilian Society of Hand Surgery for data collection. Results A total of 104 consultations were performed in 5 hospitals. The majority of the patients were male (61.5%), with a mean age of 36.14 years. Twenty patients (19.23%) had previous use of some type of drug before the accident. Regarding the etiology of trauma, the following were the direct traumas (31.73%) and falls (25%). The most frequent diagnosis was fracture, 52 (44.44%) and the distal radius fracture was the most common (14.52%). Conclusion Despite the importance of this research for the specialty of Hand Surgery, there was little adherence to the collection of these data. We believe that there is a need for financial support for this type of research so that we can have the participation of a larger number of hospitals with complete coverage of the Brazilian territory.

Carlos Henrique Fernandes, Lia Miyamoto Meirelles, Marcela Fernandes, Luis Renato Nakachima, João Baptista Gomes dos Santos, Flavio Faloppa

Hospital São Paulo/Universidade Federal de São Paulo/ Hand Surgery Unit, Brazil

Objective: An intra-individual comparison of surgical results between the open and endoscopic release was performed in patients with bilateral carpal tunnel syndrome, each of the hands operated by one of the technique. Material and Methods: Fifteen patients (30 hands) were evaluated in the preoperative, second week, first month, third month and sixth months in the postoperative period. The patients were evaluated by Boston questionnaire, visual analog pain scale (VAS) and grip strength. A comparative study was performed between the endoscopic and open surgeries at each of the follow-up times, and the evolution of each surgery over time. Results: Evaluating the symptoms between endoscopic and open release in each of the follow-up times (pre-operative, 2nd week, 1st month, 3rd month and 6th month), for the strength, only the tripod strength suffered difference in the 6th month, in the other follow-ups there were no differences. There were no differences in pain scores. The Boston questionnaire showed differences in the 1 st and 6 th months in the SSS(symptom severity score) and no change in the FSS (functional status score). Both surgeries behave in a similar way, as well as all the requirements measured over time. Discussion: Although many articles compare the different techniques, few were compared in patients operated bilaterally. The advantage is that we eliminate the individual variation to evaluate the measures between the different techniques. Conclusion:We concluded that using the intra-individual evaluation we did not find differences between open and endoscopic release in the evaluation of pain intensity, Boston protocol score and strength measurement.

Young Hak Roh 1, Hyun Sik Gong 2, Goo Hyun Baek 2

1 Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea; 2 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective: The aim of this study was to compare the efficacy of a corticosteroid injection for the treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud’s phenomenon. Methods: In a prospective study, 139 patients with CTS were treated with a corticosteroid injection (10 mg triamcinolone acetonide); 34 had Raynaud’s phenomenon and 105 did not . Grip strength, perception of touch with a Semmes-Weinstein monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the injection. Results: The two groups had similar baseline BCTQ scores, but the scores in the Raynaud’s phenomenon group were significantly higher than those in the control group at 12 and 24 weeks after the injection. Throughout the 24-week follow-up, there were no significant differences in the mean grip strength between the groups, whereas the mean Semmes-Weinstein monofilament sensory index for the control group was significantly higher than that of the Raynaud’s phenomenon group. The mean CISSs were not significantly different between the groups at baseline and at 24 weeks. After 24 weeks, 11 patients (32%) in the Raynaud’s phenomenon group and 16 (15%) in the control group required carpal tunnel decompression (p = 0.028). Multivariable analysis indicated that concurrent Raynaud’s phenomenon (odds ratio (OR) 2.6) and severe electrophysiological grade (OR 2.1) were independently associated with a failure of treatment after a corticosteroid injection. Conclusions: Although considerable improvements in symptoms will probably occur in patients with Raynaud’s phenomenon who have CTS, they have higher risk of poor functional outcomes and failure of treatment than those without Raynaud’s phenomenon.

Alexander Schuetz

Sporthopaedicum Straubing - Regensburg, Straubing, Germany

Introduction: The most common peripheral neuropathy in upper extremities is caused by the idiopathic carpal tunnel syndrome (CTS). In Germany, if invasive decompression surgery is needed, it is usually performed with an open carpal tunnel release operation (OCTR) and not with endoscopic carpal tunnel release (ECTR). The ECTR is suspected to show a flat learning curve and to be technically more demanding than the OCTR. Worldwide, the one-portal technique by Agee has become a standard procedure in minimal invasive operations. We wanted to verify the learning curve and any early complications while establishing this technique in our clinic. Methods: From April to November 2017, in a pilot study, 52 patients with idiopathic CTS were operated in a single center by one surgeon using the one-portal ECTR-procedure. The operative time was measured, as well as any remaining hematoma (score: 0=none-5=revision necessary) at the time of stitch removal 12 days after surgery. The postoperative pain level was evaluated by using the VAS score (0-10). Regression of the typical CTS symptoms such as nocturnal numbness and pain (NMP) was also monitored. Results: In the first 30 patients, greater variabilities in the operative time from 6 to 27 min. were recorded. In this period, 2 ECTR-procedures were converted into an open surgical approach, owing to unclear intraoperative conditions. In the first third of 52 patients (1-17), the average operative time was 11.8 min., in the second third (18-35) 8.0 min. and in the last third (36-52) 5.5 min. were needed. There was a trend to greater postoperative hematomas and pain in the first 2/3rd. of the patients. Operative revisions, due to complications like hematoma, were not observed. There were no complications assessed, such as iatrogenic nerve or tendon injuries. By all patients, the NMP disappeared immediately post-operatively. Summary: In the present study, at least 30 endoscopic operations were needed, to achieve a stable and representable process, in order to establish the one-portal ECTR-procedure. By all 52 patients that were included, no major complications or surgical revisions were observed. Thus, these results do not confirm the assumed prolonged learning process while establishing this endoscopic technique in our clinic.

Chae Seungbum

Daegu Catholic University Medical Center, Daegu, South Korea

Abstract Background This study aim is to know the usefulness of the ultrasonography in diagnosis of carpal tunnel syndrome and possibility of replacement of the ultrasonography in diagnosis of the carpal tunnel syndrome instead of electrophysiologic study. Method Fifty one patients with unilateral carpal tunnel syndrome confirmed using Carpal Tunnel Syndrome-6 for the diagnosis of carpal tunnel syndrome were enrolled. Ultrasonography was performed on both wrists by single radiologist who didn’t know the affected side. Electrophysiologic study was perform on the both side by single examiner without any information of the affected side. The cross-sectional area and the ratio of those between the inlet and the outlet was measured on the median nerve of the both side. We compared the accuracy of the ultrasonography and the electrophysiologic study in the diagnosis of carpal tunnel syndrome. Result In patients diagnosed with carpal tunnel syndrome by the carpal tunnel syndrome -6, sensitivity and specificity of ultrasonographic measurement of the median nerve inlet diameter for diagnosing carpal tunnel syndrome was 0.818 mm2 and 0.864 mm2, and cutoff value was 0.105mm2 respectively. Also, the sensitivity and specificity of ultrasonographic measurement of the inlet and outlet diameter for diagnosing carpal tunnel syndrome was 0.886 and 0.886, and cutoff value was 1.29 respectively. The sensitivity and specificity of the nerve conduction study was 0.841 and 0.818, respectively. There were no significant difference in diagnosing carpal tunnel syndrome by ultrasonography or nerve conduction study. Conclusion We conclude that ultrasonographic studies are highly accurates in the diagnosis of carpal tunnel syndrome and the electrophysiologic studies are not necessary in most cases. Keywords : Carpal tunnel syndrome, Diagnosis, Ultrasonograohy, median nerve

Kaori Sugiura 1, Takao Omura 2, Michihito Miyagi 2, Hiroaki Ogihara 3, Tomokazu Sawada 4, Yukihiro Matsuyama 2

1 JA Shizuoka Kohseiren Enshu Hospital, Japan; 2 Hamamatsu Univercity School of Medicine, Japan; 3 Japanese Red Cross Hamamatsu Hospital, Japan; 4 Shizuoka City Shizuoka Hospital, Japan

Objective: Carpal Tunnel Syndrome (CTS) is the most common peripheral compression neuropathy primarily affecting postmenopausal women. Trapeziometacarpal (TMC) arthritis is also commonly seen in postmenopausal women and is currently estimated to affect 1/3 of the women population. Although association between carpal tunnel syndrome and TMC arthritis has been suggested, it is not known how much of the patients with carpal tunnel syndrome have radiographically apparent TMC arthritis. The purpose of this study is to examine the prevalence and the characteristics of CTS in patients with TMC arthritis. Methods: We studied 73 patients (94 hands) who had undergone carpal tunnel release with the clinical and electrophysiological diagnosis between January 2012 and June 2017. The patients consisted of 29 men and 65 women, ranging from 44 to 92 years old, with a mean of 67.2 (44～89)years old. The mean follow up period was 10 months. The diagnosis of TMC arthritis was made based on plain radiographs, and the severity of the arthritis was determined using Eaton’s clacification. Joints with stage2 and beyond were considered to as positive finding of osteoarthritis (TMC+ group). Manual muscle testing (MMT) on abductor pollicis brevis (APB) muscle and distal motor latency (DML) detected on APB was examined for the evaluation of CTS. The characteristics of TMC+ group were compared with the TMC stage 1 and less (TMC-) group. Results: The prevalence of TMC arthritis was 43% in patients with CTS. The mean age for the TMC+ group was 72.0(53～89)years old. According to Eaton’s classification, twenty-four hands were classified as stage2, nine hands were stage3 and eight hands were stage4. TMC- group consisted of fifty-three hands (57%), with a mean age of 63.6(44～83) years old. With electrophysiological study, the mean preoperative DML was 7.29ms for TMC+ group and 7.73ms for TMC- group with 17 and 13 undetectable compound muscle action potential (CMAP) in TMC+ and TMC– group. There was no statistical difference between the two groups. Similarly, the mean postoperative DML was 4.82ms for TMC+ group, and 4.72ms for TMC - group, with 8 and 7 CMAP undetectable hands, showing also no statistical difference. However, the mean final MMT of APB was 3.87 in TMC- group, while 3.12 in TMC+ group. Furthermore, in cases with severer stage of TMC arthritis (Eaton stage3,4), the mean postoperative MMT of APB was limited to 2.76, which was statistical significance in comparison with the TMC- group. Conclusions: We conclude that the prevalence of CTS and TMC arthritis was 43% and that the presence of TMC arthritis in patients with CTS negatively affects the postoperative recovery of the APB muscle.

Ryosuke Ikeguchi, Souichi Ohata, Hiroki Oda, Hirofumi Yurie, Hisataka Takeuchi, Sadaki Mitsuzawa, Bungo Otsuki, Shuichi Matsuda

Department of Orthopedic Surgery, Kyoto University, Japan

Objective Non-surgical treatment is the primary option for hand disease, but the effects of conservative treatment on carpal tunnel syndrome (CTS) are uncertain and the factors predictive of outcome are unclear. The purpose of this study is to investigate the efficacy and prognostic factors of splinting therapy for CTS. Methods From 2006 to 2016, 80 hands of 77 patients diagnosed with CTS were treated with splinting therapy (average age 65.2 years old). Each hand was treated with a nocturnal-wear custom-fabricated wrist splint for eight weeks. The outcomes were investigated retrospectively and logistic regression analysis was used to examine the prognostic factors for the effectiveness of splint treatment. The independent explanatory variables were patient age, disease duration, nocturnal symptoms, physical findings (Phalen test, thenar muscle atrophy and Tinel’s sign), electrophysiological findings ( distal latency and amplitude) and CTS severity. Results Subjective symptoms disappeared in 10 hands (12.5%), improved in 55 hands (68.75%) and worsened or did not change in 15 hands (18.75%). The efficacy rate of splinting therapy was 81.25%. With regard to the prognostic factors, there was a significant relationship between ineffectiveness and patient age when patient age was greater than 80 years; the odds ratio was 0.11 (p=0.0027). There was no significant relationship between ineffectiveness and disease duration, Phalen test, thenar muscle atrophy, distal latency, amplitude or disease severity. Conclusions Splinting treatment for CTS is minimally invasive, and the current study shows that splinting therapy is effective in about 80% of cases. In patients over 80 years of age, however, it does not lead to improvement. CTS severity, physical findings and electrophysiological examination cannot predict the effectiveness of splinting treatment. For CTS patients under 80 years of age, splinting treatment is considered to be the first choice regardless of disease severity.

Andrzej Zyluk, Paulina Zyluk-Gadowska, Piotr Puchalski, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Outcomes of surgery for carpal tunnel syndrome may differ in relation to certain factors like age, duration of symptoms, clinical and electrophysiological severity. The objective of this study was an investigation into the hypothesis that several factors are predictive of results of surgical treatment of the condition. The pre- and postoperative records of 1,117 patients: 909 women (81%) and 208 men (19%) with a mean age of 63 years were analysed. The whole group was divided into subgroups, depending on the variables analysed: sex, age, duration of symptoms, clinical and electrophysiological severity of and presence of comorbidities. The effect of these variables on outcomes of surgery at 6 months was investigated. Results. None of the considered variables had a substantial impact on the results of carpal tunnel release which were sufficiently satisfactory at any circumstances. Slightly poorer outcomes in grip strength were observed in elderly patients, with clinically severest condition and with concomitant comorbidities.

Andrzej Zyluk, Paulina Zyluk-Gadowska, Piotr Puchalski, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

Clinical presentation of carpal tunnel syndrome may differ in relation to certain factors like sex, age, duration of symptoms and severity of compression. The objective of this study was an investigation into the hypothesis that several distinct factors are predictive of the clinical profile for the condition. The records of 1,117 patients: 909 women (81%) and 208 men (19%) with a mean age of 63 years, were analysed. The whole group was divided into subgroups, depending on the variables analysed: sex, age, duration of the condition, severity of symptoms, severity of electrophysiological abnormalities and occurrence or lack of comorbidities. Results. Of all the considered variables, the Levine symptom scores had the greatest impact on the condition’s clinical profile: the higher scores the more severe pain, poorer sensation, weaker grip and worse hand function. Also, ages greater than 80 years had a significant negative effect on most of the considered parameters. None of the remaining analysed variables had a substantial impact on the clinical profile of the condition.

Gyeong Min Kim, Seungjae Shim, Kyu Bum Seo

Jeju National University Hospital, Jeju, South Korea

Introduction Carpal tunnel syndrome is the most common compressive neuropathy in the hand. And lipoma is one of the most common soft tissue tumors. But lipomas are rarely present in the hand, and carpal tunnel syndrome due to compression of lipomas is rarely reported. Case Description A 66 - year - old woman with diabetes mellitus was visited to our clinic with complaints of numbness and mass of the left hand. On physical examination, the mass was palpable near the thenar muscle of the left hand and there was no tenderness. There was no weakening of the grip strength. Electromyography and nerve conduction study were suspected to be median nerve neuropathy at the distal part of the transverse carpal ligament in the left hand. On magnetic resonance imaging of the left hand part, a lobulated mass with fat-like signal intensity was observed and was surrounded by flexor tendons. The proximal portion of the median nerve showed high signal intensity on T2-weighted images and suspected neuropathy. After the incision, a yellow mass that was compressing the median nerve was observed. The mass and epineurium were carefully detached and completely resected. Histological examination confirmed the lipoma. The numbness of the patient's left hand has improved and is currently on follow-up. Discussion If physical examination, electromyography, and nerve conduction study have abnormal findings on one side, it is necessary to consider the possibility of carpal tunnel syndrome due to other causes such as space occupying lesion. In this case, consideration of ultrasonography, magnetic resonance imaging, and other tests will be helpful for accurate diagnosis and treatment.

JuiTien Shih

Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan

Objective : Carpal tunnel syndrome (CTS) is a common and sometimes challenging condition, which causes pain; paresthesia; tingling of the thumb, index and long fingers; and even thenar weakness in the hands. The endoscopic transcarpal ligament (TCL) released is effects but need more time for nerve regeneration in previous studies. In recent years, platelet-rich plasma (PRP) has proven to bean alternative as it encourages nerve regeneration. Methods : From 2012 to 2014, we rolled 32 patients with CTS, the mean aged was 57.6 ( range 50-68 years). There were 24 female and 8 male patients in our series and they all underwent endoscopic TCL release with PRP injection. Results: We hereby describe a patient with CTS showing significant improvements early in electrophysiological parameters after receiving endoscopic TCL release with PRP injections. The results revealed significant improvements in the distal motor and sensory latencies as well as the sensory nerve action potential and compound muscle action potential amplitudes of the both median nerves. Conclusion: In summary, patients with CTS underwent arthroscopic TCL release with PRP injection get more early recovery of symptoms and nerve.

Kiyohito Takamatsu 1, Akira Kawabata 1, Yasunari Awa 1, Megumi Ishiko 1, Ema Onode 2

1 Dept. of Orthop. Surg. Yodogawa Christian Hospital, Osaka, Japan; 2 Dept. of Orthop. Surg. Osaka City University, Osaka, Japan

Introduction For a detailed evaluation of patients with thoracic outlet syndrome (TOS), we had previously performed three-dimensional computed tomography (3DCT) after brachial plexography. Recently, we focused on patients with TOS of traction type who complained of symptoms in the sitting or standing position but not in the position assumed during the Wright’s maneuver provocation test. Furthermore, the results of first rib resection surgery in these patients were reported to be poor. Dynamic 3DCT in different positions enhanced the definition of the brachial plexus anatomy and enabled a dynamic assessment of the compressed brachial plexus. For further examination of TOS, this method also enabled evaluation of the relationship between the clavicle and the rib, which is impossible to assess using typical brachial plexography. Purpose The purposes of this study were to assess the narrowest costoclavicular space using 3DCT after brachial plexography and evaluate changes in the costoclavicular space in the supine position with/without upper limb traction, thus revealing the costoclavicular relationship in the sitting and standing positions. Materials and Methods TOS was suspected based on patient history, symptoms, neurological findings, provocation test results, and electrophysiological examination findings. Patients with other conditions associated with neuropathy (e.g., hypothyroidism and diabetes mellitus), bilateral conditions, and clinical findings of neuropathies, such as cervical radiculopathy and polyneuropathy, were excluded. Brachial plexography and 3DCT were performed in 10 female patients with a mean age of 35.3 years. First, brachial plexography was performed, following which dynamic 3DCT was performed not only in the resting supine position but also in the supine position with upper limb traction to assess the costoclavicular relationship in the standing and sitting positions. The 3DCT images were assessed, with special attention given to reconstituting the images in the oblique sagittal view, and cross sections of the brachial plexus in 3DCT were observed. In these reconstituted images, we specified the narrowest costoclavicular space and assessed the distance between the clavicle and the rib as well as the thickness of the subclavius muscle. These values were compared between the affected and healthy sides. Results On the affected side, the narrowest space was the second rib–clavicular space in nine cases and the second intercostal–clavicular space in one case. On the healthy side, it was the second rib–clavicular space in seven cases, the first intercostal–clavicular space in one case, and the second intercostal–clavicular space in two cases. The mean values for the narrowest costoclavicular space at rest were 31.1 mm on the healthy side and 26.7 mm on the affected side, and the values with limb traction were 23.9 and 21.1 mm, respectively. In addition, the mean ratio of the values of thickness of the subclavius muscle to costoclavicular space with limb traction were 21.5% on the healthy side and 25.4% on the affected side. However, there were three cases with ratios of >30%. Conclusion In patients with TOS who complained of symptoms in the sitting or standing position, the narrowest space was mainly the second rib–clavicular space and not the first rib–clavicular space.

Yong-Suk Lee, Jin-Woo Kang, Seung Han Shin, Yang-Guk Chung

Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of South Korea

Objective Carpal tunnel syndrome is one of the most common clinical problems hand surgeon encounters. In recent days, mini-open techniques (limited longitudinal incision techniques) have been popular method to release carpal tunnel. The purpose of our study is to compare the results of percutaneous (our method) and mini-open carpal tunnel releases among patients with primary idiopathic carpal tunnel syndrome. Method We performed a comparative prospective study on two different methods of carpal tunnel release in 60 wrists of 46 patients since March, 2016 until Feb, 2017. Thirty-one wrists underwent percutaneous carpal tunnel release using hook knife, and 29 wrists underwent mini-open release. Percutaneous releases were performed through a small transverse incision just proximal to wrist crease using a curved hemostat and a hook knife under local infiltration of lidocane at day surgery center. Primary outcome is the severity of symptoms of carpal tunnel syndrome and functional status scores. Secondary outcome is the severity of postoperative pain in the scar & pillar. The postoperative functional statuses were evaluated with Quick DASH and Boston questionale at the 2nd weeks, 6th weeks, 3rd months, 6th months, and 12th months. Results All except 2 cases (29/31, 93.5%) of percutaneous carpal tunnel release and all but for 2 cases (27/29, 93.1%) of mini-open release patients showed complete symptomatic recoveries and were satisfied with the final result (p>0.05). One of patients with no resolution had overlapping thoracic outlet syndrome, which made patient’s symptom unresolved. The two patients with unsatisfied results had bilateral carpal tunnel releases using different methods and preferred mini-open method. Twelve patients among 14 patients who underwent bilateral carpal tunnel release (one wrist with percutaneous method and the other wrist with mini-open) preferred percutaneous method due to less scar and pillar pain. The final Quick DASH scores were 18.03 (percutaneous) VS 23.04 (mini-open). The final function score of Boston questionale were 1.60 (percutaneous) VS 2.01 (mini-open) and the final symptom score of Boston questionale were 1.56 (percutaneous) VS 2.09 (mini-open) respectively. There were no significant complications during both percutaneous and mini-open procedures. Conclusion Compared to mini-open method, percutaneous carpal tunnel release is a preferable method with less postoperative pain and good functional outcome.

Tatsuki Ebata, Ikuo Nakai, Akira Kogure, Ken-ichiro Goto

Sakura Orthopaedic Hospital, Sakua, Japan

Objective: Carpal tunnel syndrome (CTS) is the most common upper extremity entrapment neuropathy. Nerve conduction studies are used for the diagnosis of CTS. As the severity of CTS progresses, the nerve conduction velocity in the carpal tunnel reduces. The compound muscle action potential of the abductor pollicis brevis (APB-CMAP) demonstrates progressively increased latency and decreased amplitude. In the most advanced stages of CTS, APB-CMAP finally becomes undetectable and the motor conduction velocity cannot be measured. The purpose of the present study was to investigate the epidemiology (risk factors) of CTS in relation to APB-CMAP. Materials and Methods: Seven hundred eighty-six hands of 572 idiopathic CTS patients whose latencies of APB-CMAP ≥4.5 ms between 2012 and 2017 were included in the present study. The diagnosis of CTS was established based on neurological and electrophysiological examinations. Secondary CTS patients, including those undergoing hemodialysis and those associated with other neuropathies or diabetes, were excluded. Patients had a mean age of 60.7 years. Among the 572 patients, 136 were men (23.8%) and 436 were women (76.2%); 542 patients were right-handed (94.8%) and 30 were left-handed (5.2%). Results: Among 786 hands, 191 hands were of men (24.3%) and 595 were of women (75.7 %). The number of hands of women was 3.1 times greater than that of men. Four hundred forty-six hands (56.8%) were dominant and 340 (43.2%) were non-dominant. The number of dominant hands was 1.3 times more than that of non-dominant hands. In 290 patients with bilateral CTS, dominant hands had statistically significantly greater undetectable APB-CMAP rates (83 hands, 28.6%) than non-dominant hands (52 hands, 18.0%). In 162 patients with bilateral CTS and bilateral detectable APB-CMAP, the average latency of APB-CMAP of dominant hands (7.00 ms) was statistically significantly greater than that of non-dominant hands (6.29 ms). The number of hands of patients aged 60–69 years was the highest (227 hands, 28.9%), and the number of hands of patients aged 50–59 years was the second highest (222 hands, 28.2%). The patients aged 70–79 years had the highest undetectable APB-CMAP rates (29.7%). The hands of patients aged 80 years and older had the second highest undetectable APB-CMAP rates (27.6%). Conclusions: There are some possible risk factors of idiopathic CTS. Being a woman is one of them. In the present study, women were 3.1 times more susceptible to CTS than men. This may be because estrogen plays a part in the development of CTS. Dominant hands tended to develop CTS and were more susceptible to progression than non-dominant hands. The cause of CTS may be related to overuse of the hand, as repetitive motion at work. The age distribution curve of CTS peaked in the sixties and fifties. The most serious CTS occurred in seventies. Therefore, age is also an important factor of CTS. A combination of these risk factors appears to contribute to the development of CTS.

HL Stark, B Crowley

Royal Victoria Infirmary, Newcastle-upon-Tyne, UK

Objective Carpal tunnel syndrome in adults with congenital hand anomalies is infrequently described. We present two cases of carpal tunnel syndrome in adults with congenital hand anomalies. Method A review of case notes and operative records. Results Case 1: 19 year old female with right radial dysplasia and hypoplastic thumb Manske grade IIIA. Clinical and neurophysiological findings consistent with right median nerve compression at wrist level Case 2 : 64 year old male with bilateral ulnar dysplasia with absent ulnar digital rays in both hands. Clinical and neurophysiological findings consistent with left median nerve compression at wrist level. Surgical treatment, carpal tunnel decompression, was undertaken in both cases. Operative findings were similar in both patients. The median nerve and carpal tunnel were located more radial than normal. The ulnar artery and nerve were found more centrally in the proximal palm. The median nerve was adherent to the overlying flexor retinaculum and deep aspect of the thenar muscles. Dense palmar aponeurotic bands compressed the median nerve distal to the carpal tunnel causing an hour-glass constriction of the nerve (see photographs of operative sequence case 1). Conclusion Our cases highlight the anomalous anatomy that may be found when undertaking carpal tunnel decompression in patients with congenital hand anomalies. We advocate brachial plexus block or general anaesthetic for this surgery. The skin incision should enable extension proximal to the wrist to facilitate identification of nerve anatomy. Awareness of this allows the hand surgeon to make an appropriate operative plan.

Amirouche Dahmam, Gero Meyer zu Reckendorf, Jean-Luc Roux

Institut Montpelliérain de la Main, Montpellier, France

Introduction: A direct approach is the standard procedure for the treatment of recurrent carpal tunnel syndrome. However, this may be technically challenging due to adhesions and an increased risk of iatrogenic injuries. Endoscopic release of the median nerve within the carpal tunnel has become a well-controlled procedure, providing better anatomical vision than the conventional technique, thanks to the advances in technology. The aim of this work is to study the interest and feasibility of endoscopic release in the event of carpal tunnel recurrence. Material and Method: Seven patients (5 women and 2 men) with a mean age of 61 years old (38-92), presented a clinical symptomatology of carpal tunnel syndrome after an average of 6 years (6 months - 15 years) following initial surgery for median nerve release, by mini-open surgery in 6 patients and endoscopic surgery in one patient. An ultrasound was performed to rule out an endocanalar cause. Electromyography was positive in all patients and confirmed the recurrence. All patients were treated under regional anesthesia with endoscopic carpal tunnel revision surgery. They were informed of the risk of conversion to open surgery and all were reviewed and clinically evaluated. Results: Endoscopic release was successfully performed except in one case in which the anterior carpal retinaculum did not deviate sufficiently in its distal part due to its thickness. We undertook an open conversion to complete the release. In all cases, the following anatomical elements, the median nerve, flexor tendons and the superficial palmar arch were visualized in order to protect them before section of the anterior carpal retinaculum. All patients were satisfied and reported an improvement in symptomatology, as well as the recovery of sensitivity and strength. Discussion: Recurrence after carpal tunnel surgery is rare and should trigger a search for incomplete release in the majority of cases. Open surgery is the most commonly used technique and some authors advocate neurolysis of the median nerve associated with a protection flap as required. The interest of endoscopy is to visualize all the anatomical parts such as the median nerve, flexor tendons and the superficial palmar arch, in order to protect them before safely cutting the anterior retinaculum on its ulnar side, unlike with the open approach. Neurolysis exposes the patient to a risk of iatrogenic nerve damage. We believe that, for a first recurrence, it is sufficient to perform a simple release without any associated procedures. This study shows that endoscopic release of recurrent carpal tunnel can be safely performed with good results. Mastering the endoscopic technique is essential and reverting to open surgery must be the rule for cases with difficult visibility.

Amirouche Dahmam, Jean-Luc Roux, Gero Meyer zu Reckendorf

Institut Montpelliérain de la Main, Montpellier, France

Endoscopic release of the median nerve according to Agee's original technique is limited to section of the flexor retinaculum without endocanalar exploration. We present a video of the modified Agee technique the purpose of which is to explore the carpal tunnel, including its contents and walls. The procedure is performed under locoregional anesthesia with a tourniquet at the root of the arm. As soon as the endoscope is introduced into the carpal tunnel, the median nerve is located and section of the retinaculum is only performed afterwards. Once the retinaculum has been divided, exploration becomes easier. By longitudinal rotational movements of the endoscope we may visualize the following anatomical elements: the retinaculum margins confirming its complete section, the median nerve and its motor branch on the radial side, the long flexor of the thumb in its sheath outside, the flexor tendons of the 4th and 5th fingers with their lumbrical muscles on the ulnar side, the uncus of the hamatum and finally, behind the flexor tendons, the anterior capsulo-ligamentous parts of the carpus. On a continuous series of 100 carpal tunnels, the median nerve was always visualized before section of the retinaculum and the motor branch was visualized 82 times. Release of the motor branch was performed under endoscopy in 27 cases who presented thenar atrophy or a compressive anatomical element. In most of these cases, endocanalar vision associated with passive flexion/extension movements of the first metacarpal, revealed shearing of the motor branch due to fibrous reinforcement of the flexor fascia, this arch was sectioned. The long flexor of the thumb was individualized 87 times, the flexors of the 4th and 5th fingers with the lumbrical muscles 68 times. In 18 cases we found degenerative tendon lesions with a rough hamate. The anterior part of the carpus was visualized by passing the endoscope under the flexor tendons. A synovial cyst was found in one case. This film shows that the endoscopic technique offers endocanalar anatomical vision with better quality than the classical open technique. It proves that complementary procedures, such as neurolysis of the median nerve and its motor branch, associated with section of the retinaculum are possible by endoscopy. This experience has led us to believe that, just as with wrist arthroscopy for the carpus, endoscopy will become a standard means of exploring the carpal tunnel.

Petra Brinskelle, Saskia Kotschar, Birgit Michelitsch, Daniel Georg Gmainer, David Benjamin Lumenta

Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria

Introduction To adequately describe the treatment for a given morbidity and its recurrence following a previous therapeutic intervention, agreement on the definitions is a prerequisite to evaluate and describe the state-of-the-art. There exist no common definitions on the recurrence of carpal tunnel syndrome and no previous such review was performed. Methods Following ethical board approval and prospective registration in the Prospero database, we used a literature search with the terms carpal tunnel syndrome and recurrence in the PubMed database, including publications from 1972 onwards, and sub-searched within previous reviews of carpal tunnel syndrome for additional literature. Inclusion criteria for screening of publications were the mentioning of included patients/hands, level of evidence, type of surgical incision, follow-up duration, recurrence rate with standard deviation, symptom-free interval, and time-to-recurrence. Exclusion criteria were reviews, and case reports. Symptoms on recurrence were also screened for numbness, weakness, tingling, and nightly pain. Two independent reviewers used a standardized reporting sheet, in case of disagreement a decision was reached following a joint discussion. Results The initial search retrieved 177 publications, and a PRISMA flowchart derived to demonstrate the included literature. The common denominator of the included publications will be presented at the conference. Discussion Contesting the definitions non-uniformly used across studies dealing with carpal tunnel syndrome and its recurrence we suggest a common denominator to adequately describe the term recurrence in the context of the most common peripheral neuropathy of the upper extremity.

Nahoko Iwakura 1, Hisanori Fukaya 1, Yoshihito Takatsuki 1, Yasushi Terayama 2

1 Tokyo Women's Medical University, Japan; 2 Hasuda Hospital, Saitama, Japan

Objective Some patients with hemodialysis-associated carpal tunnel syndrome (HD-CTS) do not experience improvement in nerve conduction velocity (NCV) after carpal tunnel release. The purpose of this study was to investigate the relationship between structural changes in magnetic resonance imaging (MRI) and changes in NCV before and after surgery for HD-CTS. Methods Sixteen hands belonging to 14 hemodialysis patients (nine male and five female patients) who had previously undergone endoscopic carpal tunnel release (ECTR) for CTS were enrolled in the study. Recurrent cases of CTS were excluded. Patients were divided into two groups: those who experienced improvement in NCV (I group), and those who did not experience improvement in NCV (NI group) two years after surgery. MRI of the carpal tunnel was performed prior to and 12 months after surgery. The cross-sectional area of the carpal tunnel and median nerve at the hook of hamate level, and distance from the volar side of the carpal bone to the flexor pollicis longus (FPL), flexor digitorum superficialis (FDS), and flexor digitorum profundus (FDP) were measured and compared before and after ECTR. Further, the difference between time points was calculated for each measurement and compared between the study groups. Results Fourteen hands (12 patients) were in the I group and two hands (two patients) were in the NI group. The mean patient age was 67±7.5 and 70±7.1 years, and the mean duration of hemodialysis was 18.7 and 23.5 years for the I and NI groups, respectively. In both the groups, the cross-sectional area of the carpal tunnel and median nerve and the distance from the bone to the tendon increased after ECTR. The difference in the cross-sectional area of the median nerve before and after surgery was 9.0±3.5 mm2 in the I group and 2.0±1.4 mm2 in the NI group, significantly greater in the I than the NI group. Conclusions Equivalent to previous reports on idiopathic CTS, we found the median nerve and carpal tunnel at the hamate level to be expanded and the flexor tendons shifted to the volar side following ECTR for HD-CTS. Our results suggest that if MRI does not indicate that the median nerve has become sufficiently large within 12 months of ECTR, the NCV two years after surgery is unlikely to have improved.

Sergio Daroda, Ezequiel Fernández, Facundo Zabaljáuregui, Fernando Menvielle, Rodolfo Cosentino, Clara Benedetti, Paul Pereira

Clinica de la Mano GAMMA, La Plata, Argentina

Objetive: Our aim is to present the results of the open release of the suprascapular nerve in the coracoid notch, by an upper shoulder approach. Methods: Thirty patients with entrapment of the suprascapular nerve were included in a retrospective analysis from 2010 to 2016. All the patients were operated on by the same surgeon with an open release of the transverse ligament in the coracoid notch through a superior approach. The average age was 52.1 years and 60% of the patients were women. All the patients had pain at the posterolateral region of the shoulder, and in 2 cases there were hypotrophy of the supraspinatus muscle. The average duration of the symptomatology last for 15.1 months (range 1-48 months) prior to the surgery. All the cases were studied with shoulder x-rays (antero-posterior and profile) and magnetic resonance. An electromyogram of the brachial plexus was performed in all the cases by the same physician, being positive in 100% of the cases. They were evaluated using the Visual Analogue Scale (EVA) of pain, ASES scale (American Shoulder and Elbow Society) and the patients were asked if they were satisfied or not. Results: The average follow-up was 31.4 months (range of 12-72 months). The diagnoses associated to the entrapment of the suprascapular nerve were: rotator cuff injury (11 cases), direct trauma (5 cases), subacromial bursitis (4 cases), osteoid osteoma of the scapula (1 case), thoracic operculum syndrome (1 case) and pure entrapment (8 cases). 93% presented immediate relief of symptoms. One patient remained in pain for 1 month and another for 4 months. The average preoperative EVA was 8.43 and the postoperative EVA was 0.86. All the patients were satisfied with the treatment. The average preoperative ASES scale was 22.32 and the postoperative scale was 84.86. Conclusions: We consider that the release of the suprascapular nerve in the coracoid notch produces a complete relief of the symptoms, and a functional recovery that allows the patient to resume his daily tasks at an early stage.

Ki-tae Na, Sang-uk Lee, Won-woo Kang, Jong-yoon Lee

Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea

Objective Clinical manifestations of thoracic outlet syndrome are vague pain or symptoms in upper extremity. Hence, the diagnosis is often delayed or misdiagnosed as cervical HNP, shoulder pathology or peripheral neuropathy. For this reason, many patients spend time and money for unnecessary or ineffective treatments. There is no definite treatment guideline that helps decide when to perform surgery or when not to. We report the outcomes of thoracic outlet syndrome when treated by conservative care or surgical intervention. Methods Twenty-seven cases diagnosed as thoracic outlet syndrome were reviewed retrospectively between January 1999 and March 2013. Eleven patients (41%) had surgery and sixteen patients (59%) had conservative care in outpatient clinic. Light exercises of upper extremity such as stretching of neck and shoulders were recommended at initial visit. After two or three months of conservative care, clinicians reassessed the patients to determine whether doing the surgery or not. Surgical method included anterior and middle scalenectomy, neurolysis of brachial plexus, and resection of first rib. As the case of cervical rib syndrome, resection of cervical rib was performed as well. The outcomes were assessed based on the follow-up duration, postoperative improvement and the results of conservative treatment. Results Mean age was 45 years (range, 22-68 years) at their first clinic visit. Nine patients (81%) were improved to nearly normal within 6.5 months (range 2-21 months), two patients (19%) had mild discomfort after the surgery. We performed anterior and middle scalenectomy in all cases, first rib resection in four cases, and cervical rib resection in three cases. No post-operative complications were noted in this series. Among sixteen patients treated by conservative methods, eleven (69%) were free of symptoms, and five (31%) showed no significant improvement in symptoms. Conclusion Conservative treatment is an effective method for thoracic outlet syndrome patients at initial clinic visit. If ineffective, surgical methods may require. Thorough exploration of brachial plexus and anterior and middle scalenectomy are most helpful for successful outcomes. Other pathologic lesions such as cervical rib or space-occupying lesion must be removed for the complete decompression of brachial plexus.

Belén García-Medrano 1, Clarisa Simón Pérez 1, Blanca Ariño Palao 1, Julián Alía Ortega 1, Benedicta Catalán Bernardo 2, Miguel Martín-Ferrero 1

1 Orthopaedic Surgery, Hand Unit, Hospital Clínico, Valladolid, Spain; 2 Neurophysiology Department, Hospital Clínico, Valladolid, Spain

Introduction: Recently, increasing evidence has revealed the beneficial effects of PRP on axon regeneration and neurological recovery in animal or vitro studies. Demostrated and defended its positive effect during carpal tunnel release (CTR), according to our previous researchs. Objectives: Compare perineural and intraneural PRP infiltration after carpal tunnel release. Material and Method: Prospective, experimental study including 60 patients with severe and very severe CTS. Local addition to the median nerve of 3 cm3 of PRP previously activated, during surgical neurolysis, after opening of the annular carpal ligament. 3 groups: simple CTR, with perineural PRP, and intra-epineurum infiltration. Primary outcomes: pain and paresthesias (Boston test). Secondary outcome measures: Durkan, Phalen, Tinel test, grip and clamp strength; cross-sectional area, perimeter, and vascular ultrasound measures of the median nerve; motor and sensory electrophysiological study. Results: Evaluation at 6 months. 100% refers a clear improvement in their symptomatology (EVA, Boston test) and pain relief; feeling of pressure in the immediate postoperative period in intraneural infiltration; occasional residual pulp paresthesias in 29%; progressive improvement in the grip and clamp force was observed, faster in PRP groups (56% before the third month). The magnification of the tunnel perimeter as well as its diameter and the reduction in the vascularization before the tunnel are statistically significant in both PRP groups. EMG control quantifies an acceleration in conduction velocity with reduction in latency. No statistically significant improvement of results in intraneural group. Conclusion: PRP accelerates and improves the functional outcome in the most complex cases of compressive neuropathy. But the function of the blood-nerve barrier of perineurium and endoneural vessels could limit the difference between the peri and intraneural PRP addiction.

Marcello Cunha, Jose Pistelli, Antonio Emanoel Miachon, Marcio Cunha

Hospital Albert Einstein, São Paulo, Brazil

THE PURPOSE OF THIS STUDY WAS TO EVALUATE THE RESULTS OF ENDOSCOPIC CARPAL TUNNEL RELEASE BY USING A MODIFICATION OF THE DUAL PORTAL TECHINIQUE,THIS INVOLVE DILATATION OF THE PATH WITH URETERAL PROBE THAT REDUCE THE CHANCE OF NERVE INJURY. A TOTAL OF 1537 PROCEDURES IN 1487 PATIENTS FOLLOW UP OF 11 YEARS ECTR – DUAL PORTAL TECHINIQUE PROBE URETERAL N:14 SUCESS RATE WAS 99% COMPLICATION RATE 1%(PILAR PAIN,CICATRICIAL) NO SERIUS COMPLICATION OCURRED 100% OF WORKER´S COMPENSATION AND 90% OF WORKERS COMPENSATION RETURNED TO WORK WITHIN 04 WEEK´S THIS STUDY SUGGESTS THAT ECTR FOR CARPAL TUNNEL SINDROME IS REALIBLE PROCEDURE WITH HIGH SUCESSES RATE,IT ISSAFE AND IATROGENIC COMPLICATIONS CAN BE AVOIDED WITH METICULOUS SURGICAL TECHNIQUE

Masatoshi Takahara, Shuji Toyono, Mikiro Kondo, Hiroshi Satake, Michiaki Takagi

1 Izumi Orthopaedic Hospital, Sendai, Japan; 2 Yamagata University, Yamagata, Japan

Aim: Carpal tunnel syndrome (CTS) is a common complication following distal radius fracture. The onset is various, including past, acute, late or subclinical. The aim of this study was to investigate the onset and course of carpal tunnel syndrome associated with volar locking plate fixation for the distal radius fracture. Materials and Methods: During the past 2.5 years, 130 cases underwent volar locking plate fixation for the distal radius fracture. Of the 130 cases, 101 were selected as the subjects of this study, because they were above 18 years old and had preoperative distal latency of the median nerve. 17 cases preoperatively had numbness of the hand, including the two cases that had had the numbness before the fracture. The delayed distal latency (> 4.0 msec) of the median motor nerve was shown in 22 cases. According to the presence or not of the numbness and delayed distal latency, we diagnosed preoperative CTS as the following four: 1) past onset: numbness before fracture, 2) acute onset: numbness immediately after fracture, 3) subclinical: no numbness with delayed distal latency, and 4) none: no numbness or delayed distal latency. Two cases had past onset CTS, 15 had acute onset CTS, 17 had subclinical CTS, and 65 had no CTS. All cases underwent volar locking plate fixation and nine cases concomitantly did endoscopic carpal tunnel release (ECTR). The mean follow up period was 6.7 months. We examined the results of numbness. Results: Two cases with past onset CTS underwent concomitant ECTR and the numbness was relieved. Six cases with acute onset CTS underwent concomitant ECTR and the numbness was disappeared in four and relieved in two. Nine cases with acute onset CTS did not underwent concomitant ECTR and the numbness was disappeared in all except one case who had progressed numbness and underwent ECTR 4 months after plate fixation. The numbness was disappeared in all of 17 cases with subclinical CTS while only one cases had concomitant ECTR. Of 65 cases with no CTS, two cases postoperatively had numbness and delayed distal latency, and were diagnosed as delayed onset CTS. Discussion: We found the following three onsets of symptomatic CTS associated with volar locking plate fixation for the distal radius fracture: past (2 %), acute (15 %), and delayed (2 %). We indicated concomitant ECTR for past CTS, acute CTS with the distal latency of 4.0 msec and more, and subclinical CTS with the distal latency of 6.0 msec and more. After the plate fixation, three (3 %) patients developed symptomatic CTS: one with subclinical CTS had severe numbness and two with no CTS had delayed CTS. The fact that the incidence of postoperative symptomatic CTS after volar locking plate fixation was only 3 % suggested that preoperative distal latency of the median nerve was helpful.

Malin Zimmerman 1,2, Marianne Arner 3, Ingela Carlsson 1,2, Simon Farnebo 4, Lars Dahlin 1,2

1 Department of Translational Medicine – Hand Surgery, Lund University, Skåne University Hospital, Malmö, Sweden; 2 Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; 3 Department of Hand Surgery, Södersjukhuset (KI SÖS), Stockholm, Sweden; 4 Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

Objective Carpal tunnel syndrome (CTS) is more common amongst women. Our aim was to investigate any gender differences in symptoms before and outcome after open carpal tunnel release. Methods All (n=10770) open carpal tunnel releases, registered in the Swedish National Quality Register for hand surgery (HAKIR) between 2010 and 2016, were included. Outcome was assessed by QuickDASH questionnaires and eight VAS-questions assessing pain, stiffness, weakness, numbness/tingling, cold sensitivity and ability to perform daily activities preoperatively and at three and 12 months postoperatively. Results In the study population 67% (n=7169) were women with an age of median 54.0 years (IQR 42.0-66.0; men median 59.0 years IQR 48.0-70.0; p<0.0001). VAS and QuickDASH data were available in 33% (n=3600) preoperatively, in 26% (n=2826) at three months and in 19% (n=2037) at twelve months. Preoperative QuickDASH scores were higher in women (median 54.5; IQR 38.6-68.2) than in men (median 43.2 IQR 27.3-59.1; p<0.0001) and they scored higher than men at three (25.0 IQR 11.4-45.5 vs. men median 18.2 IQR 6.8-36.4; p<0.0001) and at 12 (women: 18.2 IQR 4.5-40 vs. men: 11.4 IQR 2.3-34.1; p<0.0001) months after surgery. Women had a bigger decline in their QuickDASH scores over the 12 months of follow-up (median 27.3 IQR 11.4-40.9) than men (median 20.5 IQR 9.1-36.4; p=0.002). Women scored higher on load pain, weakness, ability to carry out daily activities, opening a tight or new jar, doing heavy household chores, carrying a shopping bag/briefcase, using a knife to cut food and ability to do recreational activities, where some force or impact is taken through the arm at all three occasions. For pain with movement without load, numbness/tingling, washing your back, severity of pain and difficulty sleeping women scored higher than men before surgery and at three months after surgery, but the differences had disappeared after 12 months. Scores for pain at rest, stiffness, interference with social activity and interference with work were higher in women preoperatively, but no differences were found at three and 12 months postoperatively. Men scored higher on cold sensitivity at three and 12 months after surgery, but no differences were found before surgery. Women rated numbness/tingling higher than men preoperatively, but at three months postoperatively the score was higher for men. At 12 months, no differences were seen between men and women. Conclusion From a large National Quality Register, we conclude that women with CTS generally rate their symptoms higher than men in QuickDASH, and for some tasks evaluated by VAS, before and after open carpal tunnel release, but the improvement is relatively higher in women. Tasks requiring more grip strength are scored higher by women than by men, which remain after carpal tunnel release. Gender differences should be considered when evaluating patients before and after carpal tunnel release.

Silviu Marinescu 1, Ana-Maria Boiangiu 1, Anca Ruxandra Oporanu 1, Ruxandra Mihai 1, Carmen Giuglea 2

1 “Bagdasar-Arseni” Clinical Emergency Hospital, Bucharest, Romania; 2 Saint John's Clinical Emergency Hospital, Bucharest Romania

Objective: This paper aims to present our experience in managing the 23 patients of the mass casualty fire of 30th October 2015 that were brought to our hospital, out of which all had thermal injuries of the hands and upper limbs. Methods: Escharotomies were performed upon admission on the upper limbs of 15 patients with circumferential deep burns. 17 patients out of the 23 were treated by enzymatic debridement of their hands, in the first 12-84h since injury, while 2 were treated by surgical excizion and grafting, starting 4 days since injury. 70% of the burns treated by enzymatic debridement were grafted and 100% of those treated by surgical excision. Results: We achieved complete coverage of the burned hands at 10 to 25 days since injury. 5 patients out of the 23 died, 8 patients were treated abroad. The remaining patients were treated afterwards with compressive garments, silicone dressings, steroid injections, laser therapy, with very good results. 3 patients needed additional surgeries, performed at 1 year after injury (scar excision, grafting, web space corrections). Conclusions: In the case of a mass casualty fire, immediate attention goes to increasing the survival rate of the patients and less to the management of essential functional areas, such as the hands. We believe both can be taken care of simultaneously, by enzymatic debridement, which is a fast, selective and efficient method of removing the burn eschar, with minimal effort, man power and blood loss, an asset in a mass casualty incident.

Kana Kataoka 1, Soya Nagao 1,2, Hiroko Shiraishi 1, Koji Tanimoto 1, Yoshiaki Tomizuka 1, Masahiro Nagaoka 1, Yasuaki Tokuhashi 1

1 Nihon University School of Medicine, Tokyo, Japan; 2 Itabashi Medical Association Hospital, Tokyo, Japan

[Introduction] To perform carpal tunnel release low-invasively and safely, preoperative diagnosis of a space occupying lesion (SOL) in the carpal canal was extremely important to improve the postoperative outcomes and to avoid the complications and recurrence. The purpose of this study is to establish the diagnostic algorithm to detect SOL for carpal tunnel syndrome (CTS) preoperatively. [Materials and Methods] Seventeen hands in 16 cases were treated for CTS accompanied by SOL. There were 9 male and 7 female, with a mean age of 60.4 years (range of 18-84 years). Affected hands were 5 right hands, 10 left hands, and 1 bilateral hands. Variety of SOL, diagnostic imaging method, and correlation between imaging and operative findings were investigated in all cases. [Results] The origins of SOL were synovitis in 6 hands, calcification in 4 hands, bifid median nerve in 3 hands (2 cases), gout nodule in 2 hands, cystic lesion in a hand and lipofibromatous hamartoma in a hand. Calcification and gout nodule are detected preoperatively by plain radiographs and additional computed tomography (CT) in all cases. Other lesions were discovered by ultrasonography in all cases and additional magnetic resonance imaging (MRI) in some cases preoperatively, however they were not found by any radiographic examinations. Additionally, each lesion had a specific finding in ultorasonographic examinations respectively, and easily diagnosed the origins. [Conclusions] The combination with plain radiographs and ultrasonography was easy, time-saving and cost-effective method for screening of SOL associated with CTS. Additional CT and/or MRI should be examined as necessary, if SOL is detected by plain radiographs and ultrasonography.

Emanuele Pamelin 1, Belinda Cedron Novoa 1, Alessandra Scalese 1, Riccardo Budroni 2

1 Hand Unit I - IRCCS Istituto Ortopedico Galeazzi Milan, Italy; 2 Ortopedia e Traumatologia Osp. San. Francesco Nuoro, Italy

Objective: Many sports are associated with a variety of peripheral nervous system (PNS) injuries specific to that sport. The sports most commonly reported with PNS injuries are football, hokey, soccer baseball, cycling and winter activities. Among the different winter activities Alpine skiing have shown an unusual entrapment of the ulnar nerve at Guyon’s canal. Matherials and methods: we report seven cases of alpine skiers suffering weakness of interossei, 4th and 5th loumbricals, adductor pollicis and abductor digiti minimi secondary to the deep motor branch of the ulnar nerve entrapment. Four men and three women, with average age 45 years (28-62) have been evaluated after intense and repeated sport activity. All the patients underwent physical examination of the peripheral entrapment before imaging and EMG and Nerve Conduction Studies. Results: all the skiers have shown a Type II compression according to the Shea and MaClain classification with the site of compression located in the distal portion of the Guyon’s canal at the origin of abductor digiti minimi and Pitres-Testut, Froment and Wartemerg sign positivity. No sensory nerves involvement have been demonstrated. MR images studies demonstrated no masses or ulnar artery thrombosis or hamate’s hook occult fractures. Conservative treatment have been proposed by resting and activity avoidance combined with splinting regimen and NSAIDs and modalities to decrease inflammation and pain. Conclusion: ulnar motor branch entrapment is a rare but typical PNS inyurie occuring in repeated ulnar deviation of the wrist owing to the extrinsic load of the ski pole in the traction phase.

Tugba Karaaslan, Ela Tarakci, Hayri Omer Berkoz

Istanbul University, Istanbul, Turkey

Objective: Carpal tunnel syndrome (CTS) is the most common type of trapped neuropathies that occurs when the median nerve is exposed to pressure within the carpal tunnel at the level of the wrist and post-surgical rehabilitation of patients is of great importance. The aim of our study was to investigate the efficacy of mirror therapy applied early after carpal tunnel open surgery on the reduction of pain and improvement of sensation and function. Methods: In the randomized controlled study with 35 patients who appropriate the inclusion criteria to investigate the efficacy of MT patients were divided into two groups by simple drawing method. In the control group (n=17), the classical physiotherapy program was applied when the post-operative immobilization period ended, MT was applied to the mirror group (n=18) in addition to this treatment for 20 minutes and a total of 10 sessions in the immobilization period. Patients who were scheduled for operation due to CTS, evaluated that pain (VAS), sense (monofilament test, esthetiometer), function and symptoms (BCTQ, MHQ, 9-hole peg test) before surgery, 3 weeks and 6 weeks after surgery. The SPSS 20.0 statistical program was used in the data analysis of the study and the level of significance was accepted as p<0,05. Results: There was no statistically significant difference between the groups in terms of demographic features and symptoms at the beginning (p˃0,05). There was a statistically significant difference in pain at rest (p = 0.004) and pain at night (p = 0.037) in favor of mirror group in the 2nd and 3rd measurement results, but there was no significant difference in other parameters (p˃0,05). There was no statistically significant difference in sensory test scores between the groups (p˃0,05). While there was a statistically significant difference in favor of the control group in the first and second measurement results (p = 0,018) and in the second and third measurement results (p = 0,032) in the 9 hole peg test, no significant difference was found in other parameters p˃0,05). There was no statistically significant difference between the Boston Carpal Tunnel Questionnaire and Michigan Hand Outcomes Questionnaire scores between the groups (p˃0,05). Conclusions: The data obtained from the study indicated that the improvement in the related parameters, the early introduction of mirror therapy to carpal tunnel open surgery after classical methods has been started after immobilization with physiotherapy exercising compared, there was no significant difference between the groups, however, in the reduction of pain in CTS patients, in the improvement of the sense of light touch and in the improvement of function. In the repeated measurements, both groups showed that the treatment had a positive effect at post operative 6th week.

Konstantinos Tolis 1, Kalliopi Diamantopoulou 2, Dimitrios Vasileiou 1, Emmanouil Fandridis 1, Frantzeska Zampeli 1, Sarantis Spyridonos 1

1 Hand surgery,Upper limb and Microsurgery Department, General Hospital KAT, Athens, Greece; 2 Pathologic Anatomy Department, General Hospital KAT, Athens, Greece

Objective : Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Etiologies can be numerous but rarely a vascular cause is referred in medical literature. We present a case of chronic CTS due to a post traumatic aneurysm of the superior palmar arc. Methods: A 63 years old woman was referred to our clinic for further evaluation of a large mass at the center of her left palm, with simultaneous symptoms of median nerve entrapment. Her medical history was free of chronic diseases. She reported a fall from a ladder two years before presentation, when a large hematoma covered most of the palmar area. Tinel sign was positive for carpal tunnel syndrome, as well as the neurophysiologic studies. Under brachial plexus anesthesia and tourniquet, a z-plasty incision extending from the carpal tunnel area to the distal transverse palmar line revealed a large, dark red mass. The median nerve was decompressed at the carpal tunnel. After careful dissection and identification of the palmar arc the mass was removed en bloc. No digital blood insufficiency was documented intraoperatively. The wound was closed and a short palmar plaster cast was used for rest. Results : The plaster cast was removed after two weeks. The histopathology of the specimen revealed organizing and recanalizing thrombi, consisting of anastomosing channels, leading to aneurismal type dilatation of the vessel lumen. Relief of symptoms continued progressively during one year follow up. Discussion : An aneurysm of the superior palmar arc is an extremely rare cause of CTS. A careful preoperative examination, followed by accuracy in surgical resection will provide a postoperative normal digital blood circulation.

Lia Miyamoto Meirelles 1, Carlos Henrique Fernandes 1, Benno Ejnisman 2, Moises Cohen 2, João Baptista Gomes dos Santos 1, Flávio Faloppa 1

1 Hospital São Paulo - Universidade Federal de São Paulo - Department of Orthopedic Surgery - Hand Surgery Unit, Brazil; 2 Hospital São Paulo - Universidade Federal de São Paulo - Department of Orthopedic Surgery - Centro de Traumatologia do Esporte

The increase in the number of athletes in sports for people with disabilities (henceforth, SPD) has been growing all over the world. Surveys conducted with these athletes showed alterations in the median nerve in ultrasound and electrical studies. We did not find research on the clinical signs and symptoms of Carpal Tunnel Syndrome (STC) or the need for some type of treatment in SPD. The goal of this study was to evaluate the clinical signs and symptoms of CTS in SPD, as well as the need for clinical and/or surgical treatment. This study was observational and transversal. It included athletes in SPD that involved palmar grip or hand support in the flat position and flexion of the wrist when supporting the weight of the body, regardless of wheelchair use. In the evaluation, we investigated the complaint of nocturnal paraesthesia, Tinel's signal on the wrist and the Phalen maneuver. To measure the symptoms, we applied the visual analog scale for pain, as well as the Boston and the CTS-6 questionnaires. We evaluated 75 SPD athletes, totaling 147 hands (73 right hands, 74 left hands). The mean age was 32.2 years, ranging from 14 to 53 years. 29 (38.67%) were weightlifters, 15 (20.00%) were (sitting) volleyball player, 14 (18.66%) wheelchair fencers, 13 (17,33%) wheelchair basketball players, 2 (2.67%) capoeiristas (a Brazilian martial art) and 2 (2.67%) table tennis players. No athlete reported presence of nocturnal paraesthesia or pain in the hands. The Tinel Sign was present in the right hand of 4 athletes (5.47%) and in the left hand of 4 athletes (5.40%). The Phalen maneuver was present in the right hand of 12 athletes (16.43%) and in the left hand of 8 athletes (10.81%). The presence of two symptoms or signs occurred only in 5.6% of right hands and in 4.2% of left hands. The median score of the Boston Questionnaire for right (resp. left) hands was 11.75 (11.36), whereas the mean CTS-6 score for right (resp. left) hands was 1.08 (1.06). The few athletes who reported some signs and/or symptoms of CTS showed no interest in performing complementary tests or some type of treatment. Our results show that changes -- found in complementary tests -- in the shape and electrical conduction of the median nerve in SPD athletes do not lead to clinical manifestations that require clinical or surgical treatment.

Dawid Mrozik 1,2, Agnieszka Jackiewicz 1,2

1 HANDPROJECT Clinic, Gdańsk, Poland; 2 SWISSMED Private Hospital, Gdańsk, Poland

Background: Compression of the ulnar nerve in the cubital tunnel is the second most frequent entrapment neuropathy of the upper extremity after carpal tunnel syndrome. None of the described techniques have proved to be superior in randomized prospective trials. We therefore present our series of endoscopically decompression of the ulnar nerve at the elbow to determine the effectiveness of this procedure. Methods: It was prospective, non-randomize two-center clinical study. In 45 patients: 25 men and 20 women (age's range 28-77) with clinical McGowan grade I (6 patients), II (29 patients), and III (10 patients) and electrophysiological signs of cubital tunnel syndrome, 21-cm of the ulnar nerve was released through a 2-cm long skin incision. Diagnosis was based on history, clinical examination (i.e. pain over medial epicondyle, sensory loss, positive Tinnel's sign, weakness or atrophy of the muscles innervated by the ulnar nerve, and positive elbow flexion test) and confirmed by neurophysiological studies (nerve conduction velocity and electromyography). A 4-mm, 30° standard endoscope and Wolf retractor were used during the procedure, and the mean postoperative follow-up examination was 12 months. Results: There were no visible nerves and vessels injured during the procedure. The main postoperative complication was hematoma in 4 patients that resolved after conservative management. There was no elbow extension deficit after surgery and surgical wounds all healed within a week. Grip strength showed a highly significant increase after surgery. Outcomes were excellent in 27 of 45 cases and good in 13 of 25 cases. Grip strength showed a highly significant increase after surgery compared to the non-operated hand (p<0.005). The mean DASH score was decreased significantly about 65% (from 74,8 before operation to 26,3 after procedure) (p<0,005). 88% patients were satisfied with the procedure. Conclusion: Endoscopic technique for treating cubital tunnel syndrome is a safe and reliable procedure, characterized by a short incision, minimal soft tissue manipulation, less scar sensitivity and early postoperative mobilization. It demonstrates promising benefits against conventional approaches (complete release and good visualization), and reduced complication profile (painful scarring and elbow contracture). Endoscopy is a widely imaging study for assessing nerves providing useful information on the severity and stage of nerve pathology.

Mark Mikhail, Roisin T Dolan 1, Michelle Baker 1, Ciara Deall 1, Ravi Knight 2, David Wilson 3, Henk P Giele 1

1 Department of Plastic and Reconstructive Surgery; 2 Department of Neurophysiology; 3 Department of Radiology Oxford University Hospitals NHS Trust, Oxford, UK

Objectives Thoracic outlet syndrome (TOS) is a symptom complex caused by compression of one or more of three neurovascular structures: the brachial plexus, subclavian vein, or subclavian artery, between the first rib and clavicle. A paucity of standardised objective diagnostic criteria renders accurate diagnosis of thoracic outlet syndrome (TOS), and reliable indicators for surgical intervention, challenging. The aim of this study is firstly, to correlate symptoms, pre-operative clinical provocative tests, radiological and neurophysiological studies with findings at surgical exploration and outcomes. Patients and Methods We performed a retrospective review of a prospectively maintained database comprising patients presenting consecutively to a quaternary level centre for surgical management of TOS. All patients were clinically assessed by the senior author (HG) at the Nuffield Orthopaedic Centre or John Radcliffe Hospital, Oxford University Hospitals NHS Trust between April 1997 and November 2017. Each patient was assessed as follows: 1. Clinical history 2. Clinical tests for vascular compression (Adson’s manoeuvre, Reverse Adson’s test, Wright’s hyperabduction test, Falconer’s test) and for neural compression (Roos’s test, Spurling’s test, Morley’s compression test and Tinel’s sign over the supraclavicular area). 3. Radiological investigations (MRI of cervical spine and brachial plexus, plain film x-ray of the c-spine) and 4. Neurophysiological studies. Surgical outcomes (resolution of symptoms, recurrence rate) were assessed at latest follow-up using Derkash’s classification category. Outcomes were then correlated with pre-operative clinical examination/investigations to identify predictive accuracy of these screening modalities. Results One-hundred and twenty-five patients (n=125) underwent thoracic outlet exploration (+/- decompression with neurolysis, +/- arteriolysis +/- excision of scalenus muscles +/- excision of cervical/ first rib) on one-hundred and sixty limbs. There was a female preponderance in this cohort (n=94, 75%) and age ranged from 22-75 years (mean: 41 years). At latest follow=up (minimum of 3 years), recurrences were noted in n=18 patients (14%) and n=99 patients (79%) reported Derkash’s full/good outcomes. Morley’s compression test was the most commonly positive provocative test (82%), MRI demonstrated pathology in 49% of patients and nerve conduction studies were suggestive/positive in 36%. Patients with > 4 pre-operative positive clinical tests demonstrated highest Derkash’s outcome scores. Conclusions Thoracic outlet syndrome is a diagnosis of exclusion and presents with atypical symptomatology in the majority of cases. Standardised clinical diagnostic criteria are less useful in this setting. We identified the quadriad of 1.positive Morley’s test, 2.positive nerve conduction studies, 3. positive findings on MRI and 4. presence of cervical rib, associated with highest diagnostic accuracy and complete resolution of symptoms. Future studies should focus on the diagnostic work-up of TOS.

Avshalom Carmel

Laniado Hospital, Netanya, Israel

Background: CTR can be achieved by open or endoscopic techniques alike. Currently, most hand surgeons use "mini open" (less then 3 cm skin incision) technique. some cut the transverse carpal ligament (tcl) with sccisors in a "semi blind" way, thereby potentially exposing the median nerve to harm. Different tools (carpaltomes) were developed in order to enhance safety but most are single use tools or expensive. objective: to describe a surgical technique using new equipment: smilley meniscotome and cannula trocar for mini-open CTR and show safety and preliminary short term results. Method : A retrospective chart review. I used a newly developed canula/trocar tool. This tool is based on a modified tool that I used for 12 years in more than 700 ctr operations with reported good results . the tool is a simple cannula and trocar of 5 mm diameter and 13 cm length that serve as a guide for a smiley meniscotome that cuts the canal roof. I will report my experience with the first 50 patients operated. patients were evaluated after 2 weeks for short term results and complications, focusing on reported sensory loss or symptom aggrevation (potential nerve damage). Result : preliminary results were good and will be reported Conclusion: this is a safe and simple way to perform mini open CTR. It is low-cost. Estimated <5euro per procedure.

Claudia Bauer, Reinhold Stober

Handchirurgie Kantonsspital Olten, Switzerland

Objective: In a previous retrospective review we provided data on long term patient satisfaction after supraclavicular first rib resection for Thoracic Outlet Syndrome (TOS) by postoperative assessment using the Quick DASH questionnaire (mean score 21 after mean follow-up of 11 years in 87 patients). Objective of the current prospective study is to systematically evaluate the outcome after supraclavicular first rib resection for TOS using validated questionnaires pre- and postoperatively. Method: All patients scheduled for supraclavicular first rib resection for TOS are assessed pre- and postoperatively (3-12 months) by Quick DASH and CBSQ (Cervical Brachial Symptom Questionnaire). Results: 20 consecutive patients are included by now. Of 11 patients pre- and postoperative questionnaires are available by now. Mean Quick DASH score before operation was 74, mean CBSQ score 95. During mean follow-up of 8 months (range 3 -12 months) Quick DASH score dropped from 74 by 34 points to 40. Concerning the CBSQ, score more than halved (dropped from 95 by 57 points to 38) indicating significant improvement after supraclavicular first rib resection. Poorer scores are associated with higher age, multiple operations, opioid use and coincidence of chronic pain syndromes. All but one patient would do the operation again. Reported subjective improvement ranges from 10 to 100%. Conclusion: The most pronounced improvement seems to occur in the first 3, rarely up to 6 months after supraclavicular first rib resection for TOS. Quick DASH and CBSQ yield valuable instruments in evaluating the outcome. Supraclavicular first rib resection can offer consistently good results with high patient satisfaction in carefully selected patients.

Nerves and Brachial Plexus (62 abstracts)

Lucy Homer, Samuel George, Irfan Khan

Whiston Hospital, Liverpool, UK

Introduction and Aims The few reports in the literature about digital nerve repair techniques are mostly regarding the use of allografts and conduits. We present a novel technique that can be used to bridge nerve gaps of up to 1.5 cm to achieve a primary, tension-free repair. Patients and Methods A V-Y advancement flap, of the overlying skin and soft tissue is used to achieve advancement of the underlying neurovascular bundle to approximate the ends of the nerve. This was raised similar to the Venkataswami flap used for fingertip injuries but designed more proximally. We present the case of a 48 year old male right hand dominant company director who suffered a complex circular saw injury to his left thumb and index finger with tissue loss to both fingers, a defect of the extensor pollicis longus (EPL) tendon and a 13mm defect in the radial digital nerve of his index finger. Results The technique enabled us to achieve a tension-free coaptation of the digital nerve and close the soft tissue defect. A Foucher flap from his left index was used to reconstruct the left thumb after an EPL turnover flap and this did not affect the nerve repair on the index finger. Follow-up at 3 months showed full recovery and in particular the index finger had similar sensation and 2-point discrimination when compared to the contralateral side. Photographs of all stages are presented. Conclusions A tension-free coaptation is the goal of any nerve neurorrhaphy and we know from the literature that achieving a primary closure will give you better outcomes when compared to a graft or conduit. We present a simple, yet effective technique to treat the moderate <1.5cm nerve defects saving the more expensive, less reliable conduits and grafts for the larger defects.

Karan Dua 1, Catherine Miller 2, Joshua M Abzug 3

1 SUNY Downstate Medical Center, Brooklyn, USA; 2 University of Maryland Medical Center, Baltimore, USA; 3 University of Maryland School of Medicine, Baltimore, USA

Objective: Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. Previous studies have reported increased rates of depression in mothers of children with an OBPI and parents having unresolved feelings of sadness and anger. The presence of post-traumatic stress disorder (PTSD) and depression are well established in parents of babies that require a neonatal intensive care unit (NICU) stay. The purpose of this study was to assess the mental health of parents with newborns with an OBPI as compared to parents of NICU babies and babies in the healthy newborn nursery. Methods: Three groups of parents were prospectively given a 10-minute self-reported survey: 1) Newborns with OBPI; 2) Newborns in the healthy newborn nursery without OBPI; 3) Newborns in the NICU. The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents’ exposure to community violence, family support, and use of drugs or alcohol. The PHQ-9 is a 10-item depression survey that asks respondents to rate their mood symptoms on a Likert scale and the PCL-S is a 17-item PTSD survey that rates symptoms on a Likert scale. Results: 51 parents were enrolled including 41 mothers and 10 fathers. 33 mothers took the PHQ-9 portion of the survey and 4 screened in for depression (15.4% for NICU, 0% for newborn nursery, 9% for OBPI). 41 mothers took the PCL-S portion of the survey and 18 screened in for PTSD (46% for NICU, 0% for newborn nursery, 45.5% for OBPI). Of the 10 fathers, two in the OBPI group screened in for depression. Conclusions: The birth of a child with an OBPI can be very difficult to cope with for parents. The rate of PTSD is equal, being nearly half (46%), between mothers with newborns with OBPI and children in the NICU. These rates are significantly higher than the national average of 3.5% for PTSD following pregnancy. PTSD is treatable and possibly preventable with appropriate psychosocial care following newborn delivery. In contrast, untreated PTSD in parents with a child with an OBPI can affect the entire family and society. OBPI clinics should be staffed similarly to the NICU with clinical social workers that can appropriately screen and treat parents with PTSD symptoms. Orthopaedic surgeons who treat OBPI should be aware of the mental health implications on families and employ an interdisciplinary team to address these needs.

Joshua M Abzug 1, Charles Mehlman 2, Jun Ying 3

1 University of Maryland School of Medicine, Baltimore, USA; 2 Cincinnati Children's Hospital Medical Center, Cincinnati, USA; 3 University of Cincinnati College of Medicine, Cincinnati, USA

Objective: Brachial plexus birth palsy (BPBP) is quite common, however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known and unknown risk factors, and evaluate the length of stay (LOS) and costs of children with an associated BPBP injury. Methods: Data from the 1997-2012 Kids’ Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and cost was also performed. Multivariate logistic regression analysis was utilized to assess the association of BPBP with its known and unknown risk factors. Results: The incidence of BPBP has steadily decreased from 1997-2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number one risk factor for the development of a BPBP injury, (OR 166.01). Hypotonia is a newly recognized risk factor for the development of BPBP (OR 1.93). Fifty-five percent of infants with BPBP still have no known risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay costs are approximately 40% higher. Conclusions: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the number one risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer length of stays and hospital costs compared to children without a BPBP injury.

Steven M. Koehler, Ronnie L. Shammas, Fraser J. Leversedge

Department of Orthopaedic Surgery, Duke University, Durham, NC, USA

Purpose: To assess outcomes of ulnar nerve decompression and anterior transposition at the elbow using a pedicled adipofasical flap. Methods: A retrospective cohort of patients who underwent primary or revision ulnar nerve decompression and anterior transposition using an adipofascial flap for a preoperative diagnosis of ulnar neuropathy at the elbow at a single center between 2006-2016 was examined. Pre-and post-operative visual analogue scale scores, modified McGowan classifications, complications, and physical exam findings were used to assess patient outcomes. Results: 22 patients underwent ulnar nerve decompression with anterior transposition using an adipofascial flap, and 16 patients were eligible for inclusion in the study. 11 cases were primary nerve procedures and 5 patients were revision ulnar nerve surgery with a mean postoperative follow-up time of 352 days (range: 122-701). There was a significant mean improvement in global intrinsic strength when comparing pre- and post-operative measures (3.7/5 v. 4.6/5, p<0.05 ). 50% of patients had improvement in their two-point discrimination postoperatively. Following the operation, all patients experienced a significant reduction in their VAS pain scores (4/10 v. 0.6/10, p<0.05). 12 of 16 of patients were classified as demonstrating an improvement in their modified McGowan classification score, while 4 out of 16 were classified as having no change. No patient had a worse post-operative score. All patients maintained preoperative elbow range of motion. There were no perioperative complications. Conclusions: Use of the adipofascial flap for anterior transposition of the ulnar nerve at the elbow generally provided patients with significant improvement in measured clinical outcomes, even in the revision setting. Ulnar nerve sensation and global intrinsic strength improved postoperatively, corroborating the initial published report that analyzed this technique. In patients for whom ulnar nerve decompression with or without anterior transposition is indicated, anterior transposition using an adipofascial flap may be a valuable technique for improving nerve function and for improving overall patient outcomes.

Constantinos Kritiotis 1,2, Jan Friden 3, Sabrina Koch-Burner 3, Christiana Fakonti 4

1 Manchester Hand Centre, Salford Royal NHS Foundation Trust, Manchester, UK; 2 Iasis Private Hospital, Paphos, Cyprus; 3 Swiss Paraplegic Centre, Nottwil, Switzerland; 4 Paraplegic Department, Nicosia General Hospital, Nicosia, Cyprus

Background : Hand Surgery in Tetraplegic patients has been described as the ultimate method of rehabilitation. It has been around and evolving for more than 50 years and it can significantly improve the upper limb function in selected tetraplegic patients, providing these patients with an extra level of independence. We present the story as well as our first results of our service since it was created three years ago. Methods : Following lectures in the Paraplegic Department of the Nicosia General Hospital as well as the Cypriot Paraplegic Organization, fifteen patients were reviewed for prospective surgery. The patients were evaluated using the ICSHT (International Classification for Surgery of the Hand in Tetraplegia) and three patients that were suitable candidates decided to go ahead with surgery. In these three patients four procedures were carried out, two posterior deltoid to triceps transfers as well as two grip reconstructions. Results : No complications were noted. In the case of triceps recosntruction, both patients recovered a significant strength in their reconstructed triceps and were able to use their transfers for independent mobilization. Especially one of the two patients used a hoist for his transfers prior to the procedure and now he can transfer independently using a sliding pad. The grip reconstruction procedures were done in an ICHST grade two patient (who was one of the patients that had the triceps reconstruction) and an ICHST grade four patient. Mean operating time for both procedures was 5.5 hours. Both patients had a change of dressings the next morning and started a targeted rehabilitation program. Both patients saw an increase in the functionality of their operated hands and a significant increase in their COPM scores Conclusions : Hand surgery reconstructive procedures should be offered in every suitable tetraplegic patient. The triceps reconstruction using the posterior deltoid to triceps transfer can significantly improve these patients' ability to transfer and the grip reconstruction can increase the functionality of their hands.

Hirofumi Yurie 1, Ryosuke Ikeguchi 1, Tomoki Aoyama 2, Akira Ito 2, Mai Tanaka 2, Junichi Tajino 2, Souichi Ohta 1, Hiroki Oda 1, Hisataka Takeuchi 1, Sadaki Mitsuzawa 1, Shizuka Akieda 4, Koichi Nakayama 3, Shuichi Matsuda 1

1 Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 2 Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 3 Department of Regenerative Medicine and Biomedical Engineering Faculty of Medicine, Saga University, Saga, Japan; 4 Cyfuse Biomedical K.K., Tokyo, Japan

OBJECTIVE: The treatment of the peripheral nerve injuries with nerve defect include end-to-end suturing, autologous nerve graft and nerve conduit. Recently, the implantation of neural stem cell, undifferentiated bone marrow stromal cells (uBMSCs), or fibroblasts to the nerve conduit has been shown as a beneficial effect on peripheral nerve regeneration. However, the seeding efficacy and viability of the implanted cells remain unclear. And, synthetic nerve conduits are associated with a risk of infection and low biocompatibility. So as previously reported, we created a scaffold-free Bio 3D conduit from normal human dermal fibroblasts. To promote peripheral nerve regeneration, we have made a Bio 3D conduit from uBMSCs. So, in the current study, we examined the efficacy of the peripheral nerve regeneration using a Bio 3D conduit from uBMSCs (uBMSCs group) compared to the control group from fibroblasts. METHODS: Primary uBMSCs were isolated from bone marrow of femurs of female Lewis rats and fibroblasts were from subcutaneous tissue of the skin. Using Bio 3D printer, we have made Bio 3D conduits from both cells in same procedure as we previously reported. These conduits were interposed to the rat sciatic nerve at the mid-thigh level with a 5 mm nerve gap. Eight weeks after surgery, several assessment were conducted. Data were analyzed by using student t test. Values of P < 0.05 were considered statistically significant. RESULTS: Electrophysiological studies revealed significantly higher compound muscle action potential in the uBMSCs group both in the gastrocneminus and pedal adductor muscle compared to the control group (P < 0.05). Morphometric studies revealed that the uBMSCs group exhibited a significantly greater myelinated axon number compared to the control group (P < 0.05). In the uBMSCs group, the nerve gap was bridged successfully and Bio 3D conduit was maintain tube-like structure around the regenerated axons at eight weeks after surgery. Immunohistochemical examination revealed abundant angiogenesis in the regenerated nerve and uBMSCs composing Bio 3D conduit were positive for S-100 in the eight weeks after surgery. CONCLUSION: In the present study, we created scaffold-free Bio 3D conduits from uBMSCs and confirmed peripheral nerve regeneration in a rat sciatic nerve model compared to the control group. Recent studies have demonstrated uBMSCs facilitate peripheral nerve regeneration because uBMSCs differentiated into Schwann cell-like cells and produce various types of neurotrophic factors. The immunohistochemistory suggested uBMSCs composing Bio 3D conduit differentiated into Schwann cell-like cells. And the stability of the tube-like structure even in the eight weeks was advantageous for axonal regeneration. There are several limitations associated with the current study. First, the 5-mm nerve gap was not long enough to assess the efficacy of the Bio 3D conduit from uBMSCs. Second, the duration of the observation period after transplantation was insufficient to evaluate nerve function. In the present study, we confirmed that Bio 3D conduit from uBMSCs contribute to peripheral nerve regeneration. Further studies of Bio 3D conduit are needed for clinical applications.

B Jagannath Kamath, Premjit Sujir, Mithun Pai Arkesh

Kasturba Medical College, Mangalore, Manipal University, India

AN INNOVATIVE NERVE REPAIR SIMULATION Introduction Traumatic nerve injury and its repair or reconstruction are an integral part of hand surgery. Unpredictability and the critical time have been the hallmarks of results of Nerve repairs. Clinical and Investigative modalities to confirm the success or failure of results take time. With the advent of the nerve transfers the training has acquired a new Importance. An ideal stimulatory exercise in micro neural repair should not only mimic the technical challenges but should also allow the trainees to evaluate their own techniques. Apart from the tension at the anastomotic site the important factor for favourable outcome during repair is the ability of obtaining the coaptation of fascicles. We are describing a simple method of simulation of nerve repair emphasising the method of evaluating the fascicular coaptation following the repair. Method The method that is being described involves preparing the 2 conduits of desirable size using the sterile disposable hand towels available in operation theatres. The conduits are cut into a size of 2.5 cms to mimic the proximal and distal cut ends of nerve to be repaired. Three or four pieces of small hollow plastic tubes of length 2.5 cms obtained by trimming the middle thirds of the cotton ear buds to simulate the fascicles. Three or four such white coloured tubes are inserted into one of the Conduits (proximal segment) and through the other conduit (distal segment) the same number of different coloured plastic tubes are inserted to mimic the 2 segments of nerves for simulated repair. The 2 segments can now be transfixed using a nerve apporximator to suture the anterior wall . The trainees are now allowed to bring about simulated repair keeping in mind the fascicular alignment. Once the repair is complete we know use the Android flexible HD Camera with a diameter of 3.5 mm, to evaluate the degree of coaptation at the anastomotic site of the simulated repair. The flexible camera is placed at a distance of 1-1. cms from each of the white coloured plastic tubes, and the image is captured on the laptop using the appropriate App. The overlap of the coloured circles on the white circles on the monitor, and the configuration of the overlap will give the evaluator an idea of the degree of coaptation. This can even be evaluated depending on the overlap as Grade 4 (100- 75%), Grade 3 (75-50%), Grade 2( 50-25%), and Grade 1 ( less than 25%). It will thus be possible to evaluate the coaptation obtained for each of the fascicle in the simulated repair to assess the competence of the trainee Conclusion The above described method of nerve repair is not only simple but also allows the evaluation of degree of coaptation of the fascicles following the simulated nerve repair.

Mohamed Elsaid Abdelshaheed

Faculty of medicine, Mansoura university, Mansoura, Egypt

Objective Lipofibromatous hamartoma (LFH) is a rare and benign fibro-fatty tumor of the peripheral nerves. Only a handful of cases are available in the literature with the median nerve is the most common site of affection. Cases with LFH of the digital branches of the median nerve have also been documented. Different lines of treatment of LFH were described according to the clinical presentation. Methods Here, I am presenting two cases of LFH of the digital branches of the median nerve undergone intraneural fascicular dissection and mass excision. Results Good results were obtained in the form of disappearance of numbness and regain of intact sensation. Conclusions Intraneural fascicular dissection and mass excision is a good option for management of lipofibromatous hamartoma of the digital branches of the median nerve.

Renata Paulos, Emygdio José Leomil de Paula

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil

Objectives: To describe the use of pronator teres motor branch as a donor nerve for achieving fingers flexion in a tetraplegic patient. Although it is used as a donor nerve in brachial plexus lower trunk lesions, it is the first description of its use in tetraplegia. Methods: a 29 years-old tetraplegic patient had both upper limbs operated on one year after injury. Upper limb function was classified as group 4 ICSHT at both sides. We performed bilaterally transfer of the supinator motor branches to posterior interosseous nerve and transfer of one branch of the pronator teres to the anterior interosseous nerve. During the procedure, we identified on each side two branches destinated to the pronator teres muscle, and we used just one as a donor nerve. At the right side, we identified the branch to the flexor digitorum superficialis along with the AIN and it was included in the suture. Results: Patient didn’t lose the ability to pronate his forearms immediately after surgery. Five months after surgery, he presented some movements of his left hand (M2 finger extension). Eighteen months after the surgery, he has on the left side M4 fingers extension and M3 fingers flexion (FPL and FDP) and on right side M3 fingers extension and M2 fingers flexion (only FDS). Conclusion: Pronator teres motor branch can be an option of donor nerve to achieve fingers flexion in tetraplegic patients.

Amir Adham Ahmad, Sellakkuddy Selvaganesh, Vaikunthan Rajaratnam

Khoo Teck Puat Hospital Singapore

Outcome of nerve allografts in nerve injuries of the hand – single unit experience Nerve injury results are still to be improved. The nerve gap bridging needs nerve graft. The nerve auto-graft is still the gold standard. The donor site morbidity, delay in mobilization and limited availability are still significant clinical problems. Nerve allograft is an off the shelf option negating the above issues with the auto graft. Method – We are doing a prospectective interventional study in our unit using processed allografts which do not need immune suppressive therapy as there is no cellular lines in that. Axogen allograft from 1-2mm to 4-5mm size grafts varying from 15mm to 70 mm are used in this study. All the operations were done using microsurgical techniques and the measurements were taken to the nearest mm. All the data collected by interviewer administered questionnaire. The analysis done using excel spread sheets. Results – Majority of our patients were foreign workers and there was difficulty in following them up due to less turn over in follow up visits. We were able to review around 50% of them. All had insurance cover and no one had previous nerve injury of the related nerve. More patients were digital nerve injuries and the clinical outcome (Sensory nerve - 76%, Motor nerves -71%, Mixed Nerves - 54%) was satisfactory in majority. Conclusion – It has given good outcome without donor site morbidity. Chances of immediate mobilization for pure nerve injury patients were possible. But cost is a concern.

Bauback Safa 1, Jaimie T. Shores 2, Yasser El-Sheikh 3, Timothy R. Niacaras 4, Leon J. Nesti 5, Ian Valerio 6, Dominic M Power 7, Mehir J. Desai 8, Gregory M Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 North York Hospital, Toronto, Canada; 4 JPS Health Network, Forth Worth, USA; 5 Walter Reed National Military Medical Center, Bethesda, USA; 6 Ohio State University, Columbus, USA; 7 Queen Elizabeth Hospital, Birmingham, UK; 8 Vanderbilt University Medical Center, Nashville, USA

Objectives Processed nerve allografts (PNA) have been shown to be safe and effective option to repair nerve gap injuries in a growing number of clinical studies. The RANGER registry is an active database designed to collect outcomes data for processed nerve allografts (Avance® Nerve Graft, AxoGen) on sensory, mixed, and motor nerve repairs. The registry has continued to collect long term follow-up and has also expanded to include data from additional centers. Here we report on meaningful recovery of the expanded cumulative registry for injuries spanning 70 mm and on higher thresholds of recovery in PNA repairs with long term follow-up as compared to historical controls for nerve autograft and tube conduit. Methods The RANGER database was queried for nerve repairs in the upper extremity using PNA that reported a minimum of 6 month of quantitative outcome data. Reported sensory and/or motor assessments included 2-point discrimination, Semmes-Weinstein Monofilament (SWMF) testing, range of motion, strength test. Reported outcome data were incorporated into the MRCC scale for sensory and motor function. Meaningful recovery was defined as ≥ S3/M3 on the MRCC scale. Higher thresholds of recovery, defined as S3+/M4 or greater, were evaluated in repairs reporting a minimum of 15 months of follow-up. Demographics, outcomes and covariate analysis were performed to further characterize the sub-groups. Results The current RANGER® registry has sufficient quantitative outcomes data on 303 repairs (255 sensory and 48 mixed/motor nerve injuries). Mean age of the cohort was 42 ± 16 (18 – 81) years. Mean gap length was 22 ± 14 (3 – 70) mm with an average follow up time of 11 months. Meaningful recovery was observed in 85% of all repairs. Further analysis by nerve type observed meaningful recovery in 85% of sensory and 79% of mixed nerve repairs. Among repairs reporting longer term follow-up, mean follow-up 22 ± 7.3 (15 –42) months, 79% reported higher thresholds with S3+/M4 or greater. No related adverse events were reported. Conclusions Processed nerve allografts continue to be a safe and reliable off-the-shelf alternative for the reconstruction of nerve deficits. Quantitative data demonstrate meaningful recovery in 85% of all repairs. Repairs with longer term follow-up demonstrated higher levels of recovery at 79%. These results compare favorably to historical outcomes for autografts and exceed those for conduits. The registry remains ongoing and will continue to expand to further collect outcomes data on processed nerve allografts.

Bauback Safa 1, Andrew Watt 1, Paul Sibley 2, Robert Hagan 3, Mark S Rekant 4, Harry Hoyen 5, Brendan Mackay 6, Gregory Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Hand and Upper Extremity Surgery, Allentown, USA; 3 Neuropax Clinic, St Louis, USA; 4 The Philadelphia Hand Center, Philadelphia, USA; 5 MetroHealth System, Cleveland, USA; 6 Texas Tech University, Lubbock, USA

Introduction Inflammation, scar formation, and adhesions are inherent following injury or surgical intervention. When peripheral nerves are involved, resultant scarring and inflammation around nerves can lead to poor outcomes and make re-access difficult in the event of secondary surgical procedures. Placental membranes, historically used as wound dressings and coverings, while containing beneficial biological properties lack the qualities ideal for surgical applications as an interpositional barrier. Human umbilical cord is a naturally resorbable and permeable membrane that’s shown to modulate inflammation, separate tissue layers, and contains essential extracellular matrix molecules and endogenous growth factors. Avive® Soft Tissue Membrane (AxoGen, Alachua FL, USA) is processed human umbilical cord membrane (cord membrane) intended for use as a soft tissue covering. This material is designed to overcome specific shortcomings of placental membranes and remains intact at least 16 weeks making it ideal for use during the critical time of scar formation and maturation. Here we report on the use of cord membrane as an interpositional barrier for exposed peripheral nerves. Methods Case evaluation was conducted on the utilization of cord membrane during peripheral nerve surgery when post-operative scar and inflammation were a concern. Following relevant consents, data was collected in cases where cord membrane was used during a surgical procedure on an exposed nerve. Information on injury, placement, and outcomes were collected. Data was reviewed to evaluate clinical application and outcomes after use in peripheral nerve surgery. Results This series included 13 patients undergoing surgical procedures with exposed nerve in the zone of injury. The average age was 45(11-62) years. Pre-operative and surgical procedures were based on institution’s standard of care. Procedures included nerve decompression, reconstruction after traumatic injury, and planned reconstructive procedures. A majority of these nerves were in the upper extremity (radial, median, ulnar nerves). After exposure and neurolysis, cord membrane was hydrated and placed as a covering over the nerve. In eight cases, sutures (6-0/8-0) were used to secure in place. All surgeons reported the membrane conformed well, easily positioned, and remained intact. The average follow-up was 6 months. There were no reported complications /revisions and patients are recovering as expected. Additional follow-up is on-going. Conclusions Processed human umbilical cord membrane can be used as a soft tissue covering during nerve surgery. This series included multiple injury types where the potential of post-operative scar and inflammation were a concern. Placement was successful in all cases. There were no reported complications or revisions and patients continue to recover as expected.

Curt Deister, Stefanie Villender, Anne Engemann, Brian Romot; Erick DeVinney

AxoGen, Alachua, USA

Introduction: Inflammation is a normal component of wound healing and can result in increased scar formation and adhesions. Placental tissues have been studied as possible mediators of inflammation but their use as an implant for internal surgical applications has suffered from inherent limitations in mechanical properties. This work describes minimally processed placental membranes, isolated from human umbilical cord membrane that retain the beneficial placental properties of the tissue, with its known potential for reducing inflammation and adhesion formation. Processed umbilical cord membrane provides ideal mechanical properties appropriate for a surgical implant while remaining in the wound throughout the wound healing cascade. Methods: Human umbilical cord membrane tissue was obtained and minimally processed following established procedures. Proteins were quantified using Milliplex® kits and analyzed using a Luminex 200TM. Resorption rate was determined by subcutaneous implant in a rat model followed by macroscopic and histological evaluation of resorption at 16 weeks. Thickness was determined by use of a push-gauge as the average of 3 sites along the graft. Tensile strength was measured at a rate of 25.4 mm/min. Suture retention strength was measured with 6-0 suture, bite depth of 3-6mm and a rate of 25.4mm/min. Results: Protein quantification included identification of 28 proteins detected at either higher (13), similar (5) or lower (10) levels compared to unprocessed controls. Proteins found at relatively high levels included several interleukins, TIMP-4 and several growth factors including EGF, FGF, PDGF, VEGF and TGF-β3. Macroscopic and histologic evaluation methods determined that approximately 75% of the implant was resorbed at 16 weeks. Average thickness of the processed umbilical cord membrane was 176µm compared to <25µm for placental amnion. Mean tensile strength of processed umbilical cord membrane was 12.3N and the mean force required for suture pull out was 1.47N. Conclusions: The results of these studies demonstrate that minimally processed umbilical cord membrane retains the inherent properties of native tissue, when implanted remains present for at least 16 weeks, is approximately 8 times thicker than placental amnion, and possesses sufficient mechanical properties to allow normal handling and use in the surgical environment.

Zeynep Tuna 1, Deran Oskay 1, Oktay Algin 2, Orhan Murat Koçak 3

1 Gazi University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Ankara, Turkey; 2 Atatürk Education and Research Hospital, Ankara, Turkey; 3 Kirikkale University Faculty of Medicine Department of Psychiatry, Turkey

Obstetric Brachial Plexus Injury (OBPI) may cause permanent disability through into adulthood. Persistent disability is recently thought to result from central problems rather than peripheral ones. However, studies investigating the cortical changes after OBPI are very poor. Therefore, aim of this study is to investigate the cortical activity during impaired movements by functional magnetic resonance imaging. Five adult patients with right upper trunk involvement and 5 age-matched healthy volunteers participated in the study. Participants watched videos of 2 movements (hand to mouth and neck) of either side inside the scanner with the integrated eyeglasses. Statistical Parametric Mapping (SPM) was used for statistical analysis. The cortical activity level during action observation in the patient group was significantly lower in the control group (p <0,05). Areas of difference were middle temporal gyrus, premotor area and inferior parietal lobule. Region of Interest (ROI) analysis showed that the signal change in these areas was significantly lower in the patient group than in the control group (p <0,05). Observing right and left arm movements in the patient group resulted in similar activity in the cortex (p> 0,05). In conclusion, OBPI causes neuroplastic changes in the cortex, although it is a birth injury and involves peripheral structures. The motor representation of some movements does not appropriately develop as those patients have to grow up into adulthood with significant input lack. Therefore, it is concluded that even if the patients observe the correct pattern of the movements, the motor representation is still impaired in the associative areas.

Karan Dua 1, Lucas Fishman 2, Nathan O’Hara 2, Raymond A. Pensy 2, Walter A. Eglseder 2, Joshua M. Abzug 2

1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA

Introduction: Injury to major peripheral nerves can occur as a result of direct penetrating trauma or crush injuries and subsequently require surgical intervention. Previous studies have mainly reported on digital nerve injuries, whereas the purpose of this epidemiologic study was to characterize patients who have undergone surgical repair of major peripheral nerves at a Level-1 trauma center over a 15-year period. Methods: A retrospective review was performed, assessing all patients who underwent major peripheral nerve repair at a level-1 trauma center over a 15-year period. Patients who underwent digital nerve repair were excluded from the study. Demographic data, type of nerve injured, mechanism of injury, and if the injury occurred as a result of poly-trauma were recorded. Qualities of the nerve repair were assessed including the type of repair and nerve gap distance. The epidemiology of injuries was described using univariate analysis. Nominal logistic regression was used to estimate the effect of model variables on the type of surgical procedures performed. Results: One hundred sixty-four patients were identified that underwent major peripheral nerve repair. Of these patients, 74.1% were male, 55.1% were African American, and the mean age was 31.0 years (SD: 12.0). The most common mechanism of injury was a laceration (36.0%), followed by a gunshot wound (17.7%), and then motor vehicle accidents (16.5%). The most commonly injured nerve was the ulnar nerve (n=39, 23.5%), followed by the median nerve (n=38, 22.9%), and then the radial nerve (n=29, 17.5%). The overall reoperation rate was 9.8%. 20% of patients who underwent either autograft or allograft repair required a reoperation. Nerve gap distance was the only significant predictor of the type of surgical repair performed (p<0.0001). Age (p=0.42) and gender (p=0.65) did not have a significant influence on the type of surgical repair performed. Conclusion: Ulnar and median nerves are the most commonly injured major peripheral nerves. Nerve gap distance was found to be the most significant predictive factor in deciding which repair technique was utilized. Patients who underwent autograft and allograft repair were more likely to require a reoperation.

Ulrike Schnick, Richarda Boettcher

Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Unfallkrankenhaus Berlin, Germany

Objectives: Active elbow and shoulder function are prerequisites for the usability of an affected arm and should be reconstructed. Intra- and extraplexal neurotisations are established surgical techniques. A long term follow-up of several years is necessary to record definite results. Constant assessments of follow-up are required to compare results. Methods: 79 patients with brachial plexus injuries were treated by 95 operations between January 2010 and November 2017. In 53 cases different neurotisations like transfers of intercostal nerves to axillary nerve (15), intercostal nerves to musculocutaneus nerve (21), accessory nerve to suprascapular nerve (30), triceps branch to axillary nerve (19) and modified Oberlin transfer (18) were performed. Neurotisations of musculocutaneus, axillary and suprascapular nerves were usually combined in one surgical session.One year between operation and follow-up was the minimum of this evaluation. Range of motion and muscle force of shoulder and elbow were reported. Comparison with the literature showed limited comparability due to different assessments. Results: Follow-up of 39 patients until December 2016 was included. Shoulder abduction of ≥40° was achieved in 9/12 cases by transfer of intercostal nerves to axillary nerve with median MRC of 3 and in 9/12 cases by transfer of a triceps branch to axillary nerve with median MRC 4. Transfer of accessory nerve to suprascapular nerve led to a satisfying shoulder function in 18/22 cases - mainly in combination with reconstruction of axillary innervation. Elbow flexion of ≥ 90° and MRC ≥ 3 was successful in 12/17 cases by transfer of intercostal nerves to musculocutaneus nerve. A better success rate was achieved by modified Oberlin transfer(12/13). Median muscle force rated 4/5 MRC in all transfers for the musculocutaneus nerve including intercostal transfers and for the neurotisation of axillary nerve by triceps branch. Elbow flexion and shoulder function were both reconstructed in 32 patients. 19/27 (70,4%) of the assessed patients achieved a combined MRC ≥ 3 strength movement of shoulder and elbow. Thus they regained a suitable upper extremity which allowed to use grip and grasp by residual lower plexus innervation or further reconstructive procedures. Conclusion: Nerve transfers are a successful method to regain function in partial or complete plexus injuries. They are the first choice in treatment of root avulsions and long-stretched lesions. In addition pain is significantly reduced by shoulder stabilisation. Better results have been attained by intraplexal neurotisations like Oberlin procedure and transfer of triceps branch to axillary nerve than by extraplexal neurotisations as intercostal transfers. This is probably due to the shorter distance to the recipient muscle. According to other studies short latency between trauma and surgery has a prognostic value. An early and comprehensive diagnostic is determinative for success. In combination with extended contralateral transfers and/or free muscle transfers it might be possible to gain useful results for the whole arm including a simplified grip and grasp.

Femke Mathot 1,2, Nadia Rbia 1, A.T. Bishop 2, S.E.R. Hovius 1, A.Y. Shin 2

1 Erasmus Medical Center, Rotterdam, The Netherlands; 2 Mayo Clinic, Rochester, Minnesota, USA

To optimize the biological support and to enhance the functional outcomes of clinically available nerve replacement treatments (the Avance Nerve graft and the NeuraGen Nerve guide), we attempted to seed adipose derived Mesenchymal Stem Cells (MSCs) on the surface of these nerve substitutes. Subsequently, we studied the MSC viability, the optimal seeding time and the distribution of the MSCs throughout the nerve substitutes. In this study we used human adipose derived MSCs that are well described and characterized. An MTS assay was used to examine the viability of MSCs after different time intervals when a 2mm segment of Avance Nerve Graft or NeuraGen Nerve Guide was added to their environment (3 samples per group per time point). MSC seeding was obtained with a dynamic seeding method using a bioreactor, preserving the inner ultrastructure of the nerve substitutes. Cultured MSCs in growth medium were transferred to conical tubes containing either a 10mm Avance nerve graft or a 10mm NeuraGen nerve guide. An amount of 1 million MSCs per nerve substitute was used. The conical tubes were rotated in the bioreactor for 6, 12 and 24 hours after which cell counts were performed of the remaining ‘free floating’ MSCs in the medium in order to calculate the amount of MSCs attached to the nerve substitutes. For each time point 10 Avance Nerve Grafts and 6 NeuraGen nerve guides were used. The distribution of the MSCs was mapped with live/dead and Hoechst staining. Hoechst stain was also used to observe the distribution of cells on the inside of the graft, by staining fixed cross-sectional sections of multiple segments of the nerve substitutes. Compared to the samples containing only MSCs or only medium, neither the presence of the Avance Nerve Graft nor the NeuraGen nerve guide negatively influenced the viability of the MSCs. For the Avance group, a seeding efficiency of 18% was obtained after 6 hours, increasing to almost 70% after 12 hours after which the efficiency decreased to 65% after 24 hours. For the NeuraGen group, the seeding efficiency increased from 52% after 6 hours to 94% after 12 hours and decreased to 53% after 24 hours. Live/dead stain on all time points showed an equal distribution of viable MSCs over the entire surface of both nerve substitutes. The Hoechst stains showed the same equal distribution on the surface of the nerve substitutes, and revealed that the MSCs were absent on the inside of the nerve substitutes and thus did not migrate into the nerve substitutes. Our study has shown that MSCs are able to survive in the presence of the Avance Nerve graft and the NeuraGen nerve guide. With an optimal seeding time of 12 hours, we successfully seeded viable MSCs onto both nerve substitutes without harming the inner ultrastructure. Seeded MSCs did not migrate into the nerve and remained on the surface of the grafts. This study shows that our methods have great clinical potential to improve and individualize peripheral nerve repair in the future.

Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Atakan Aydın 1

1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, İstanbul, Turkey

Objective: Many scales have been developed to assess daily living activities and clinical functions of the patients on the brachial plexus palsy. “"Brachial Plexus Outcome Measure (BPOM)" was developed in 2012 by Emily Ho, activity and substance containing a total of 14 self-rating scale consisting of the components. Our aim in this study, make an intra-inter rater reliability of BPOM scale, is used to make clinical trial in patients with brachial plexus palsy. Methods: The scale was translated into Turkish by following the appropriate translation step. The demographic data of patients were recorded. The ratings were repeated after 2 weeks. Inter- and intra-rater reliability in items was examined by using weighted kappa statistics. Results: In our study, 18 female (37,5%), 30 male (62,5%) 48 patients were included. Mean age was 8,68±2,432, mean birth weight was 4054,86±538,504 gr. The mean intra-rater agreement in items was excellent (kappa 0.810) in the raters. Fit statistics showed too much variation in the rater, who also had only good (kappa 0.450) agreement in items. The mean inter-rater agreement in items was fair; kappa 0.620, between the experienced raters and kappa 0.50 between raters. Conclusions: The BPOM is a valid and reliable measurement for assessing functions in children with OBPP in Turkey. Overall, the agreement was higher in the more experienced raters, indicating that reliable measures of the BPOM.

Zeynep Hoşbay 1, Safiye Özkan 2, Müberra Tanrıverdi 1, Ömer Berköz 2

1 Bezmialem Vakıf University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Turkey; 2 İstanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Turkey

Objective: We aimed to learn the relationship between range of motion of shoulder and mallet classification, also seperately evaluated mallet scores which are abduction, external rotation and internal rotation in children with obstetric brachial plexus palsy (OBPP). Methods: All datas of children with OBPP had shoulder tendon transfer operation called Modified Hoffer Tecnique were recorded from their file and parents. Range of motion was measured with goniometer by physiotherapist and function of shoulder evaluated with Mallet Classification. Parameters were analysied with SPSS packet program with descriptive, frequenciency and Pearson correlation analysis. The p<0.05 was accepted significantly statistically. Results: Fifty-four (64.3%) boys and 30 (35.7%) girls totally 84 children with OBPP included in the study. When looked at demographics; 47 (56%) have right involvement, 42 (50%) have C5-7 involvement type by Narakas, mean age was 7.30±2.35, and birth weight was 4138.42±512.54. The correlation analysis performed using the results of this study found a positive, moderate, statistically significant correlation between the Mallet total score and mallet abduction (r=0.305; p<0.01) and external rotation (r=0.531; p<0.01) scores, and the Mallet abduction scores and range of motion of abduction (r=0.414; p<0.01), and the mallet internal rotation and range of motion of internal rotation (r=0.298; p<0.01). A negative correlation was found between the children’s the mallet external rotation with mallet internal rotation scores (r= -0.623; p<0.01) and range of motion internal rotation (r=-0.345; p<0.01). Conclusions: The results show us; after shoulder tendon transfering increased external rotation and abduction, however limitation of internal rotation caused the Mallet Classification having wide range of motion. In future studies will focus on evaluating internal rotation with glenohumeral and scapulathorasic joints, seperately.

Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Ömer Berköz 1, Türker Özkan 1

1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey

Objective: We aimed to investigate the relationship between involvement type and upper limb functions of children with obstetric brachial plexus palsy (OBPP). Methods: Demographic characteristics and physical measurements of children with OBPP were recorded. The upper limb functions were evaluated by Brachial Plexus Outcome Measurement (BPOM) scale which that developed by Emily Ho, and contains 14 items. The BPOM has 2 subtitle – activity scale (AS) and self evaluation scale (SES). The AS scored by functional movement scale (1-5). High score, 5 means completes task with normal movement pattern, and lower score, 1 means cannot complete task. The AS has 11 items, totally scored between 11-55. The SES scored by visual analog scale which that 0-10 line. Three lines, first one “my arm works ..”, second one “my hand works …” and third one “my arm and hand looks …” are evaluated apperance and functions from children eyes. Lower score, 0 means bad and poor, high score, 10 means good and excellent. Totally 3 lines scored between 0-30. Results: Forty-eight (18 (37.5%) girl, 30 (62.5%) boy) children with OBPP were included in the study. Mean age was 8.68±2.43 (min-max=4.5-14), when looked at involvement type of children 3 (6.3%) has C5-6, 19 (39.6%) has C5-7, 9 (18.8 %) has C5-T1 and 4 (8.3 %) children has C5-T1 + Horner Syndrome, and the means of BPOM subtitle scales are seperately, AS was 42.21±8.01 (min-max=17-52) and SES was 20.54±7.39 (min-max=2-30). The only statistically significant difference was found in involvement type between the BPOM AS (z= -.495; p<0.01) while no differences were found in other correlations between the scores and characteristics (p>0.05). Conclusions: There is no statistically significant differences between AS and SES scale because of we are thinking that extremity is not participate in activity cause from body imagination, sociocultural levels of children and their parents. In our opinion; in future studies will study to develop on body imagination and participation.

Teodor Stamate 1, Camelia Tamas 1, Radu Budurca 1, Mariana Stamate 2, Ionut Atanasoae 1, Ionut Topa 1

1 University of Medicine and Pharmacy “Gr.T.Popa”, Iasi, Romania; 2 Laboratory of Neurophysiology – Neurosurgery Hospital, Iasi, Romania

Objective Axillary vascular lesions associated with brachial plexus injury pose difficult decisional problems about the moment and the type of microsurgical reconstruction. Treating this kind of lesions at the same operative time has some strong advantages and should be regarded as standard. Methods 82 cases of brachial plexus injuries were selected from which 27 had associated axillary neuro-vascular lesions and were treated by a mixed team: vascular surgeon – microsurgeon. Axillary artery reconstruction was done with saphenous vein interposition grafts in 25 cases and with PTFE grafts in 2 cases. In 21 cases vascular reconstruction was performed immediately and in 6 cases after 24-48 h, delayed emergency. Nerve lesions were located at the level of cords in 19 cases, retroclavicular in 3 cases and supraclavicular lesions in 5 cases. Retro- and infraclavicular nerve lesions were treated primarily in 19 out of 21 cases by external neurolysis and neuroraphy, the reconstruction for the other 2 being through secondary nerve grafting. Spraclavicular lesions especially in elongation and avulsion injuries required secondary reconstruction through combined methods: nerve grafts, nerve transfers (intercostals ± phrenic) and palliative muscular transfers (one pectoralis major, two latissimus dorsi and two triceps). Patients were reviewed at 6, 12 and 36 months postoperatively. The mean age of the patients was 29 years. The average posttraumatic interval prior to surgery was 6-9 months. Muscular reinnervation was evaluated according to BMRC scale. Emergency repair patients presented M3-4 results on BMRC scale in comparison with secondary reconstruction patients with rezults M1-2. Results Neurological recovery was better in primary cases than in secondary reconstructions and nerve dissection was more difficult in these late cases due to scarring and the risk of iatrogenic vascular lesion. Emergency repair of both vascular and nervous lesions is mandatory. Even if the evaluation of the nerves lesions dimensions is difficult in emergency, the clinical experience of the surgeons in replantations and reconstructions of the severe damaged tissue, allows - in many cases - a reasonable evaluation of nervous tissue which is going to be sacrificed or not. Lesions evaluation in combined surgical approach with vascular surgeon and microsurgeon is the best surgical attitude towards this kind of trauma avoiding scared tissue and allowing good anatomy viewing and restoration. Primary reconstruction avoids difficult scar tissue dissection, large nerve graft reconstruction Conclusions In conclusion combined neuro-vascular axillary lesions should be treated by a mixed team – vascular surgeon + microsurgeon – with primary repair of all structures as stated by G. Brunelli. Except for elongation lesions, the other type of brachial plexus injuries associated with axillary vascular lesions worth repairing in immediate emergency after vessel repair or in delayed emergency (5-7 days) after patient stabilisation, can lead to better clinical results than secondary reconstruction. This strategy avoids iatrogenic injury to the vascular graft possible and the difficult dissection in secondary brachial plexus repair.Primary repair by mixed surgical team guarantees the best functional results in complex cases.

J. Braga Silva, G. M. Marchese, C. G. Cauduro, M. Debiasi

PUCRS University, Porto Alegre, Brazil

Objective: systematic review aims to gather evidence regarding the use of nerve conduits for peripheral nerve repair peripheral nerve injuries are a major public health problem. Nerve conduits have been developed in the recent years, although it is still not clear if they should replace nerve grafting and neurorhaphy. Methods: the following electronic databases were searched: MEDLINE, Cochrane Library (CENTRAL) and Embase. Study selection and data extraction followed the PRISMA guidelines. The systematic review of the literature retrieved 6767 articles. Only 27 studies were retained accounting for 1022 patients: 10 randomized controlled trials, 15 case series and 2 cohort studies. Results: ten different types of tubes were described and a variety of evaluation methods were used to assess outcomes in terms of efficacy (motor and sensory recovery) and complications. The Semmes–Weinstein monofilament test and the static and moving 2-point discrimination test were the most commonly applied tests to evaluate nerve recovery. In general, outcomes showed no significant difference between groups. Conclusions: synthetic conduits had more complications. Despite major methodological limitations in the studies, we can conclude that use of nerve conduits is preferable over suture repair and nerve grafting, as the functional recovery rates are above 80%. The choice of conduit is based on the surgeon’s expertise, but use of synthetic conduits is discouraged due to their higher complication rates. 

Panupan Songcharoen, Panai Laohaprasitiporn, Saichol Wongtrakul, Torpon Vathana, Roongsak Limthongthang

Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Background: Limiting source of donor nerve for primary nerve transfer has long been a great obstacle for restoration of function in total arm type brachial plexus injury (BPI) patients. Contralateral donor nerve transfer is an optional treatment for functional restoration of the injured limb. Ulnar nerve has advantage for transferring to contralateral side without using interposition nerve graft and its consistent vascular supply for vascularized nerve transfer. Objective: To report long-term (over 10 years) functional outcomes after vascularized contralateral ulnar nerve transfer to median nerve in 2 total arm type BPI patients. Material and Method: Two patients with total arm type BPI underwent vascularized contralateral ulnar nerve transfer to median nerve and end-to-side anastomosis of distal ulnar donor nerve stump to median nerve. Functional recovery of injured limb and residual deformity of donor limb were recorded during follow-up period. Results: Two patients were male sustained motorcycle accident at the age of 17 and 32 years old. The index surgery was performed at 7 and 6 months, respectively, after the injury. Motor recovery of wrist flexor was regained to Medical Research Council (MRC) grade 2 at 2 years and grade 3 at 6 years follow-up. MRC grade 1 of finger flexion was detected at 6 years follow-up. One patient has been followed for 16 years and found recovery of wrist flexor to MRC grade 4. The thumb and finger flexor were recovered to MRC grade 3. All of the patients had initial sensory deficit along donor-side ulnar nerve distribution with claw deformity. However, sensory deficit and claw deformity gradually recovered in all of the patients at 3 ½ years after surgery. Conclusions: Vascularized contralateral ulnar nerve transfer to median nerve with end-to-side anastomosis of distal ulnar nerve to median nerve can be a treatment option for total arm type BPI patients with limiting donor nerve.

Shigeya Suzuki 1, Masashi Abe 1, Kio Suzuki 1, Yosuke Usui 2, Takao Omura 3, Yukihiro Matsuyama 3

1 Fujieda Municipal General Hospital, Fujieda, Japan; 2 Mizutani Pain Clinic, Shizuoka, Japan; 3 Hamamatsu University School of Medicine, Hamamatsu, Japan

Objective: Intraoperative monitoring during hand surgery using WALANT (wide awake, local anesthesia, no tourniquet) is a powerful technique which is now utilized worldwide. However, when performing peripheral nerve surgery, tumescent injection of lidocaine with epinephrine into the area surgical field will also block the objective peripheral nerve adjacent to the injected area and is not an ideal method when the peripheral nerve is preferred to be intact and un-anaesthetized. Here, we report a novel ultrasound guided selective nerve block for ‘Intraoperative monitored peripheral nerve surgery ’. Methods: We performed ultrasound guided selective nerve block in three cases. Two cases were on cubital tunnel syndrome patients and one case was on a schwannoma arising from the median nerve. For cubital tunnel decompression, radial nerve, medial cutaneous nerve of the forearm, medial cutaneous nerve of the arm was blocked and the ulnar nerve was left intact in order to perform intraoperative monitoring. During operation, elbow flexion test was performed to ascertain the degree of decompression. The extent of ulnar nerve release was determined by the diminished symptom by elbow flexion test. For enucleation of the schwannoma arising from the median nerve, radial nerve, ulnar nerve, musculocutaneous nerve, medial cutaneous nerve of the forearm was blocked and the median nerve was left intact. 0.15% ropivacaine 4ml was used for each nerve block. 1:100,000 epinephrine was injected into the surgical field and no tourniquet was used. Results: Cubital tunnel decompression; In one patient, elbow flexion test became negative after Osborne ligament was released whether as in another patient, elbow flexion test persisted until the anterior nerve transposition was complete. Schwannoma enucleation; The intact median nerve enabled us to monitor the appearance of numbness or pain during incision of the nerve sheath until enucleation. The patient could feel the tactile sensation, when an intact fascicle was touched. This lead us to minimize the damage to the nerve fascicles and there was no neurological deficit postoperatively.Conclusions: Peripheral nerve can be monitored intraoperatively with our novel ultrasound guided selective nerve block anesthesia. Our technique enables more precise and safer surgery on peripheral nerve.

Bauback Safa 1, Jaimie T. Shores 2; John V. Ingari 2, Renata V. Weber 3, Mickey Cho 4, Jozef Zoldos 5, Timothy R. Niacaras 6, Leon J. Nesti 7, Wesley P. Thayer 8; Gregory M. Buncke 1

1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 Multi-Disciplinary Specialists, Rutherford, USA; 4 San Antonio Military Medical Center; Fort Sam Houston, USA; 5 Phoenix, USA; 6 JPS Health Network, Fort Worth, USA; 7 Walter Reed National Military Medical Center; Bethesda, USA; 8Vanderbilt University Medical Center; Nashville, USA

Introduction: Severe trauma to the upper extremities often results in the transection of mixed and motor peripheral nerves. Without surgical management, these transection injuries result in functional loss that can seriously affect the patient’s overall quality of life. Clinical data demonstrate that PNA is safe and results in positive functional outcomes for the reconstruction of nerve gaps up to 70 mm in length. However, these studies mostly report on sensory outcomes. The RANGER® Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc.). Here we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature. Methods: The RANGER® database was queried for acute mixed and motor nerve injuries in the upper extremities, head and neck area having completed greater than six months of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the MRC scale. Demographics, outcomes and covariate analysis were performed to further characterize this sub-group. Results: The sub-group included 33 subjects with 36 nerve repairs. The mean ± SD (minimum-maximum) age was 39±19 (16-77) years. The median time to repair was 8.5 (0-133) days. The mean graft length was 34±20 (10-70) mm with a mean follow up of 594±441 days. No significant differences were found in subject age, pre-operative interval or follow-up length among subgroups (P> 0.05, ANOVA test). Meaningful motor recovery was observed in 75%. When looking at higher thresholds of recovery, 53% of these demonstrated M4 or greater recovery in repairs with at least 1 year of follow-up. The cohort was also divided and analyzed in three subgroups based on gap length: 10-25 mm, 26-49 mm and 50 mm or greater. Meaningful recovery of motor function was reported in 69%, 77% and 86% of repairs in these subgroups, respectively. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events reported. Conclusion: Processed nerve allografts provided functional motor recovery when used for mixed and motor nerve repairs. Outcomes compare favorably to historical controls in the literature for nerve autograft and exceed those for hollow tube conduit. Processed nerve allograft may be considered as an option when reconstructing major peripheral nerve injuries.

Sergii Strafun, Oleksii Dolhopolov, Serhii Bezruchenko

State Institution «The Institute of Traumatology and Orthopedics by the National Academy of Medical Sciences of Ukraine”, Ukraine, Kyiv

The microsurgery technique development has considerably extended the possibilities of functional recovery in case of ischemic severe injury of upper limb. During the period of 11 years 25 patients operated with injuries of peripheral nerves and posttraumatic ischemia of upper limb. Depending on the stage of ischemia process, the patients were subdivided into 3 clinical groups. The first clinical group included 9 (36%) patients with compartment syndrome and neurovascular injuries. The second group - 10 (40%) patients with injured peripheral nerves of upper limb in reactive-recovery period of ischemic contracture. The third group – 6 (24%) patients with Volkmann’s ischemic contracture in residual period and injured peripheral nerves of upper limb. Patients of all clinical group underwent precise clinical and instrumental examination to exclude sensitive and functional disorders of upper limb as well as sonography and MRI examination in dynamics. Among the 9 patients of the first group the most frequent was the suture n.medianus and/or n.ulnaris in the middle and lower part of forearm 6 (66.7%). In 2 (22.2%) patients the suture was performed at the edge of the middle and lower parts of shoulder. In one case (11.1%) there was a suture of finger nerves at the level of palm. Special conditions for recovery of these nerves were adjustment of performance of fasciotomy wounds with approaches to neurovascular batches. In 5 (55.5%) patients with compartment syndrome the damage of peripheral nerves was combines with comminuted fractures of bones of upper limb. In these patient’s recovery of nerves has been performed after elimination of acute ischemia signs (3 weeks) and osteosynthesis by external fixation. Among 10 patients of the second group in 5 (50%) cases we performed neurolysis of n.medianus and/or n.ulnaris. In 3 (30%) the suture of the abovementioned nerves was performed. Plastic by n.suralis has been performed in 2 (20%) cases. Peculiarity of neurolysis of the abovementioned nerves was that it has been performed almost along the whole ischemic compartment. In some cases, the area of neurosis exceeded 9-12cm. While suturing the peripheral nerves we observed big areas (over 4cm) of intra-stem neuromas. In process of nerve plastics we tried to put the transplants of n.suralis out of limit of ischemia diseased compartments. In the third group all 6 patients underwent plastics of peripheral nerves. It should be mentioned that even if a size of an initial defect of nerves was up to 2cm, after resection of neuromas in proximal and distal parts the size increased to 4-6cm, requiring plastics by transplants of n.suralis. Long term results of treatment were assessed according to AOOS as modified by Kurinnyi I.M. (1996), for the period over 2 years. In 14 (56%) patient the achieved result was excellent, in 8 (32%) was good, in 3 (12%) it was satisfactory. The total increase of the function of ischemic upper limb in average was over 40%, being sufficient for medico-social adaptation of this complicated category of patients.

M Yavari, D Royeentan, H Mahmoudvand

Shahid Beheshti University of Medical Science, Tehran, Iran

there is a very small chance of success for nerve reconstruction in the patients with old total brachial plexus palsy who refer after two years or suffer from flail upper extremity after the failure of prevues operation. for these individuals, the surge has to find a recipient motor nerve in order to perform free gracilis muscle transplantation. in this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve, then in the second operation, approximately 15 month later, free gracilis muscle transfer was performed. the gracilis muscle was removed and transferred to provide the elbow and finger flexion. in a retrospective study (Over 10 years) we reviewed 68 patients, for whom this method has been performed, after 1 year , the result were investigated using MRC grading system. five patients did not participate in the study. muscle power of M3 and M4 was regained in 26 and 21 patients, respectively contralateral pectoral nerve transfers followed by the free muscle transplantation can be used as a good option for patients with ld total racial plexus palsy

Onur Seyrek 1, Burcu Semin Akel 2

1 Hacettepe University, Faculty of Health Sciences, Department of Physical Therapy And Rehabilitation, Ankara, Turkey; 2 Hacettepe University, Faculty of Health Sciences, Department of Occupational Therapy, Ankara, Turkey

Objective Guitar players are at high risk of facing neuromuscular and musculoskeletal injuries. Guitarists are experiencing and reporting pain more than other instrumental musicians. The pain and discomfort they have may be due to neurovascular entrapment. In this study, we aimed to relieve the symptoms caused by neurovascular entrapment by using myofascial releasing techniques. Methods A 38-years-old guitar player with the diagnosis of Thoracic Outlet Syndrome had stiffness and coldness at the right hand for 6 months. Inspection of the upper limbs bilaterally showed vasomotor changes. Pain was present during forearm supination at 1 cm lateral to the extensor muscles’ belly. Symptoms aggravate while playing and patient had poorer performance due to the symptoms. Demographic information and painful movements were noted. Posture analysis of static erect posture and static guitar holding was made. Upper extremity neurovascular entrapment was assessed with Roos, Wright’s, Adson’s Tests and Suprascapular maneuver before and immediately after the session. The myofascial releasing session included releasing of right anterior and middle scalene, sternocleidomastoid, levator scapula, upper trapezius, pectoralis major and minor, subscapularis, teres major and minor, latissimus dorsi muscles and lateral and medial intermuscular septum of the right arm. Results The patient was playing guitar for 15 years amateurly and 3 years professionally. Average daily practicing time was 3 hours. Coldness was present at all fingers and ulnar side of the hand. Static erect posture analysis showed forward and right lateral tilt of head, shoulder protraction, right shoulder elevation, left rotation of torso, right rotation of pelvis, external rotation of hips. Static posture analysis on guitar showed tibial and femoral external rotation, left rotation and lateral flexion of torso, right shoulder protraction and elevation, excessive thoracic kyphosis and head-neck flexion, right lateral tilt and rotation of head. Before the session Roos and Wright’s tests were positive for neurovascular entrapment. Patient graded the pain at Roos Test as 6/10 on visual analog scale. Adson’s Test and Suprascapular Maneuver was negative. Pain during forearm supination was 3/10. After the session Wright’s Test was negative and pain at Roos Test reduced to 2/10. Pain during forearm supination was absent. Coldness reduced at the ulnar side of the hand but not at fingers. Conclusion Asymmetrical posture while playing guitar for years may cause stiffness following muscle chains from bottom to top. Assessment of the playing posture made us think, constantly depressing upper body with thoracic kyphosis cause tightness at quadratus lumborum and abdominal muscles. Right laterally rotating and tilting head makes sternocleidomastoid muscle overactive. To balance the force generated by tight abdominals and forward head posture, upper trapezius, anterior and middle scalene will be overloaded. Tightness at abdominal muscles and right shoulder protraction compromises pectoral muscles and reduce subacromial space. Possible entrapment sites were between scalene muscles and under pectoralis minor. The immediate relief of symptoms contributes to the muscle chains mechanism. Therefore, myofascial releasing would be an effective approach to the guitar players who have neurovascular entrapment caused by soft tissues. Long-term follow up with larger sample is needed to provide further proof.

Ryo Okabayashi 1, Takao Omura 2, Takato Ohishi 1

1 Iwata City Hospital, Iwata, Japan; 2 Hamamatsu University School of Medicine, Hamamatsu, Japan

Objective Humeral shaft fracture associated with radial nerve palsy post-injury mostly occurs in distal third of the shaft. However, it is sometimes difficult to decide whether these cases should be treated conservatively or surgically. The purpose of this study is to analyze the relationship between the location of humeral shaft fracture and the recovery of radial motor nerve paralysis. Methods Medical records of 11 patients who underwent open reduction and internal fixation for humeral shaft fractures with radial nerve paralysis which developed prior to injury between 2010 and 2017 were reviewed. The patients consisted of 3 male and 8 female with an average age 54.7 years old (21 to 90). Location of humeral shaft fracture, the distance from the proximal edge of the olecranon fossa to the fracture location measured using plain radiograph, the fracture type, the period from surgery to the recovery of extensor carpi radialis (ECR) and extensor digitorium communis (EDC) by MMT of 3 or more and the status of the radial nerve during operation were investigated. Children under fifteen years old were excluded from this study. Results The fracture locations were one each at the proximal third and middle third, and 9 at the distal third. The average distance from the proximal edge of the olecranon fossa to the fracture location was 69.1mm(42~92mm). Four patients had spiral, 2 had oblique 1 had transverse, and 4 had comminuted fracture. The average recovery period for the recovery of MMT 3 in ECR was 3.7 months and 4.6 months for EDC. There was one case of an open fracture, which took five months for the recovery of ECR and 12 months for the recovery of EDC. There was no significant difference between the recovery period and the fracture type. Seven cases were surgically explored and all of their radial nerves were in continuity. Conclusion The recovery of the radial nerve paralysis does not depend on the fracture type and in most of the cases, the recovery of ECR can be achieved in less than 4 months.

Joshua M. Abzug 1, Alexandria L. Case 1, Orlando Merced-O'Neill 2, Eric DeVinney 2

1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 AxoGen, Inc., Alachua, Florida, USA

Introduction: Tension at nerve repair sites is associated with impaired nerve regeneration and thus poor clinical outcomes. Additionally, lacerated nerve ends that have edema, scar, and/or hemorrhage, without exposed axons, limit the potential growth of regenerating axons. Thus, it is often necessary for nerve ends to be trimmed prior to direct repair or nerve grafting. The purpose of this study was to determine what effect trimming nerve ends has on the tension at the repair site. Methods: The common digital nerves to the 2nd, 3rd, and 4th webspaces were exposed in six cadaveric hands. Each nerve was then sharply lacerated. Subsequently, with the aid of a digital caliper, one nerve was trimmed 2 mm (equivalent to trimming 1 mm of each cut end of a nerve) and one nerve was trimmed 5 mm (equivalent of trimming 2.5 mm of each nerve stump.) The nerve trimming distance (0, 2, or 5 mm) was randomized in each hand. Following transection and trimming, the nerves were reapproximated, such that they were just “kissing” and the tension required to do so was measured with a tyrolean tensiometer. The tension required to make the nerve ends oppose each other was measured 10 times for each nerve. Statistical analysis was then performed. Results: Tension at the nerve repair site significantly increased as more nerve was trimmed. The average tension required to oppose the nerve when no trimming occurred was 1.3 N. Tension increased to 3 N when 2 mm of nerve was trimmed. When 5 mm of nerve was trimmed, the tension increased to 7.1 N (p<0.05). Conclusion: Removing the damaged nerve tissue plays a critical role in preparing a transected nerve for repair. As one trims a lacerated nerve to expose “good” nerve ends, significantly more tension is required to permit a direct repair. The exact threshold of acceptable tension at a nerve repair site remains unknown. However, it is important to recognize that if significant trimming of the nerve ends is performed, one may want to consider utilization of a nerve conduit or nerve graft to minimize the tension at the site of the nerve repair.

Sergio Daroda, Facundo Zabaljauregui, Fernando Menvielle, Rodolfo Cosentino, Paul Pereira

Clínica de la Mano GAMMA, La Plata, Argentina

Objective: The main purpose of this poster is to show the preliminary results in our first patient using the Great Occipital Nerve as a donor nerve in brachial plexus reconstruction. The secondary objectives are to describe the path, the relations and peripheral nerve length and its mobilization to reach the suprascapular nerve. Materials and methods: Eight cadaveric specimens were used with dissections of the two Great Occipital Nerves (GON) with a total of 16 GONs. They were dissected from the outlet at the rachis up to its surface emergence. Length measurements were registered between these points; the topographic point of its emergence in the nape skin was identified. Also the mobilization from this point to the inner scapula angle was recorded. Finally, the number of axons before and after the exit of the motor branches for the nape muscles was histologically studied. A 25-years-old patient with a total preganglionar brachial plexus palsy was operated on with a nerve transfer from the great occipital nerve to the supraescapular nerve using a nerve graft. The time from the injury to the surgery was 18 months. Results: Anatomical results: Six and 2 specimens out of 8 were males and females respectively. The length from its exit between the first and second cervical vertebrae and its emergence in the nape skin was 62 mm average. With lateral nerve mobilization, a distance of 27 mm to the medial border and superior angle of the scapula was reached. Also the length to the suprascapular notch was measured obtaining an average distance of 73 mm. Clinical result: after one postoperative year the patient shows an M3 activity of the supra and infraespinatus muscles confirmed by electromyography. Conclusions: Using the mobilization, the GON can be reached close to the suprascapular notch. This is an alternative to neurotize the suprascapular nerve and to free the accessory nerve for another transfer. Even though the sample is very low, we believe the GON can be a new source of nerve donor motor for brachial plexus reconstruction.

C.K. van der Sluis, J.M. van Bodegom, K. Postema, P.U. Dijkstra

University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands

Introduction: A brachial plexus injury (BPI) has a restricting effect on the function of the arm. As a result, the non-affected arm performs more daily tasks or perform tasks unilaterally which normally are executed bilaterally. This could lead to overuse injuries of the non-affected arm, neck or upper back. Objective: To assess the prevalence of overuse injuries of the non-affected arm, the neck and/or upper back in patients with BPI compared to a control group. Secondary objectives were to investigate factors predicting pain and disability. Patients: Patients were recruited from three outpatient departments of rehabilitation medicine in the northern region of the Netherlands. Eligibility criteria were: Having a unilateral brachial plexus injury (not due to plexus neuralgia), aged 18 years or older, date of injury more than 1 year ago, understanding written Dutch language, no co-morbidities influencing upper limb function Methods: Musculoskeletal pain was defined as pain in the muscles, tendons and/or bones not caused by an accident, sports injury, infection or joint disease. Prevalence of MSC was defined as the proportion of individuals with MSC in the preceding year. A survey was distributed by mail. The questionnaire comprised personal, work-related, social and pain specific questions: Upper Extremity Work Demands (UEWD), Pain Disability Index (PDI), Utrechtse Coping List (UCL) with active, avoidance, and support seeking questions and the RAND-36 with subscale health perception, mental health and pain. Results: Seventy-nine patients (mean age 51 years; 65% men) and 114 controls (mean age 50 years; 63% men) participated. The prevalence of MSC was significantly higher in the BPI-group (52%) compared to the control group (38%, P=0.041). Patients with BPI experienced more disability in participation (P=0.005). Mental and general health (RAND36), upper extremity work demands (UEWD) and coping styles (UCL) were similar in participants with BPI and the controls. Presence of MSC was associated with worse self-reported mobility of the affected arm, an active coping style, and lower mental and general health. Higher disability was associated with the presence of MSC, worse self-reported mobility of the affected arm , female sex and a shorter time since injury. Discussion and conclusions: The high prevalence of MSC in individuals with BPI indicates that patients with BPI are at risk for developing musculoskeletal complaints in the non-affected arm, neck or back. The self-reported functional mobility of the affected arm seems to be a useful predictor for clinical practice, since it predicted MSC as well as disability. The influence of coping styles on MSC in patients with BPI needs further attention.

Franco Bassetto 1, Manfredo Atzori 2, Matteo Cognolato 2,3, Diego Faccio 1, Gianluca Saetta 4, Arjan Gijsberts 5, Valentina Gregori 5, Mara Graziani 2,5, Francesca Giordaniello 2,5, Andrea Gigli 5, Francesca Palermo 2,5, Peter Brügger 4, Barbara Caputo 5, Henning Müller 2, Cesare Tiengo 1

1 Clinica di Chirurgia Plastica, Azienda Ospedaliera Universitaria di Padova, Padova, Italy; 2 Department of Business Information Systems, University of Applied Sciences Western Switzerland, (HES-SO Valais), Switzerland; 3 Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland; 4 Department of Neurology, University Hospital of Zurich, Zurich, Switzerland; 5 Department of Computer, Control, and Management Engineering, University of Rome “La Sapienza”, Rome, Italy

Objective This work presents the Megane Pro project, which has three main objectives: first, to improve hand prostheses by reproducing eye-hand coordination in prosthetic hands; second, to better understand phantom limb sensation and the neurocognitive effects of hand amputations; third to better integrate surgical procedures with prosthetics. The overall aim is thus to improve the capabilities and quality of life of amputees, who are - despite recent scientific progress – still affected by the limited control of prosthetic hands. Phantom limb sensation is a good predictor of how well amputees can control a robotic prosthesis, but little is known about the mutual interactions between different types of sensation and the use of a prosthesis. Methods The data acquisition setup for detecting hand movements includes 12 surface electromyography electrodes, a pair of eye tracking glasses equipped with a scene camera and a laptop. The acquisition protocol includes four exercises and a set of neurocognitive tests. The first exercise aims at improving robotic hand prostheses control. The subjects are asked to repeat 12 times several hand grasps on a set of various objects. The movements are collected from the hand movement taxonomy literature and they are presented to the subjects as videos. The grasps are repeated both as static and functional movements. The second, third and fourth exercise aim at better understanding phantom limb sensation and the neurocognitive effects of hand amputations. They include the repetition of executed and imagined movements as reported in Sirigu et al., the classical apparent motion paradigm with body parts introduced by Shiffrar and Freyd, and an experiment based on imagined and executed movement of the hand in presence of an obstacle, aimed to study obstacle shunning. The neurocognitive experiments are enriched with gaze and sEMG measures. Phenomenal characteristics of individual phantom limb sensations are assessed by structured interviews such as the interview on phantom sensations (RAM SIPS) and the phantom and stump phenomena interview. The multimodal data are analysed with statistical and artificial intelligence methods. Results The results highlight the usefulness of the acquisition setup and protocol both for prosthesis control and for neurocognitive research. Surface electromyography, eye tracking and computer vision allow to obtain more complete data. The acquisition protocol allows for a qualitative and quantitative assessment of painful, not painful and residual phantom limb sensations and examines the properties of a phantom limb when brought “in contact” with material objects. The results suggest that the interaction between sensory-motor imagery and the visual observation of objects in the environment might critically influence the properties of a phantom limb. Conclusions This paper provides an interdisciplinary insight into hand amputations and hand prosthesis control. A proper integration between surgical procedures, neurocognitive analyses, multimodal data acquisition and artificial intelligence algorithms can make current prostheses more autonomous, restoring eye-hand coordination, leading to naturally controlled robotic hands with better performance. The experiments are highly informative regarding phantom limb properties, both painful and painless, and when a phantom gets “in contact” with external objects.

Cesare Tiengo, Arianna Gatto, Andrea Monticelli, Franco Bassetto

Plastic Surgery Department, Padova, Italy

Objective: Peripheral nerve injuries following traumas are an epidemiologically relevant problem due to their poor outcome. They still need an appropriate and effective management. In the last decades, improvements in the field of biomaterials and nanotechnologies have offered a suitable alternative to more invasive methods such as autografts or allografts, leading to the production of far more sophisticated scaffolds which are able to interact with cells and macromolecules on a nanoscale. Prompted by an in depth review of current biomaterials and nanotechnologies, by the encouraging results of various in vitro studies on a novel MWCNT-PhMO_PLLA(4-methoxyphenyl-functionalized-multi walled-carbon nanotubesand PLLA-nanofibers)-based scaffold, we tested this material, combined with an external CNTfree-PLLA-wide mesh supporting structure, in vivo on a murine model of injuried sciatic nerve. Our study aimed to evaluate its effectiveness when used as a wrapping sheat compared to the actual gold standard, the epineurial suture. Moreover, we aimed to demonstrate its biocompatibility, its ability to prevent adhesions and collateral sprouting and the absence of Wallerian degeneration downstream the injury. The latter would be the real improvement compared to wraps actually on the market which have only a protective function, preventing from adhesions as well. Materials and methods: The right sciatic nerve of 7 mice was transected, repaired with an epineurial suture and then wrapped with our novel wrapping sheat. Other 3 mice underwent sciatic nerve transection and epineurial suture repair to be used as controls. All of them were monitored for the following 30 days and tested through functional tests, such as De Medinaceli test, Open Field test, Walking Track test and EMG. On the 30th day nerves and muscles were taken to be histologically analyzed. Results: Results from De Medinaceli, Open Field and Walking Track tests were statistically different between CNT-PLLA mice and sutured mice. The CNT-PLLA group showed a faster and greater improvement in all the performed tests. Friedman's test indicated improvement in the CNT-PLLA group has been far more relevant. Electrophysiology confirmed the absence of Wallerian degeneration and the presence of a biphasic compound muscle action potential (CMAP). Histology showed no adhesions and no fibrotic reaction. Muscle showed a certain grade of atrophy albeit higher among the suture group. Conclusions: Statistical analysis highlighted the better results gained by CNT-PLLAgroup in functional tests. Electromiography excluded the presence of denervation downstream the suture site and confirmed the CMAP is restored. Therefore histology confirmed that no foreign body reaction has occured and adhesions and neuromas have been avoided and showed a higher grade of atrophy in the suture group. Our MWCNT-PhMO-PLLA nanofibers based scaffold has proved to prevent Wallerian degeneration, being fully biocompatible and protective from adhesions ande neuromas at the same time.

Viviana Maja Rosero 1, Katalin Dévay 1, Zsuzsanna Aranyi 2

1 Merenyi Gusztav Hospital, Budapest, Hungary; 2 Department of Neurology, Semmelweis University Budapest, Hungary

Objective: To assess with high resolution ultrasound penetrating nerve injuries before or after nerve reconstruction. Methods: Between 2016 and 2017, consecutive patients with complete or incomplete penetrating nerve injuries were included in the study prospectively. All patients underwent clinical, electrophysiological, and B-mode and color Doppler ultrasound examination. The size of the scar / neuroma at the injury site was measured, and correlated with the degree of reinnervation where reconstruction was carried out and sufficient time has elapsed. Intraneural blood flow was quantified. Results: 30 patients with 34 injured nerves were included in the study. Most of the nerves were treated with epi- / perineural nerve suture. The earliest time point for assessment was 2.5 months, the latest was 30 years after the injury. No significant correlation was found between the degree of reinnervation and the size of the scar / neuroma. However, in a number of cases ultrasound has shown findings which prompted surgical intervention / revision. These included unrecognized neurotmesis, complete misalignment of the sutured stumps, and suture neuroma. A consistent finding was marked intraneural blood flow, not normally detected in intact nerves, proximal to the injury site. The hypervascularization was seen in all nerves, both in untreated and treated injuries. Conclusions: Hypervascularization of the nerves proximal to injury site appears to be an essential element of nerve regeneration after penetrating nerve injuries. We hypothesize that hypervascularization reflects neovascularization triggered by axonotmesis. Ultrasound may also provide important information with respect to the therapeutic pathway.

Dalia Mohamed, Dominic Power

The Hand and Peripheral Nerve Research Network, Institute for Translational Medicine, Birmingham, UK

Objective: Randomised controlled trials involving interventions in an emergency setting are notoriously difficult. Successful recruitment and retention of participants into research studies is critical for optimising internal and external validity. Balancing service pressures and the administrative burden necessary for robust trial methodology creates challenges that must be reconciled to maintain recruitment targets Methods: The CoNNECT study is a randomised controlled interventional trial with three arms evaluating the role of tension in a digital nerve repair model. The study centre is a tertiary referral hand trauma service with approximately 600 new attendances resulting in approximately 350 hand trauma cases each month. Recruitment is through a 2-stage eligibility screening process with final confirmation of eligibility after surgical exploration of the wound. At this stage the nerve to be repaired is randomised with stratification for age. Repair is then completed with microsurgical suture, Neurolac protection of a suture repair or with a Neuralac-assisted tension free co-aptation with remote sutures. The complexity of the trial design requires co-ordination between several different clinical areas and co-operation between junior medical staff, hand co-ordinators and research nurses. Interim recruitment audit in the early phase of the trial identified missed recruitment opportunities. A bespoke electronic patient record for hand trauma has been re-engineered to provide automated prompts during initial assessment of all patients with potential nerve injuries. Results: The E-hand system was designed at the Birmingham Hand Centre for the assessment and management of hand injuries. Referral, assessment, surgery and therapy data is compiled in a single system that generates workload data for co-ordination of the patient pathway. Activity reports provide accurate data on trial recruitment and missed potential trial patients. Redesign of the assessment tool to create an automated alert regarding trial eligibility and confirmation of inclusion criteria has resulted in optimisation of trial recruitment. Patients can be provided with trial information that they can review in advance of a planned day surgery admission for surgery and the research team are alerted to the date and time of attendance for surgery. Conclusion: Randomised controlled trials in trauma surgery are complex and there are challenges created by the short time available between presentation and surgery. Rotating junior staff are the first point of contact for new trauma patients and clinical pressures may limit trial recruitment. Redesign of the E-hands management system has ensured trial recruitment is optimised and that there is compliance with Good Clinical Practice guidelines.

Belén García-Medrano 1, Nuria Mesuro Domínguez 2, Clarisa Simón Pérez 3, Fernando Moreno Mateo 1, Manuel Garrosa García 3, Miguel A Martín-Ferrero 1, Sara Gayoso del Villar 3, Manuel José Gayoso Rodríguez 3

1 Orthopaedic Surgery, Hand Unit, Hospital Clínico, Valladolid, Spain; 2 Otorhinolaryngology Department, Hospital Clínico, Valladolid, Spain; 3 Cell biology and Histology department, Faculty of Medicine, University of Valladolid, Valladolid, Spain

INTRODUCTION: When a gap occurs in a lesion of peripheral nerve, the repair is possible by using a prothesis to bridge the gap between proximal and distal nerve ends. Many and of variegated origin prostheses have been employed, but none has rendered convincing results. The morbidity and limitations of the nowadays most employed treatment, opens the way to the search of surgical and biological alternatives. OBJETIVE: To obtain segments of decellularized human nerve by a new chemical method as a basis for the manufacture of biocompatible prostheses useful in the repair of human nerve injuries. MATERIAL AND METHODS: Nerves from organ donors were decellularized by a chemical method patented by one of us (MJ Gayoso, P201531544) without detergents. These prostheses were subsequently implanted, after anesthesia, in receiving Wistar rats, in which a 7 mm defect was made in a sciatic nerve. The implants were maintained for a period of 2, 4, 8 and 16 weeks. After the implant period the animals were subjected to Sciatic Functional Index (SFI) test and after anesthesia sacrificed by intracardial perfusion to complete the histological study using light and electron microscopy. RESULTS: Our decellularization method manages to eliminate Schwann cells, perineural and endoneural cells, preserving the extracellular matrix due to the absence of detergents. Functional test revealed poorer functional recovery in implanted rats as compared with our previous studies using allogenic grafts. Likewise, we have observed a greater graft rejection in this xenogenic grafted rats than with allogenic grafts. DISCUSSION: Our method of decellularization seems adequate for the development of allogeneic prostheses for clinical use. A biological study has been initiated to establish which part of the defensive reaction that leads to rejection of the human prosthesis by xenogene implanted rats is due to interspecies response. This defensive reaction is expected not appear in an allogenic graft implanted in human nerves.

Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Injury to the infraclavicular brachial plexus is an uncommon complication of dislocation at the glenohumeral joint that results in a devastating loss of upper limb function and debilitating neuropathic pain. The patterns of injury and associated injuries are poorly defined in this injury group. Recognition of injury patterns can guide management and prognosis. Methods: We reviewed all cases of brachial plexus injury presenting to a regional peripheral nerve injury service during a three year period from 2012-2016 with at least 12 months follow up at final review. Medical records, therapy records, imaging and neurophysiology reports were reviewed and recorded in a database derived from a prospective peripheral nerve injury workload database where injuries were coded after first assessment. Demographic and injury details were recorded and a consensus on nerve injury grade was achieved by 2 reviewers and with senior author review where no consensus was reached. Results: 2500 new patient episodes have been recorded since 2012. Database interrogation identified 110 infraclavicular brachial plexus injuries during a 3 year period to 2016 with at least 12 months follow up. Following exclusion of high energy injuries, stabs, gunshots and iatrogenic injuries there were 52 injuries classified as low energy and a sub-group of 40 cases of confirmed glenohumeral dislocation were included in the final analysis. There were 26 female and 14 male patients in this sub-group with a mean age of 61 years (range 24-86). 13 patients sustained a greater tuberosity avulsion fracture and 11 patients sustained rotator cuff tears. There were 5 vascular injuries. Nerve injury classification data was complete in 36 patients (90%). Review of the injury patterns identified axonopathy of all 3 cords (medial, lateral and posterior) in 21 cases (58%) although 2 had sparing of the axillary nerve. The medial cord was most commonly injured in 78% of cases. In 5 cases (14% of classified injuries) there was a medial cord injury with additional involvement of the lateral head of the median nerve but sparing of the musculocutaneous nerve and the posterior cord. This group has not been previously described and the outcome for the hand is generally poor due to loss of the intrinsic muscles and limited reinnervation of the extrinsic finger flexors. Conclusion: Defining injury patterns can help to evaluate outcomes after brachial plexus injuries and assist in providing a prognosis. Early recognition of an injury sub-group with medial cord and lateral head of median nerve involvement (medial cord plus median nerve) and sparing of the posterior cord and musculocutaneous nerve may provide an opportunity for consideration of novel targeted nerve transfer surgery to restore hand function despite the long reinnervation distances necessary to reach forearm and hand motor targets.

Daniel Guerero 1, Isabel Guy 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets. Methods: Review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reverse innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets. Results: The medial cutaneous nerve of the forearm (MABCN) arises as a direct branch from the medial cord of the brachial plexus and has no branches in the upper arm. Following axonopathy of the medial cord there is Wallerian degeneration of the sensory axons in the MABCN. Mobilisation of the distal end at the proximal forearm enables a loop to be created and distal to proximal retrograde innervation may be achieved using the nerve to brachialis, the medial head of triceps branch, the nerve to supinator or the extensor carpi radialis branch of the radial nerve. Staged transfer of the vascularised motor graft can be achieved following axonotomy of the proximal end of the MABCN from the medial cord after reinnervation. A number of distal targets for these motor axons can be reached within the 9-12 month window necessary for a successful reinnervation. Targets include the anterior interosseous nerve, the flexor digitorum profundus branch of the ulnar nerve and the motor fascicle of the ulnar nerve in the distal forearm. Conclusions: A novel staged motor nerve transfer using a reverse innervated in-situ vascularised sensory nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.

Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2

1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

Objectives: Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets. Methods: A review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reversed innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets. Results: The lateral cutaneous nerve of the forearm (LCNF) arises as a direct branch from the musculocutaneous nerve after the innervation of brachialis. In a patient with a functioning biceps the supinator branches from the posterior interosseous nerve can be sacrificed and used to reinnervate denervated targets, however they are too short for a direct nerve transfer. A cadaveric study was performed to identify the proximal branching patterns of the LCNF. There are no branches within the arm and before 5cm distal to the lateral epicondyle. Mobilisation of the distal LCNF and reverse innervation from the supinator branches through an anterior approach can provide a means of reinnervation of mid and proximal forearm motor targets when performed early as a prelude to staged distal transfer following reinnervation. Early prognostic prediction of poor outcome following medial cord brachial plexus injury can prompt use of this early transfer in isolation or in combination with a brachial to a medial antebrachial cutaneous nerve transfer for restoration of function to the digital flexors and the hand intrinsic muscles. Conclusions: A novel staged supinator motor nerve transfer using a reverse innervated in-situ vascularised sensory LCNF nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.

Simona Odella 1, Stefania Raimondo 2, Arianna Lovati 3, Alessandro Crosio 4, Anna Maria Biondi 5, Francesco Locatelli 1, Stefano Geuna 2, Pierluigi Tos 1

1 Reconstructive Microsurgery and Hand surgery Unit, ASST Pini-CTO Milano, Italy; 2 Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Orbassano, Italy; 3 IRCCS Isituto Galeazzi Cell and Tissue Engeneering Laboratory, Italy; 4 AOU City of Health and Science of Turin UO Orthopedics and Traumatology, 2 Hand Surgery, Italy; 5 AOU City of Health and Science of Turin, Muscolo-Scheletal Tissues Bank, Italy

OBJECTIVE Peripheral nerve injuries are more than 70% of upper limb trauma. In the case of large defects, end to end suture is not possible and conduit is not enough to obtain good results, thus the gold standard is the autograft, however this solution presents disadvantages: donor site morbility and longer surgery time. Allograft could be another alternative but nerves from donors frequently cause immunogenic response. Starting from 1980, several authors are looking for the correct way to decellularize nerves preserving both the extracellular matrix and basal lamina to improve nerve regeneration. In Italy, a recent law prohibits to commercialize human tissue for profit, thus the use of marketed human-derived devices is forbidden in the case of nerve injuries that need a graft. The purpose of this study is to find an easy, cost effective, standardized and reliable protocol for the allogeneic nerve decellularization to be stored in a nerve bank. METHODS From a literature review, we concluded that the best method to eliminate cells and to remove cell debris is the chemical one. This method is able to maintain preserved basal lamina and collagen that are indispensable for nerve regeneration. In our study, we propose two chemical-based protocols for the nerve decellularization: one chemical (TritonX100 + sodium dodecyl sulphate- SDS- detergent) in association to sonication cycles, the other also chemical (phosphate-buffered saline- TBP- detergent) in association to a DNAse. According to these protocols, we decellularized human (median and ulnar) and rat (sciatic) nerves. We processed and evaluated samples by means of histology and electron microscopy compared to commercial decellularized allografts. RESULTS The results showed that both of them could remove immunogenic components maintaining the basal lamina to improve nerve regeneration. . In particular, we found that the commercial specimens maintained some integral axons, many cellular and myelin debris within a preserved collagen structure and tissue organization. Differently, nerves decellularized with the chemical and sonication protocol showed a good tissue organization with oriented and intact collagen, but still present axons within the extracellular matrix. The best results were obtained by the chemical and DNAse protocol in which a rich matched connective matrix was maintained and no integral axons were present. CONCLUSION The purpose of this study is to identify an accessible method of decellularization that was also cost-effective, standardized and permitted to obtain a complete removal of immunogenic elements maintaining an intact basal lamina to help axon regeneration. Here, we identified the best procedure to obtain stable results even in long-term storage. In the next future, we will evaluate the nerve regeneration in an in vivo study through the implantation of decellularized allograft in a rat model.

Michele Riccio, Angelica Aquinati, Pier Paolo Pangrazi, Andrea Campodonico, Letizia Senesi

Department of Reconstructive Plastic Surgery-Hand Surgery, AOU “Ospedali Riuniti” Ancona, Italy

INTRODUCTION The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, even if this technique have some limits like a limited donor nerve supply, and morbidity of donor site. Despite good microsurgical techniques for repair of peripheral nerve lesions and the use of nerve grafts and nerve conduits for bridging the defects, functional nerve recovery is generally partial and unsatisfactory. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery. EXPERIMENTAL METHODS We present our experience regarding a new tubulization method, the amnion muscle combined graft (AMCG) technique. It consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions.rnWe also present the clinical and histological results of an experimental study on a rat model: Fourteen male Wistar rats were divided into two groups: 1.5 cm length gap on median nerve reconstructed by means of i) a reverse nerve autograft; ii) amnion-muscle combined conduits.rnFunctional recovery, evaluated using grasping test 30, 60 and 90 days after surgery, was observed in both groups. Moreover, the stereological analysis showed that, in amnion-muscle combined conduits group, regenerating median nerves have significantly more myelinated fibres with the same axon size, but significantly thinner myelin than autograft group. The experimental study on the rat model confirm the brilliant clinical results. RESULTS Follow-up ranged from 10 to 48 months. In a series of twelve patients with loss of substance of the median nerve (7 patients) and the ulnar nerve (5 patients) ranging 3–5 cm at the wrist and forearm, AMCG achieved excellent results graded as S5 in one case, S4 in seven cases, S3+ in three cases, and S3 in one case; M5 in one case M4 in seven cases and M3 in four cases according to the Sakellarides classification and the criteria of nerve injuries committee of the british medical research council modified by Mackinnin and Dellon. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was done. CONCLUSION The clinical and experimental results suggest that the AMCG is a reasonable alternative to traditional nerve autograft in selected clinical conditions. Amnion conduit, peripheral nerve repair, upper limb nerve

M.J.O.E. Bertleff

Bergman Clinics, Naarden, The Netherlands

Objective Symptomatic neuroma may develop after a nerve dissection or bruising of a nerve following any trauma to a peripheral nerve, whether accidental or planned. Neuroma-induced neuropathic pain and morbidity seriously affect the patient’s daily life and functional status. The objective of this pilot study was to provide data to assess safety and effectiveness of the NEUROCAP®, a bioresorbable capping device, to protect a peripheral nerve end and separate the nerve from surrounding tissues in order to reduce the development of a symptomatic neuroma. Methods This prospective cohort study included ten upper limb non-reconstructable symptomatic primary or secondary end-neuroma patients at three hospitals in The Netherlands. Their neuroma was treated by surgical excision followed by capping of the transected proximal nerve end with the NEUROCAP®. This nerve capping device is a tube with one closed end consisting of the bioresorbable copolyester poly(DL-lactide-ε-caprolactone), which maintains its form for up to ten weeks and then slowly degrades within approximately sixteen months. Main outcome measures of the study were VAS Pain score, QuickDASH score, recurrence of symptomatic neuroma, adverse events and use of analgesics. Primary outcome assessment of all parameters was performed after 6 weeks, secondary outcome assessment was performed at 3, 6 and 12 months after surgery. Results 10 patients were enrolled (8 females and 2 males). Mean age was 39.3 ± 22.4 years. There were five patients with superficial radial nerve (SRN) neuroma enrolled, two with neuromas of dorsal branches of ulnar nerve, two median nerves and one radial nerve. Mean VAS Pain score at baseline was 69.1 ± 27.8 on a scale of 0-100. Preliminary results indicate that this decreased to 26.9 ± 25.3 at 12-month follow up. QuickDASH scores decreased from 64.9 ± 21.2 on a scale of 0-100 at baseline to 31.5 ± 15.2 at 12-month follow up. All patients reported to use analgesics at baseline, mainly comprising a combination of Paracetamol, Naproxen, Pregabalin and/or Oxycodon. At 12-month follow up, 8 out of 10 patients reported they were not using any pain medication and in 2 patients analgesics use was significantly reduced. There was one recurrent neuroma at 12-month follow up. Adverse events (AEs) mainly included minor sensory loss inherent to the treatment (2 patients). One patient had an AE, where the device was removed after a traumatic hit on the surgical area 3 months after implantation. There was one serious adverse event (SAE), where a patient developed seroma after the surgical area was hit on furniture several weeks after the implantation. The device was removed 2.5 months later. Assessment of the origin of this SAE is inconclusive as to whether is device-related. Conclusions This pilot study shows promising results regarding treatment with the bioresorbable NEUROCAP® device in peripheral symptomatic end-neuroma in up to 12 months of follow up. The pain reduction observed significantly improves patients’ quality of life and daily function. Result interpretation is however limited by the small study group size. Further information should be collected in a larger patient population.

Aline Yen Ling Wang 1, Charles Yuen Yung Loh 1,2, Huang-Kai Kao 3,4, Fu-Chan Wei 1,3,4

1 Vascularized Composite Allotransplantation Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2 St Andrew's Center for Plastic Surgery, Chelmsford, Essex, UK; 3 Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 4 College of Medicine, Chang Gung University, Taoyuan, Taiwan

Introduction: Traumatic peripheral nerve neurotmesis occurs frequently and functional recovery is often slow and impaired. Induced pluripotent stem cells (iPSCs) have shown much promise in recent years due to its regenerative properties similar to that of embryonic stem cells. However, the potential of iPSCs in promoting the functional recovery of a transected peripheral nerve is largely unknown. This study is the first to investigate in vivo effects of episomal iPSCs (EiPSCs) on peripheral nerve regeneration in a murine sciatic nerve transection model. Material and methods: Episomal iPSCs refer to iPSCs that are generated via Oct3/4-Klf4-Sox2 plasmid reprogramming instead of the conventional viral insertion techniques. It represents a relatively safer form of iPSC production without permanent transgene integration which may raise questions regarding risks of genomic mutation. A minimal number of EiPSCs were added directly to the transected nerve. Results: Functional recovery of the EiPSC group was significantly improved compared to the negative control group when assessed via serial five-toe spread measurement and gait analysis of ankle angles. EiPSC promotion of nerve regeneration was also evident on stereographic analysis of axon density, myelin thickness, and axonal cross-sectional surface area. Most importantly, the results observed in EiPSCs are similar to that of the embryonic stem cell group. A roughly ten-fold increase in neurotrophin-3 levels was seen in EiPSCs which could have contributed to peripheral nerve regeneration and recovery. No abnormal masses or adverse effects were noted with EiPSC administration after one year of follow-up. Conclusion: We have hence shown that functional recovery of the transected peripheral nerve can be improved with the use of EiPSC therapy, which holds promise for the future of peripheral nerve regeneration, especially in the extremity.

Richarda Boettcher, Ulrike Schnick

Unit for reconstructive Surgery in brachial plexus injuries, tetraplegia and cerebral palsy, Unfallkrankenhaus Berlin, Germany

Objectives: After reconstructive surgery in brachial plexus surgery a long term follow up of several years is necessary to record definite results. Published data for these cases show quite different patterns in recording and measurement of the outcome. Therefore studies are of limited comparability. Mostly only one item (Range of motion, muscle force, pain or function) is reported. Until now no data are available showing the relationship between measurable force and ROM and usability of the arm in daily activities. Material and method: More than 50 patients after plexus lesions with different surgical treatment were long term observed. For shoulder and elbow function range of motion as well as muscle force were reported, while for the wrist and hand mostly functional items were examined. Comparing own results with the literature showed the limited comparability. Thus critical assessment of own results was limited. Results: Based on this experience a draft for a combined chart to report functional and measurable results in a short and effective way was developed. It considers range of motion for the most important functions, muscle force, functional items, pain and sensory quality. Due to limited ressources the chart include only aspects with practical importance for usability of the arm in daily life. Conclusion: The results in reconstructive brachial plexus surgery need to be comparable better with respect to function in daily life. Nevertheless measurable items are necessary to objectify the findings. A standardized chart to report long term results might help to support multicentric evaluation of defined surgical procedures or schemes of treatment and will be introduced for discussion.

Ivica Ducic 1,2, Erick DeVinney 2

1 Washington Nerve Institute, McLean, VA, USA; 2 AxoGen Inc, Alachua, FL, USA

Objectives: Harvesting nerve autograft or obtaining sensory nerve biopsy for diagnostic purposes is expected to cause permanent sensory deficits. In addition, donor site wound complications, neuroma pain and post-denervational paresthesia may follow, mandating additional treatments due to negative effect on patient’s quality of life. Systematic review is undertaken to define the incidence, healthcare cost-related sequela and available solutions for these complications. Methods: Literature search of available Pub-Med English reported studies was undertaken to address each of the three targeted goals. Results: Although various sensory upper and lower extremity nerve donor site grafts are utilized, sural nerve is reported as the most common nerve autograft or biopsy donor site. The complication rates of chronic pain (>6months) range from 11-40%, while mild pain symptoms may persist up to 5 years or more. Diabetic patients have greater risk for chronic postoperative pain (40%, up to 44 months). Allodynia was presented in 19% of patients, while dysesthesia ranged from 35-47%. Donor site wound infection or dehiscence are reported in 3-15% of patients. The extended operative time for autograft harvest was 30-75 min, with associated OR costs of $3200-$6500, and charges for prolonged stay, affected ambulation and pain management. If complication due to surgical site infection, wound dehiscence or neuroma management, health-care costs are reported in range of $9700, with $4-$22,000 cumulative hospital loses per incidence. Medical and interventional neuroma pain management have low long-term success rate as neither removed pain source-neuroma. In addition, overall 55% effectiveness of radiofrequency ablation is further troubled with high recurrence rate, while about 70% effective neuromodulation appears appealing, only about half are still effective beyond three year, with average of 39% complications. Aside from standard sterile surgical approach, previous reports of modified sural nerve biopsy aimed to minimize donor site complication, still failed to restore the original sensation. Even surgical removal of neuroma without reconstruction may have up to 20% of failure rate. Similar to other reports, sensory donor nerve reconstruction with Avance human nerve allograft appears the most promising as it restores the nerve continuity for up to 7 cm donor defects. Conclusions: Donor site morbidity due to nerve autograft harvest or diagnostic biopsy may be associated with morbidity and costly complications. The awareness of such events should aid surgeon and patient when choosing nerve autograft vs allograft reconstruction. Newest technologies utilizing human allograft enable us to restore the original donor nerve continuity, thereby eliminating neuroma recurrence, in addition to restoring original nerve function. Further prospective studies are suggested to reinforce presented evidence based-data.

Erick DeVinney 1, Anne Engemann 1, Curt Deister 1, Ivica Ducic 1,2

1 AxoGen Inc, Alachua, FL, USA; 2 Washington Nerve Institute, USA

Objectives: In the past few decades interest in nerve allograft technology has increased greatly. Numerous institutions have developed processing and preservation methodologies in an attempt to create a nerve graft that is safe, physically stable, immunologically tolerated, structurally intact, biologically active and conveniently stored. Unfortunately, achieving this has proven challenging, with only a few reaching commercialization. Nuances in tissue sourcing, processing reagents, processing conditions, quality controls, sterilization methods and storage conditions play a role in the final functionality of each type of nerve allograft. However, general statements are often made on availability, utility and functionality of nerve allografts as a group. To better characterize the similarities and differences between preparation methods, a review of the processes, their characterization assessments and critical factors to success was conducted. Methods: A systematic review of MEDLINE and EMBASE databases was conducted using a comprehensive combination of keywords and a search algorithm according to PRISMA guidelines. Identified candidates were evaluated based on key criteria, categorized and compared to examine key similarities and differences. Results: Since 1990, 16 institutions have developed and/or patented unique nerve processing methods. Globally, 3 of these methods have been successfully developed to a clinical stage. Processing methodologies were found to vary by tissue source, processing agents, structural preservation, growth factor content, growth inhibitor content, biological activity, mechanical integrity and sterility. The most prevalent method for reducing the immunologic burden is chemical extraction, with or without detergents. Tissue sources included rat, rabbit, porcine and human. Assessments of cellular extraction, growth factor preservation and growth inhibitor modification/removal were rarely performed, and varied greatly between processes. Preservation of basement membrane structure and laminin assessments were available for many, but not all processes. The degree of structural preservation as well as functional regeneration in both short and long gap models varied greatly by processing methodology. Improved functionality was significantly correlated with a greater degree of structural and laminin preservation as well as enzymatic removal of growth inhibitors. All processing methods demonstrated a favorable safety profile. Conclusions: Tissue source, processing methodologies, and both structural and bioactive laminin preservation play key roles in the utility of nerve allografts. While safety data and general utility data may be used interchangeably, functional data varied greatly between processing methods and should not be used interchangeably. Given the high degree of variability in the data examined, the tissue source and the processor and/or processing methodology used should be specified to avoid misinterpretation of relevant data.

Joaquim Forés 1, David Romeo-Guitart 2, Mireia Herrando-Grabulosa 2, Raquel Valls 3, Tatiana Leiva-Rodriguez 2, Elena Galea 4, Francisco Gonzalez-Pérez 2, Xavier Navarro 2, Valerie Petegniel 5, Assumpció Bosch 6, Mireia Coma 3, José Manuel Mas 3, Caty Casas 2

1 Hospital Clínic. University of Barcelona, Hand and Peripheral Nerve Unit, Spain; 2 Institut de Neurociències and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona (UAB), Centro de Investigación Biomedica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Barcelona, Spain; 3 Anaxomics Biotech, S.L, Barcelona, Spain; 4 Institut de Neurociències, Biochemistry and Mlecular Biology, UAB and ICREA, Spain; 5 Department of Brain Ischemia and Neurodegeneration, Tnstitute for Biomedical Research of Barcelona (IIBB), Spanish Research Council (CSIC), Institut d'investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; 6INc and Department of Biochemistry and Molecular Biology, UAB and CIBERNED, Spain

Here we used a systems biology approach and artificial intelligence to identify a neuroprotective agent for the treatment of peripheral rood avulsion. Base bon accumulated knowledge of the neurodegenerative and neuroprotective processes that occurs in motoneurons after root avulsion, we built up a protein networks and converted them into mathematical models. Unbiased proteomic data from our preclinical models were used for machine learning algorithms and for restrictions to be imposed on mathematical solutions. Solutions allowed us to identified combinations of repurposed drugs as potential neuroprotive agents and validated them in our preclinical models. The best one NeuroHeal, neuroprotected motoneurons, exert anti-inflammatory properties and promoted functional locomotor recovery. NeuroHeal endorsed the activation of Sirtuin 1which was essential for its neuroprotective effects. These results support the value of network-centric approaches for drug discovery and demonstrate the efficacy of NeuroHeal as adjuvant treatment with surgical repair for nervous system trauma.

Michele R Colonna 1, Vincent Casoli 2, Nikolaos Papadopulos 3, Francesco Stagno d'Alcontres 1, Konstantinos Natsis 4, Bruno Battiston 5, Paolo Titolo 5, Pierluigi Tos 6, Francesco Zanchetta 1, Alfio Costa 1, Pietro Micieli 1, Antonina Fazio 1, Gabriele Delia 1, Stefano Geuna 7

1 University of Messina, Department of Human Pathology of the Adult, The Child and The Adolescent, Messina, Italy; 2 Department of Hand Surgery, Plastic Surgery, Burn Surgery, CHU University of Bordeaux, Centre François-Xavier-Michelet, Groupe Hospitalier Pellegrin, Bordeaux, France; 3 Department of Plastic Surgery And Burns, Alexandroupoli University General Hospital, Democritus University of Thrace, Alexandroupoli, Greece; 4 Aristotle University of Thessaloniki School of Medicine, Department Of Anatomy And Surgical Anatomy, Thessaloniki, Greece; 5 Azienda Ospedaliero Universitaria Citta della Salute e Della Scienza di Torino, Depatment of Traumatology, Turin, Italy; 6 UOC Hand Surgery And Reconstructive Microsurgery Unit, Asst G Pini-cto, Milano, Italy; 7 University of Turin School of Medicine, Italy

Protecting distal muscle effectors from atrophy is a major challenge in patient’s care after proximal nerve trunk injuries (particularly ulnar nerve) and several distal motor nerve fiber transfers have been suggested for this purpose. More recently, sensate fiber protection has proven effective in this task, avoiding harm to motor donors. The present study was designed to test whether through an easy dissection, the radial sensate dorsal branches to the 1st space were capable to reach in the palm the deep motor branch of the ulnar nerve to perform a comfortable coaptation. Moreover, a histomorphometric analysis was planned to show whether anatomical structures (diameter, cross-sectional area, number and density of fascicles and axons) of the donor sensate branches reached the standards proposed by the literature for efficient nerve transfer. An anatomical study was undertaken on 16 fresh cadavers from the Anatomy Labs of Bordeaux and Thessaloniki Universities and from the International Center for Learning Orthopaedics in Arezzo (Italy). The study was approved by the Review Board for Anatomical Research of the Italian Association for Surgery of the Hand and by the Ethics Committee Academical Authorities. Through a careful subcutaneous dissection of the sensate radial nerve branches to the 1st web, the largest branch was cut at the metacarpal head level. A blunt dissection was then performed through the first interosseous muscle to reach on the volar aspect the terminal branches of the deep motor branch of the ulnar nerve, identifying this as the site for coaptation, whether in end-to-end or in reverse end-to side fashion. At this site, samples were taken from both the radial donor and the ulnar recipient nerve to perform histomorphometric analysis. Nerve samples were fixed in glutaraldehyde 2.5% and processed to obtain semithin sections. Both qualitative and quantitative analysis were carried out on the specimens using a DM4000B microscope equipped with digital camera DFC320 and IM50 Image Manager System. The expected donor-to recipient fiber count ratio to identify a successful nerve transfer is known as 1:3. A smaller diameter, as well as fascicular cross-sectional area, fewer fascicles and axons, and a smaller axon density were found in the donor radial sensate branch compared to the recipient ulnar nerve branch. However, a ratio of 1:5,7 was found, which identifies the sensate branches of the radial nerve as potential good fiber donors to the ulnar motor branch in the palm.

Ishan Radotra 1, Natalie Jumper 1, N Campbell 2, Anuj Mishra 1

1 Department of Plastic and Reconstructive Surgery, University Hospital South Manchester NHS Foundation Trust, UK; 2 Department of Cardiology, University Hospital South Manchester NHS Foundation Trust, UK

Despite overall complication rates of 9.1% following implantable cardiac defibrillator (ICD) placement, brachial plexus injury is infrequently reported in the literature. We describe a 26-year-old female experiencing left arm pain, hand numbness and biceps weakness following revision ICD via subclavian vein approach. Nerve conduction studies identified severe partial left brachial plexopathy, which remained incompletely resolved after conservative management. Surgical exploration revealed lateral cord impingement by ICD loop fibrosis, necessitating neurolysis and ICD box repositioning. As increasing numbers of patients undergo cardiac device implantation, it is incumbent on practitioners to be aware of potential increases in the prevalence of this complication.

Daniel Ruter, Joseph Meyerson, Ian Valerio

The Ohio State University College of Medicine Department of Plastic Surgery, USA

Objective: Approximately 40,000 Americans are living with a major upper extremity amputation. An estimated 5-25% develop painful neuromas and up to 67% experience phantom limb pain which can severely limit prosthetic tolerance and increase narcotic usage rates. Targeted muscle reinnervation (TMR) is a surgical procedure that reroutes transected peripheral nerves to the motor unit of freshly denervated muscle. First primarily utilized to improve myoelectric prosthetic signal generation, TMR has recently been advocated for the treatment of painful neuromas. Our group will report on the advantages of targeted muscle reinnervation performed at the time of index amputation rather than as previously reported mainly at delayed setting. Primary focus on neuroma prevention and prevalence of phantom limb pain will be highlighted. Methods: A retrospective study of targeted muscle reinnervation performed on upper extremity amputees was performed. Data reviewed included reason for amputation, amputation level, patient age, postoperative neuroma and phantom limb pain rates, and time to prosthetic use. Results: Thirteen patients with upper extremity amputations were identified (2 forequarter, 5 trans-humeral, 6 trans-radial). Oncologic resection and skeletal trauma were the most common indications for amputation. Only two patients had TMR performed secondarily, all others were concurrent with amputation. Ages ranged from 22-63 years old with average follow up of 13 months (range 1-29 months). None of the 13 patients developed a painful neuroma. Phantom limb pain rates at 1, 3, 6, and 12 months were 46%, 33%, 25%, and 20%. Six patients currently use a myoelectric prosthetic and three more are undergoing assessment and fitting. Average signal capture rates are greater than 96%. Conclusion: Our data suggests that regardless of the cause of or level of amputation, upper extremity targeted muscle reinnervation prevents the formation of painful neuroma postoperatively compared to previous methods. Similarly, the prevalence of phantom limb is lower than reported rates in the literature and decreases precipitously over time. Throughout our entire cohort of targeted muscle reinnervation patients we have found significantly lower pain scores when compared to a control amputee population, leading to better tolerance of the prosthetic, and less narcotic use. In addition to the improved control of myoelectric prosthetics, the prevention of painful neuromas and reduction in phantom limb pain warrant the addition of targeted muscle reinnervation at the time of index amputation.

Abbas Peymani 1,2, Anna Rose Johnson 1, Samandar Dowlatshahi 1, Simon Strackee 2, Samuel Lin 1

1 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands

Objective: Early recognition and treatment of traumatic upper extremity nerve injuries are paramount to optimize patient outcomes. Currently, a knowledge gap remains in regards to classification, distribution and variations in care delivery of nerve injuries treated in the emergency department (ED). The aim of this study is to evaluate racial, geographic and socioeconomic disparities in patients with upper extremity nerve injuries. Methods: We used the National Trauma Data Bank to investigate the prevalence of upper extremity nerve injuries seen in the ED. Statistical analyses were performed to determine factors associated with longer emergency room wait times. Additionally, variations in hospital trauma level status were investigated. Results: A total of 5742 patients with upper limb peripheral nerve injuries were identified. Patients had a mean age of 35.5 ± 17.8 and the majority were male (76.6%), Caucasian (56.3%) and had private insurance coverage (43.2%). Distribution of most commonly injured nerve in order of decreasing frequency included: ulnar (27.5%), radial (21.9%), median (19.9%) and digital nerves (19.4%). Average wait time in the ED was 249.2 minutes. Caucasians were more likely to have shorter ED waiting times compared to other racial groups (p<0.001). Level 1 Trauma Centers were associated with shorter ED waiting times (p<0.001). There was no association between insurance status and ED wait times. Conclusion: There are existing racial variations in the treatment of traumatic upper extremity peripheral nerve injuries. Further studies are necessary to gain an increased understanding of these trends in order to ensure prompt recognition, eliminate dispsarities in care delivery and optimize patient outcomes.

Romain Detammaecker, Lionel Athlani, Yohan Kim De Almeida, Sandrine Huguet, Francois Dap, Gilles Dautel

Department of Hand Surgery, Plastic and Reconstructive Surgery. Centre Chirurgical Emile Gallé CHU, France

Objective : The transfer of a triceps motor branch to the anterior branch of the axillary nerve is a young technique that helps to restore one of the main function of the upper limb : shoulder abduction by deltoid reinnervation. The aim of the study was to evaluate, with a minimum of 2 years follow-up, the clinical, functional and professional outcomes and also to find out any prognostic factors of this nerve transfer in isolated axillary nerve lesions and in post-traumatic C5 C6 brachial plexus avulsion. Methods : This was a retrospective single-center study with 19 patients (17 men and 2 women) operated by 6 surgeons from 2007 to 2014. Their average age was 30 years. All had deltoid paralysis confirmed clinically and electromyographically, with an important functional disorder and triceps graded minimum M4+ (British Medical Research Council scoring). At last follow-up, we measured pain score by Analog Visual Scale, range of shoulder motion in abduction (ABD) and external rotation (RE1), strength (BMRC), donor site morbidity, presence of co-contraction, Disabilities of the Arm, Shoulder, and Hand (DASH) score and the feeling of satisfaction. We questioned the patient about their professional situation, before and after the surgery. A subgroup analysis was also performed. Results : The mean follow-up was 74 months. 11 patients suffered from isolated axillary lesion, usually post anterior shoulder dislocation (or iatrogenic for 1 case). 8 patients had C5 C6 brachial plexus avulsion. The operation was undertaken 9,3 months after injury. At last follow-up, shoulder abduction strength was graded M3 in 73% and M4 in 63% and the external rotation strength was graded M3 in 84% and M4 in 74% and M5 in 37%. Abduction recovery averaged 128° and external rotation (RE1) averaged 62°. No donor site deficit was observed. The mean EVA was 1,3. A strong fatigability was rated at 1,7/3 to the effort. The amyotrophy improved in 79% of the cases to reach a minimum of 50% of the opposite side deltoid. The average DASH score was 28. 9 patients kept the same job. 7 needed a working reconversion. There were 14 good and excellent results. Conclusions : This study shows good outcomes in term of deltoid strength and shoulder range of motion, as good as those found in the literature in nerve transfer of one motor branch of the triceps to the anterior branch of the axillary nerve. The proposed nerve transfer constitutes a valid strategy in C5 C6 brachial plexus lesions but also in isolated axillary nerve lesions. The delay of surgery appears to be one of the most important prognostic factors. The addition of a second transfer from the accessory spinal nerve to the suprascapular nerve improves clinical and functional outcomes in C5 C6 lésions. The evaluation of the rotator cuff, before and after the surgery should also be done to improve our clinical outcomes.

Mikhail Novikov, Timur Torno, Andrey Fedorov, Armen Karapetyan

N. Solovjov’s Emergency Medicine Hospital and Yaroslavl State Children’s Hospital, Yaroslavl, Russia

In cases of complete brachial plexus palsy (BPP) with multiple spinal nerve avulsions extraplexal nerve transfers to selected targets is the only means to obtain useful function of the involved upper extremity. The Intercostal nerve (ICN) is a well-known donor for brachial plexus (BP) reconstructions. However, there are some controversies concerning the indications and different technique versions. Forty-eight patients with BPP underwent ICN transfers in our center (40 adults and 8 children). ICN transfers to the musculocutaneous (MC) nerve or its branches were performed in 37 cases. In 11 cases ICN were used for neurotization of free gracilis muscle transfer. In all cases only direct coaptations of ICNs and recipient nerves were used. The number of ICNs used depends on the target: main MC – 5 (adults) and 3 (children), branch MC to the biceps – 3(adults) and 2 (children), nerve of free gracilis muscle – 3 and 2. Branches of MC to brachialis muscle previously neurotized by ICNs were utilized in 5 patients with free gracilis muscle transfer. In our series only 4 (8%) patients did not obtain useful function after ICNs transfers. In 44 (92%) cases patients received sufficient muscle power M3-M4 (MRC). Our favorite method for complete BPP with multiple avulsions is the transfer of five ICNs to the main trunk of MC for reinnervation of both biceps and brachialis muscles followed by the use of the nerve branch to the brachialis muscle for free gracilis muscle transfer for finger flexion or wrist extension.

Young Ho Lee 1, Jung Eun Lee 2, Jihyeung Kim 1, Hyun Sik Gong 3, Goo Hyun Baek 1

1 Seoul National University Hospital, Seoul, South Korea; 2 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea

Introduction: Radial nerve palsy associated with humeral shaft fracture(HSF) is known to be the most common nerve lesion complicating long bone fractures. Although there have been some studies on the treatment and prognosis of the radial nerve palsy, but it is still controversial. Most of the patients were recovered without surgery, but there is some consensus of early surgical exploration of radial nerve concomitant internal fixation in HSF with radial nerve palsy after high energy trauma, open fractures or accompanying vascular injury. This study is to investigate clinical outcomes and prognosis of radial nerve palsy with transverse HSF showing distraction of fracture gap. Method: We retrospectively reviewed total 10 cases of the HSF patients who had radial nerve palsy immediately after trauma or who were transferred from other hospital for the same diagnosis from January 2001 to December 2014. All the cases were treated by open reduction and internal fixation with plate and screws, and radial nerves were explored under microscopy. There were 7 men and 3 women, and the mean age at the surgery was 32 years. The follow-up was more than 2 years and most common mechanisms of injury were traffic accidents. Results: Every fracture was transverse middle or middle-distal shaft of the humerus in all 10 patients. Mean distraction gap on initial or preoperative radiograph was 9 mm (range, 5 - 31 mm). Distracted-segmental injury of radial nerve was detected in all radial nerve exploration, and mean size of nerve defect was 10cm (range, 9-12cm). All injured nerves were treated with autologous sural nerve graft and all fractures were treated with plate. In every case, bone union was achieved, Recovery of motor function was 8 cases of M5 and 2 cases of M4 after nerve graft. Conclusion: In case of radial nerve palsy accompanying HSF with distracted fracture gap, there is a possibility of complete transection or long-segmental injury of radial nerve. Therefore, early exploration of radial nerve is recommended, and consider preparing for simultaneous nerve graft due to distracted-segmental injury of radial nerve.

Andreas Gohritz, Jan Fridén

Hand Surgery, Swiss Paraplegia Center, Nottwil, Switzerland

Loss of pinch power and thumb flexion can be caused by many traumatic or atraumatic origins, most frequently by carpal tunnel syndrome, flexor tendon injuries or anterior interosseous nerve (AIN) compression. A rare, but relevant differential diagnosis is an isolated flexor pollicis longus (FPL) nerve fascicle lesion. The objective of this paper is to illustrate this phenomenon with a clinical case and provide a discussion of its anatomical, clinical background and differential diagnosis of incomplete AIN syndrome in the literature. We present a 42-year-old otherwise healthy female patient who developed a weak thumb-to-index pinch and deficient right thumb flexion following the removal of osteosynthesis plates after a forearm fracture. Clinically,the flexor pollicis longus function was absent, yet index flexion and sensibility were unimpaired. Tendon rupture was excluded using a tenodesis test and the electro-physiological result of isolated interosseus nerve fascicle lesion was confirmed intraoperatively by inspection and electrostimulation. Tendon transfer using the extensor carpi radialis longus reconstruct strong thumb flexion during pinch. In conclusion, due to its specific location and anatomy, the FPL branch is more prone to isolated neuropathy, e.g. by injections or operations, than to other fascicles of the anterior interosseus nerve. When confronted with sudden and isolated thumb flexion deficiency, specialists should be aware of this rare phenomenon.

Davide Smarrelli

Humanitas-Gavazzeni Institute, Bergamo, Italy

We report our experience with cephalic or basilic vein wrapped around scarred median nerve. From 2008 from 2016 we reviewed vein wrapping for 15 median nerves. The autologous vein graft was harvested in the omolateral arm incided longitudinally and wrapped around the nerve scarring with the intima of the graft against the nerve. 11 cephalic veins and 4 basilica veins were harvested. Each patient underwent subjective and objective evaluations, VAS scale, and Semmes Weinstein test. We report excellent results on median nerve with decrease of pain in 12 cases within 5-20 days, 2 within 2 months and 1 after 10 months with important decrease of VAS from 7-9 to 0-1.The Semmes -Weinstein test showed in 10 cases recovery of complete sensibility at the end of follow up, while 5 patients showed decrease of sensibility, respectively 3 of superficial, 2 of protective sensibility. Wide neurolysis is always performed; no immobilization was applied encouraging early mobilization. 1 infection was observed; no defects in the donor area were observed Among several techniques, vascularized or free flaps, lipofilling, synthetic interposition, vein wrapping represents a reliable option: use of a vein of the same arm instead of saphenous vein as classically used, is surely less invasive for patients with a good coverage of scarred nerve, especially for big nerves. This technique is recommended mainly for treatment of recalcitrant nerve compression.

Atakan Aydin 1, Safiye Özkan 1, Zeynep Hoşbay 2

1 Istanbul Medical Faculty, Istanbul, Turkey; 2 Bezmialem Vakif University, Istanbul, Turkey

Objective: Muscle imbalance in a growing child can lead to bone and joint deformities. Obstetric palsy patients with incomplete recovery have glenohumeral joınt problems because of imbalance between shoulder adductor and internal rotator(IR) muscles & abductor external rotatuar(ER) muscles. Although shoulder internal rotation concracture preventing shoulder abduction and external rotation in the most common problem in obstetric palsy patients with partial recovery ; shoulder internal rotation limitation or external rotational conctacture is a worse condition preventing hand to belly and back functions hence limiting daily activities. An obstetric palsy child could have both shoulder external and internal rotation limitations and contractures at the same time.It is hard to explain this condition with muscles imbalance theory which is adductor and internal rotatory muscles are often out of balance with the abductor and external rotator muscle forces. May be, at incomplete recovery with C5,6,7 involvement, in every muscle unit, stem cells are differantiating to sarcomers which are short and less functioning causing contractures. Since to improve shoulder abduction and ER, tendon transfers are commonly used ,postoperative transient loss in internal rotation is expected. But some patients could not get preoperative IR functions , long after the operations. Also there are some nonoperated patients whose main problem is internal rotation limitations. We operated on these two group of patients to achieve better internal rotation function. Method: Fourteen patients had operation to improve shoulder ER and Abduction 3 years ago. Although their Abd and ER degrees improved dramatically; two years after the operation they had internal rotation limitation despite vigorous physiotheraphy. 15 patients did not have neither nerve nor palliative any operation before and had IR limitations preoperatively. During operation, posterior incision above spine of the scapula was performed, supraspinatus, infraspinatus and teres minor muscles ,and acromion bone were encountered. The intraoperative observationwas not only heavily scarred muscle fascias which needed relaxation but also shortenned external rotator muscles which needed release and lateralization with V-Y fashion so that passive shoulder internal rotation movements were possible. We did not cast or use orthosis for the patients postoperatively. At 3rd day postoperative rehabilitation program ,active range of motion exercises were initiated. All cases were evaluated by using range of motion measurement and Mallet scale. Results: Average age of the children was 6,3 years and The average follow­up period was 21 months. The preoperative values in terms of IR were 2º and postoperatively 20º. Degree of abduction was mean 136 before the surgery. After surgery, it decreased to 105º but with theraphy it catched up preoperative values. Degree of external rotation value was mean 85º preoperatively. After the treatment, the external rotation value was measured 66,2º. The mean Mallet score improved from 18 preoperatively to 20 postoperatively. Conclusion: Although shoulder abduction, ER problems are far more common in obstetrical palsy patients, there a group of patients which had internal rotation limitations either occured spontaneously or surgically. Facing with the reality we operated on these patients to achieve better hand to midline and back functions.

Anna Pittermann 1 2, Laura Hruby 2, Agnes Sturma 2 3, Oskar C. Aszmann 2

1 General Hospital Vienna, Austria 2 Medical University Vienna, Austria 3 University of Applied Sciences FH Campus, Vienna, austria

Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand and lead to numerous psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. Here we introduce a standardized psychological assessment procedure for bionic reconstruction in patients with complete brachial plexopathies. Method: Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted a semi-structured interview exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning, body image and deafferentation pain (VAS). Finally, the effect of bionic reconstruction on these parameters was analyzed over time. Results: Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. After bionic reconstruction the physical component summary scale increased from 30,80 ± 5,31 to 37,37 ± 8,41 (p-value = 0,028), the mental component summary scale improved from 43,19 ± 8,32 to 54,76 ± 6,78 (p-value = 0,018). VAS scores indicative of deafferentation pain improved from 7,8 to 5,6 after prosthetic hand replacement (p-value = 0,018). Conclusions: Bionic reconstruction provides hope for patients with complete brachial plexopathies, improves overall quality of life and reduces deafferentiation pain. Critical patient selection is crucial since high levels of adherence and compliance to a stringent prosthetic rehabilitation protocol determine optimal functional outcomes.

Richarda Boettcher, Ulrike Schnick

Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Department for Hand-, Replantation- and Microsurgery, Unfallkrankenhaus, Berlin

The risk of iatrogenic nerve lesions associated to surgical treatment is not clearly quantified. For the radial nerve a frequency up to 10% according to fixation of a humeral fracture seems to be likely. In 25% of all radial nerve lesions including primary appearance a complete reinnervation will not spontaneously occur. The study aims to define the effect of consequent diagnostic and surgical improvement on the functional result. In a retrospective analysis all surgical treated patients between 01/2010 and 11/2017 with lesions of the radial nerve were identified. All cases with isolated lesions of the superficial sensory branch and all cases with compartment syndrome were excluded for the analysis. 89 patients received neurolysis, direct microsurgical repair, repair with grafts or muscle transfers. These cases were analyzed to define the rate of iatrogenic lesions according to the anatomical level, to identify risk factors for iatrogenic complications and to allow a statement concerning treatment and outcome. 48 lesions of the radial nerve at the axillary region and upper arm were treated surgically. Under them 20 (42%) lesions occurred according to further surgical treatment. Main causing procedures were intramedullary nail fixation, plate fixation and prosthesis of the shoulder. At the lower arm level including radial head 42 lesions of the deep motor branch were operated, among them 12 cases with clear iatrogenic cause. In this area plate fixation or removal were common reasons. Three cases showed previous radial head surgery. Previous schwannoma or lipoma resection was etiological in three cases. Treatment strategies were muscle transfers in 13 cases with good results and one missing follow- up. Isolated neurolysis, in some cases combined with correction of implants, showed reinnervation in all 10 cases, while two more cases were lost for follow-up. In 6 cases with microsurgical reconstruction by graft the result showed 1 missing reinnervation, 4 good results and 1 missing follow-up. For all 32 cases of iatrogenic radial nerve lesions 25 good results with functional benefit good be achieved. For two patients with additional palsies no changing of the findings was possible. In three cases the long term result is unknown. The summarized results show a high probability to improve reinnervation or functional outcome by surgical treatment. Patients with an evidence for structural nerve lesions after surgical treatment should be revised early with an option for all different treatment methods. With this postulate permanent radial palsies following surgical treatment can be avoided better than by “wait and see”. Furthermore a better awareness of the endangered radial nerve in different surgical procedures might be reachable by interdisciplinary co-working and better instruction

Isabel Guy 1, Daniel Guerero 1, Manish Gupta 2, Petros Mikalef 2, Dominic Power 2,3

1 Birmingham University, UK; 2 Birmingham Hand Centre, UK; 3 Institute for Translational Medicine, UK

Objectives: Tensegrity is an inherent property of biological tissues. Following nerve transection a nerve gap results and repair with microsurgical sutures may result in ischaemia, fascicle distortion and intrinsic scar formation as a result of stress concentration around sutures. A delay to repair results in a greater modulus of elasticity for a nerve. The increased strain is partially mitigated by creep, however it remains higher than for a fresh repair. Techniques to reduce tension at repair sites have been widely adopted, however little clinical evidence exists for increased neural regeneration. This cadaveric pilot study examines the effect of tensegrity on nerve gap after transection and evaluates different repair techniques using a validated grading tool and provides evidence to support the development of the STRAIN protocol for a prospective study of tension alleviation using allograft in acute nerve repair. Methods: A workshop was conducted using fresh frozen cadaveric upper limbs. The procedures were completed by consultant hand surgeons. The common digital nerves (CDN) to the 2nd, 3rd and 4th webspace were transected proximal to the distal palmar crease. The digits were cycled through 5 flexion and extension arcs and the resulting nerve gaps were noted. Repairs were completed using microsurgical suture techniques, allograft interposition suture to fill the gap or using collagen connector assisted repairs. The quality of repair was graded by the operator and the study team. The repair sites were then repeatedly cycled through a full range of flexion and extension. Disruptions at the repair site were noted and the repair was regraded following the mobilisation. Results: Twenty-four CDNs were studied. The mean gap for the 2nd CDN was 6.4mm (range 2.7-9mm), 3rd CDN 6.1mm (range 3.5-9) and 4th CDN 5.3 (range 3-9). The grading of the repair was best in the epineural group. Allograft repair was better in quality than the connector assisted repair. Following repeated cycling of the repairs there was no change in repair quality in the epieneural or connector-assisted repair groups. There was one downgrading from good to fair in the allograft repair group. There were no repair ruptures. Conclusion: Epineural repair was consistently performed with a higher grade than for connector-assisted and allograft interposition repairs. This is likely to represent the past experience of the operators and the relative inexperience of the de-tensioning techniques. The learning curve for these techniques needs to be established for any future studies in order to standardise repair quality. The repeated cycling of the repairs resulted in no dehiscence at any repair site. The effects of tension on neural regeneration and clinical outcome will be examined in the STRAIN trial.

Ahmet Savran 1, Kubilay Erol 2, Levent Kucuk 2, Erhan Coskunol 2

1 Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey; 2 Ege University Medical Faculty Hospital, Izmir, Turkey

Scapulothoracic dissociation is a rare and mortal condition of "closed forequarter amputation". And it is usually associated with multiple trauma. In this case report ve present a 22 years old female patient with motor vehicle accident. Unconscious patient with Glaskow Score of E1M1V1 is intubated at emergency department. Humerus shaft fracture and forearm both bone fracture is seen at X-rays. Extravasation from subclavian artery is determined at CT-Angiography and endovascular embolisation is done. Emergent cardiovascular surgery for subclavian artery repair is perform and exploration of brachial plexus showed total avulsion of all roots. After fasciotomy and temporary stabilization of fractures with splinting, patient is followed at intensive care unit for two days. But exits of the patient is confirmed at the postoperative second day. Scapulothoracic dissociation is a rare but mortal condition. Prognosis depends on nerve injury and associated injuries.

Pain (3 abstracts)

Andrzej Zyluk, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland

We report outcomes of treatment for severe pain associated with long-standing, refractory CRPS in 10 female patients by continuous brachial plexus analgesia. Duration of the disease prior to treatment was 3.5 years on average and baseline pain intensity was a mean of 8.3 in NRS. All patients met the Budapest criteria of CRPS diagnosis. Spinal catheter was implanted into the brachial plexus via open axillary approach. Results. Each patient had performed a mean of 4.4 (range 2-8) spinal catheter implantations. Rapid and strong analgesic effect was obtained immediately after beginning of injection of bupivacaine solution: pain decreased from a mean of 8.3 to 1.6. Duration of maintaining the catheter in the brachial plexus and effective analgesia was 5.3 months (range 2-12). After removal of the catheter the pain returned to baseline. No patient obtained permanent or at least partial reduction of her pain after completion of this therapy.

Antje Straatmann 1, Adriana Miclescu 2, Torbjörn Vedung 1

1 Department of Orthopedic and Hand Surgery, Uppsala University Hospital, Sweden; 2 Department of Surgical Sciences, Uppsala University Hospital, Sweden

Objective: The main objectives for nerve repair is to optimize nerve restitution and to minimize neuroma formation. Persistent postsurgical pain is common after surgery and the predisposing factors for developing pain are mainly unknown. The aim of this retrospective study was to determine the prevalence of persistent neuropathic pain after surgical repair of traumatic peripheral nerve injury in the upper extremity. Methods: The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale questionnaire was sent to 755 patients who underwent nerve repair surgery in the upper extremity between 2004 and 2015 at the Department of Orthopedic and Hand Surgery in Uppsala, Sweden. All nerve repairs were done with epineural suture technique. Additional questions regarding cold intolerance, decreased sensitivity, pain approximated using visual analogue scale (VAS) and present medication were included in the survey. Results: 536 out of 755 patients answered the questionnaires (response rate 71%). Postsurgical pain persisted in 311 patients (58%). Pain intensity was on average rated to VAS 5. Most of the patients with VAS >5 had inadequate pain medication. Cold intolerance was present in 497 patients (93%), and 520 of the patients stated that they had decreased sensibility to stimulation distal to the nerve injury (97%). According to LANSS Pain Scale 35% of the patients developed persistent neuropathic pain. Conclusions: The prevalence of persistent pain and the extent which involves neuropathic pain according to LANSS are increased after nerve repair surgery in the upper extremity. Cold intolerance and decreased sensibility are even more common and were present in almost all patients.

Charlotte Hartig-Andreasen 1, Jytte F Møller 2, Claus Möger 1

1 Hand Surgery Unit, Department of Orthopaedic Surgery, Aarhus University Hospital, Denmark; 2 Pain management team, Department of anesthesiology, Aarhus University Hospital, Denmark

Complex regional pain syndrome (CRPS) is a neurological condition requiring early diagnosis and early multidisciplinary treatment to avoid a chronic condition. CRPS after wrist surgery is a well-known risk. To prevent an acute CRPS to become disabling and chronic intensive hand therapy is mandatory. However, the pathophysiology is not completely understood making treatment difficult. Case presentation: A 27-year-old self-employed man underwent wrist fusion surgery with a dorsal plate due to posttraumatic osteoarthritis secondarily to carpal instability. After surgery pain was controlled with supra- and infraclavicular block. Two days postoperatively the patient developed severe pain and a universal rash interpreted as a reaction to morphine and oxycodone. Fentanyl was administered and amitriptyline treatment initiated for neuropathic pain. Day 6 the pain was intractable, and CRPS was suspected. Treatment with prednisolone, calcium, alendronate and pantoprazole was started. The following two days CRPS became fulminant with classic signs: universal oedema, stiffness of fingers, neuropathic pain, color and temperature changes. Infection was excluded. Despite of fentanyl, prednisolone, calcium and gabapentin treatment pain continued to be intractable. On a numerical rating scale from 0-10 pain in rest was 6 and during activity 8 making rehabilitation with the hand therapist impossible. At day 8 postoperatively ketamine infusion in sub anesthetic doses was given with immediate effect and tablet methadone started. Pain intensity reduced, discoloration diminished and hand therapy resumed. Sixteen days postoperatively reduction in ketamine was initiated. Twenty-four days after surgery, ketamine infusion was discontinued; the patient was pain free on methadone (7.5 mg three times pr. day) and discharged. Discussion: This case present a patient suffering from fulminant CRPS after wrist surgery. Correct diagnosis and multidisciplinary treatment including anesthesiologist, hand surgeons and intensive hand therapy was initiated immediately resulting in complete remission 24 days after surgery. The role of ketamine for treating CRPS remains debated in the literature. Only few small studies exist and are inconclusive. Ketamine infusion is not without potential risk, and whether ketamine should be used in acute or chronic CRPS, or in anesthetic or sub anesthetic doses remains unknown. In this case infusion of ketamine in sub anesthetic doses combined with methadone was efficacious in controlling the pain, making intensive hand therapy possible.

Palsy and Spasticity (6 abstracts)

Caroline Leclercq 1, Catalina Parot 2,3

1 Institut de la Main, Paris, France; 2 Instituto Teletón, Santiago, Chile; 3 Hospital Luis Calvo Mackenna, Santiago, Chile

Partial wrist arthrodesis in Cerebral Palsy children PURPOSE Severe fixed wrist flexion deformity in spastic children causes hygiene problems, impairment and poor cosmesis, sometimes associated with pain. Soft tissue procedures alone have not been successful and total wrist arthrodesis is reserved for skeletally mature patients. This study evaluates the outcome of a partial arthrodesis for the treatment of spastic wrist deformities. METHODS: Eleven cerebral palsy children (12 wrists) presenting with a severe flexion deformity of the wrist were treated by a mid-carpal fusion. Results were assessed clinically (resting posture, range of motion), radiographically (union rate and delay, growth disturbance), and functionally (House scale, VAS satisfaction) RESULTS There were 9 boys and 2 girls. Mean age at the time of surgery was 12 years (range 8 – 20 years). All hands were non-functional (House 0-1), and only two had some active motion. The goal of surgery was hygiene, comfort and /or appearance. The surgical technique involved a mid-carpal dorsal wedge osteotomy, fixed with two cross Kwires. Associated procedures included: 9 muscle-tendon lengthening, 1 tendon transfers and 2 hyperselective neurectomies. The mean follow up was 20 months. The resting posture improved from 78º to 21º of flexion. The average passive range of motion changed from flexion 88º /extension minus 40º, to flexion 47º/extension 9º, and the total arc of passive motion changed from an average of 54º to 47º. The union rate was 100% at an average of 6.7 weeks. No significant complication was reported. No worsening of the growth disturbance was noted at 20 months post-op, although this proved very difficult to assess due to the initial deformity. The goal of surgery was reached in all cases, and in addition the function of the hand was improved in 3 cases (House 1 to 3). VAS satisfaction was high (average 7.8). CONCLUSIONS Dorsal carpal wedge osteotomy is an effective technique for the treatment of fixed wrist flexion deformity in skeletally immature patients, allowing to improve the resting position and to preserve some wrist motion.

Mathilde Gras 1,2, Caroline Leclercq 1

1 Institut de la Main, Clinique Bizet, Paris, France; 2 Institut Nollet, Paris, France

Objective Spasticity is characterized by hyperexcitability of the muscle. Several surgical procedures have been described in order to decrease the muscle tone. Since the description of neurotomy by Stoffel in 1912 for the upper limb, this technique has been criticized, especially because of early recurrences. Our encouraging clinical results of hyperselective neurectomy have led us to review the relevant literature and confront it to the results of our recent anatomical studies. In light of those results we propose guidelines for Hyperselective Neurectomies (NHS). Methods A Pubmed search using the terms “spasticity” and: “neurotomy”, “hyponeurotisation”, “hyponeurotization” or “neurectomy” was performed. A total of 130 articles were identified. The inclusion criteria were: English and French literature, detailed description of the technique of neurotomy (including length of incision, method of nerve identification, site of neurotomy, amount of section or resection, method of evaluation of the results), and application of the procedure to the upper limb. We performed an anatomical study of the motor branches of the main flexor, adductor and pronator muscles of the upper limb (except for the shoulder), based on 56 cadaver dissections (musculo-cutaneous nerve: 16, median: 20, ulnar: 20) and confronted these results to the different techniques reported in the literature. Results A total of 14 studies met the inclusion criteria, representing 425 cases of neurotomy. All authors performed peroperative nerve stimulation. Most of them performed a partial neurectomy (5 to 10 mm in length, and resection of 50 to 80 % of motor fascicles) rather than a neurotomy. All studies report clinical improvement, with decrease of spasticity, after a 26 months follow-up. However the majority of series (9/14 + 5 unknown) involved mainly nonfunctional hands (65 to 100% of the cases), and all were performed in case of failure of all other treatments. Their results were difficult to analyze because of the many different associated surgical procedures and the lack of objective criteria for evaluating spasticity. Our recent cadaver studies have demonstrated the complexity and the great variability of the anatomy of motor branches; the two most striking features were the very distal location of some motor branches along their target muscle in our dissections, which were most likely missed at surgery in some of the reported series, given the length of some of the incisions; and the frequency of multiples motor branches to several muscles with a common origin, which suggest to perform the neurectomy as distally as possible rather than proximally at, or close to the nerve trunk. Conclusions Previous articles have reported clinical improvement after neurectomy performed mainly for nonfunctional hands after failure of other treatments. We hypothesize that the results could be improved by treating all motor branches to each muscle, and by performing the partial neurectomy at the point of entry of each motor branch into the target muscle. Following these new guidelines, an ongoing prospective study shows satisfactory and stable midterm results on spasticity and function.

Guilherme Sevá Gomes, Marcelo Rosa de Rezende, Álvaro Bayk Cho, Laura Lorimier, Danielle Scarcella

Instituto de Ortopedia e Traumatologia da Universidade de São Paulo, São Paulo, Brazil

Objectives: Despite many existing surgical techniques, the reconstruction of the flail shoulder due to brachial plexus palsy remains challenging. The aim of this is study is to compare the shoulder function of patients before and after glenohumeral arthrodesis. Complication rates and patient’s satisfaction were evaluated secondarily. Methods: A prospective, paired study was performed. Eight patients with brachial plexus palsy underwent shoulder arthrodesis with plates and screws. DASH questionnaires and video-assisted shoulder and elbow goniometry were taken before and three months after the surgical procedure. Satisfaction, overall complication rate and bone fusion were also measured. Results: Active range of motion was improved in all three planes of shoulder movement and elbow flexion. Were statistically significant the increase in shoulder adduction-abduction (average increase of 26,38o, StDev=13,90o and p=0,001), shoulder flexion-extension (average increase of 19,25o, StDev=17,17o and p=0,018) and elbow flexion-extension (average increase of 30,90o, StDev=29,50o and p=0,021). Average improvement in DASH values was 4,62 points (StDev=13,5 and p=0,36). All arthrodesis achieved bone fusion within 3 months, all patients referred themselves as “satisfied” or “very satisfied” with the procedure, one patient had one pressure ulcer, which healed uneventfully. Conclusion: Shoulder function was improved after glenohumeral fusion. This could be demonstrated objectively and subjectively, with acceptable complication rates. The procedure, therefore, can be considered a viable and promising option in the treatment of this pathology.

Petros Mikalef, Colin Shirley, Dominic Power

Birmingham Hand Centre, UK

Objectives: Surgical neurectomy is a useful strategy in the management of recalcitrant spasticity. Adduction and internal rotation contractors at the shoulder cause pain and difficulty with activities of daily living. Total neurectomy is indicated in spasticity with early contracture and selective partial neurectomy in patients with volitional control and no contracture as an alternative to repeated chemodenervation. The surgical approach should avoid the axillary skin where hygiene is often compromised as a result of the contracture and spasticity. Methods: Using a cadaveric model we adapted the pectorals major muscle splitting approach to the brachial plexus to afford access to the infraclavicularmotor branches to the shoulder. The superficial dissection identifies an avascular plane between the clavicular and sternocostal heads of the pectorals major medial to the coracoid process. The lateral and medial pectoral nerves can be identified in the clavipectoral fascia and in the interval between pectorals major and minor respectively. Tracing the branches to their parent cords allows complete denervation when indicated. Th pectorals minor tendon is released at its insertion to the coracoid process exposing the rest of the infraclavicular brachial plexus and accompanying vessels. The interval between the lateral cord and the axillary artery is developed with inferior retraction on the vessel allowing exposure of the posterior cord. The thoracodorsal nerve is identified at its take-off between the upper and lower sub scapular nerves. Neurectomy of these threes nerves results in relation of the internal rotation and adduction contracture from subscapularis, teres major and the latissimus dorsi. The approach can be performed through small incision and does not compromise any sensory nerves. Results: The procedure has been used in 4 non-functional limbs with axillary contractures and painful shoulder spasticity without complications. Three patient has post stroke spasticity and 1 quadriplegic cerebral palsy. All patients reported improvements in shoulder posture and reduction in pain with increased passive brachiothoracic angle facilitating washing and dressing. The improvements have been maintained at 12 months follow-up. Conclusion: Management of the painful adducted and internally rotated spastic shoulder is challenging. A mini-incision pectoralis major splitting incision provides access to the key motor nerves to the shoulder for neurectomy.

Atakan Aydin 1, Ömer Berköz 1, Serhat Dündar 1, Safiye Özkan 1, Zeynep Hoşbay 2

1 Istanbul Medical Faculty, Istanbul Turkey; 2 Bezmialem Vakif University, Istanbul, Turkey

Objective:Elbow flexion is the most important function of the upper extremity,hence loss of this function leads a major disability. Elbow flexion deficit can be seen in both congenital (arthrogryposis)and acquired (traumatic /obstetric brachial plexus palsy) conditions.We describe our results for the surgical tecnique of transfer of the long head of triceps transfer in traumatic and congenital cases. Method: We performed this transfer in 15 patients, ages between 2-45 years. The six adult patients were suffering from traumatic brachial plexus injury while 9 young patients were artrogrypotic or obstetric palsy sequela. We achieved 90-120 degrees of elbow flexion in obstetric and traumatic plexus patients while preserving elbow extansion and 60-90 degrees of elbow flexion in arthrogrypotic patients . Results, All patients were happy to gain hand to mouth function, elbow extansion deficit is acceptable in acquired cases while in arthrogrypotic cases since shoulder abduction is not expected , partial triceps power loss almost never effects daily living. Conclusion: Although there are many muscle transfer methods (lat dorsi,pectoralis etc) to reanimate elbow flexion, we conclude that long head of triceps tranfer is a reliable tecnique in both acquired and congenital cases.

Atakan Aydin 1, Yasin Canbaz 1, Safiye Özkan 1, Zeynep Hoşbay 2

1 Istanbul Medical Faculty, Istanbul, Turkey; 2 Bezmialem Vakif University, Istanbul, Turkey

Objective; Since elbow extansion is a passive movement when shoulder is adducted and at secondary importance compairing elbow flexion, muscle transfer to triceps is not commonly mentioned in obstetrical palsy literature.This need was observed specially in patients whom had improved shoulder abduction with surgery but have limited elbow extansion. Method, Previously , we had operated on 13 patients with elbow extansion restoration ages between 5-16 years. We used brachioradialis muscle in 6 patients, brachialis muscle in 6 patients and posterior deltoid muscle in one patient with pros and cons of each method. Later on depending on the anatomic studies for lower trapezius transfer in order to have better shoulder external rotation, we used ipsilateral lower trapezius muscle by elongation with tensor fascia lata graft to triceps muscle, in 7 obstetric palsy cases. Results: Average elbow extansion was improved 40 degrees and shoulder abduction was improved 30 degrees in our patients. Conclusion; Ipsilateral lower trapezius transfer is a good tecnique for triceps function restoration with minimal donor side morbidity.

Rare cases (9 abstracts)

Isidro Jiménez, Beatriz Romero Pérez, Dimosthenis Kiimetoglou, Juan Sánchez Hernández, Jonathan Caballero, Gustavo Muratore, Alberto Marcos-García, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Exostosis is the formation of new bone on the surface of a bone. It usually points away from the adjacent joint and one of the most common types is osteochondroma.. Most arise from the metaphyseal surface of long bones while a solitary osteochondroma in the carpus is extremely rare, with only 15 cases reported and only four affecting the capitate. 45-year-old woman presented with pain and mass in the dorsal aspect of her right wrist. A 1-cm, solid and immobile prominence was noted on the dorsal side of the carpal bones with a palpable bump during the finger extension. X-rays showed a well-defined mass of bone density located in the dorsal aspect of the capitate and attached to it by a 3mm pedicle. Surgical treatment was carried out under regional anesthesia and arm tourniquet. Dorsal longitudinal approach, and extensor tendon synovectomy was performed and a slightly mobile bone fragment partially covered by cartilage was identified and excised. A skin closure was performed using resorbable suture and no splint was used allowing the immediate mobilization. Histopathologic study was reported as osteochondroma. Postoperative outcome was excellent achieving full range of motion and a score of 0 points in the DASH questionnaire and 100 in the Mayo Wrist Score. Whereas osteochondromas usually present as painless, slow-growing masses, nearby structures can become secondarily involved either through direct compression, displacement or inflammation and subsequent attrition. Compression of the superficial radial nerve or median nerve has been described. Tendons in proximity can become inflamed secondary to mechanical wear as in this case or even an attritional rupture may occur. The development of osteochondromas in the dorsal carpal are very rare but it represents an entity to be considered in the differential diagnosis of solid tumors in the dorsal aspect of the hand and wrist as its clinical findings may be similar to the "carpal boss".

Yannick Goubau 1,2, Bart Berghs 1, Bert Vanmierlo 1, Francis Bonte 1, Chul Ki Goorens 3, Jean Goubau 1,3

1 AZ Sint-Jan Brugge, Belgium; 2 ASZ Aalst, Belgium; 3 UZ Brussel, Belgium

In 1927 Mauclaire, and later in 1932 Dieterich, first reported on the aseptic necrosis of the metacarpal heads. Most articles describe their surgical successes, while others describe conservative treatment, where the follow up rarely exceeds 1 year. We report on the natural evolution of a case that was treated conservatively for 8 years. Our patient developed pain in his right hand after an injury at the age of 10. After 4 years, he consulted our service for a second opinion. We followed the patient clinically and radiographically for 4 more years. After reatment with a resting splint and activity modification, his symptoms rapidly decreased. On yearly follow up radiographies and CT-scans, we observed a remarkable remodeling of the articular surface, and an ever maintained articular space. It is important to realize in a world where papers on implants and surgical treatments dominate the literature, we shouldn’t forget the conservative treatment of this condition. This case proves that a conservative treatment of Dietrich-Mauclaire’s disease can result in an excellent outcome

Florence Vigouroux Guillet 1, Adeline Cambon Binder 2, Pierre Sylvain Marcheix 3, Zoubir Belkheyar 4

1 French military Hospital Desgenettes Lyon; 2 Hôpital Saint Antoine Paris; 3 Centre hospitalo universitaire Limoges; 4 Clinique de Montlouis Paris

Arteriovenous malformations (AVMs) are very difficult to treat, especially in patients who have had several previous surgical resections and embolization procedures. In these cases, tumor recurrence, regional complications of the tumor and iatrogenic complications may be associated. We report three severe cases of recurrent complicated AVMs, and the management of the multiple complications associated with. The surgical resection necessitates sometimes proximal and distal arterial ligatures to reduce the blood flow. Associated procedures include neurolysis, transposition and palliative transfers in case of compartmental syndrome. Skin defect is frequent after resection and local or distal flap are realized to manage the skin coverture. In complex AVM cases, the aims of the surgery are complete tumor resection and to restore a functional and aesthetic upper limb. It necessitates associated complex surgeries. Amputation should be considered earlier in case of major irreversible functional impairment.

Ebenezer Francis O. Arthur, Rupesh Man Sherchan, Giselle Marie Noelle T. Gabriel

Department of Orthopaedics, Makati Medical Center, Makati City, Philippines

Objective: To present a case of a multiple myeloma patient with an atraumatic cause of compartment syndrome of the volar forearm who was treated with a multidisciplinary approach. Methodology: A 63-year-old female with multiple myeloma developed compartment syndrome of the volar left forearm after lifting her dog; diagnosis was made clinically. Patient was co-managed with Hematology. Emergency fasciotomy done but the authors encountered significant bleeding post-operatively due to her hematologic disorder. Patient was losing an average of 1400 mL of blood per day. Patient required multiple blood transfusions and debridements. Eventually, patient underwent plasma exchange which helped control bleeding. Repeat debridements done afterwards with eventual skin grafting. Results: Clinical picture improved and she has since been able to return to managing her photography business. Conclusion: Recognizing compartment syndrome requires having and maintaining a high index of suspicion, particularly in cases with a non-classical history and presentation. A multidisciplinary approach addressing all medical conditions should be taken to ensure that the patient receives holistic care.

Isidro Jiménez, Alberto Marcos-García, Dimosthenis Kiimetoglou, Juan Sánchez-Hernández, Gustavo Muratore, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Pacinian corpuscles are rapidly adapting mechanoreceptors mainly distributed in the dermis of the fingers and palm of the hand. A neuroma of the Pacinian corpuscle is a rare and extremely painful condition with a few cases reported in the literature, most of them, associated with local or repetitive trauma. 71-year-old man with pain and swelling on his left index initially diagnosed as tenosynovitis resistant to conservative treatment. During surgery, a spherical, gray and in clusters lesions closer to the collateral nerve were found and excised and described by the pathological study as neuroma of the Pacinian corpuscles. Two years later, he reported the same clinical findings on his right index with no improvement after conservative treatment. During surgery, the same lesions were found and also identified by pathological study as Pacinian corpuscles neuroma. To date, 50 cases have been previously reported, in most of them, a painful swelling was the main symptom as occurred in our report. It has been reported associated to glomus tumours or Dupuytren’s disease but, to the best of our knowledge, this is the first case reported with a bilateral non-synchronous Pacinian corpuscles neuroma. We believe that Pacinian corpuscle neuroma should be considered in the differential diagnosis of localized painful swelling in hand of unknown etiology, particularly but not only in patients with previous trauma. Its bilateral development is rare but may occur as in this case.

Yasumasa Nishiura 1, Sho Kohyama 2, Sho Iwabuchi 2, Ryosuke Fukai 2, Yuki Hara 2

1 Tsuchiura clinical education and training center, Tsukuba University Hospital, Tsuchiura, Japan; 2 Department of Orthopaedic Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan

Objective: Most of fresh cases of the MP joint locking of the thumb are treated with manual reduction. An impossible case is treated with operation. But a chronic case is difficult to treat because of joint contracture. We report such a case treated with manual reduction after joint distraction using the external fixator. Methods: A patient was a 26-year-old female. She injured her right thumb during a volleyball game. She visited a few outpatient clinics but was not diagnosed. She visited our clinic at 8 months after her injury. She had swelling and pain of the MP joint of her thumb and could not flex it. X ray showed slight hyperextension of the MP joint of her thumb. We diagnosed a chronic case of the MP joint locking of the thumb. We used the hinge external fixator device (PIP WING, ARATA ®). At operation the MP joint was set in the external fixator and distracted with the rate of 0.5㎜/day from the next day. In 2 weeks, distraction was stopped. After 2 weeks, the external fixator was removed and manual reduction was tried. At first the MP joint was simply flexed but the locking was not reduced. Next the same manipulation method with a fresh case, that is, axial compression and bending, was tried. It was successful. Results: At the 7 months follow-up, she had no pain and regained ROM of ext 0°/flex 50°at the MP joint of her thumb. Conclusions: Joint distraction makes it possible to reduce chronic locking of the MP joint of the thumb. This is a simple and useful method.

Sergio Gama, Samuel Ribak, Marcelo Rezende

Pontificia Universidade Católica de Campinas, Brazil

The authors report two cases of women with Preiser disease treated with dorsal distal radius vascularized grafts. In the first case, after minor trauma, the patient had pain in the left wrist of insidious onset and evolution with significant worsening. The radiographic examination showed increased density of the proximal pole of the scaphoid, and magnetic resonance imaging (MRI) showed partial necrosis. Intraoperatively, as the integrity of the cartilage of the proximal pole of the scaphoid was observed, dorsal vascularized distal radius graft was performed using the 1.2 intercompartimental supraretinacular artery. In four months postoperatively, MRI showed almost total integration of the graft, and one year after surgery, the patient was asymptomatic, with normal mobility of the operated wrist and imaging showing a normal scaphoid. The second case had similar history and clinical picture, but the radiographs showed narrowing and diffuse sclerosis and also osteolytic areas in the proximal pole of the scaphoid; MRI showed diffuse necrosis. The same graft technique was used, considering that there was a good cartilaginous coverage of the scaphoid. After nine years of follow up, the patients remain free of pain or functional limitations. In such cases, the vascularized graft technique was effective and, therefore, a good therapeutic option, provided there is no degenerative changes in the carpus and especially the cartilage of the proximal pole is viable.

Hongje Kang, Daejin Nam, Seng Hwan Kook

Department of Orthopedic Surgery, Wonkwang University Hospital, Iksan, South Korea

A 85 year-old female patient visited outpatient clinic complaining of whitish pus like discharge at dorsoulnar side of left hand since one week ago. She had history of illegal paraffin injection 50 years ago due to muscle atrophy at her left hand. Abnormal dystrophic calcification was shown on plain radiograph and MRI. Debridement was done and she was recovered. Paraffin was widely used for cosmetic purpose in the past, and many accompanied complications have been reported. Authors have experienced a rare case of paraffinoma with multiple dystrophic calcification in hand after paraffin injection which was seldom reported, therefore we report this case with literature review.

Ishan Radotra, Maria Chasapi, Anil Agarwal

Department of Burns & Plastic Surgery, Royal Preston Hospital, UK

Introduction Bowen’s disease (BD) in the palm is extremely rare with only few cases published in the literature, often related to previous arsenic exposure. We describe a rare case of Bowen’s disease in the palm where conservative treatment resulted in a complex palmar wound requiring challenging reconstruction. Case A 65-year-old right-handed labourer presented with 10-year history of multiple erythematous plaques and non-healing ulceration to his right palm and first web space. History failed to identify previous arsenic exposure. Biopsies indicated Bowen’s disease of the palm. Non-surgical treatment with topical application of retinoid and later 5-Fluorouracil was initially attempted. Residual disease prompted a course of radiotherapy following which the patient developed a painful chronic deep sucking wound due to radio-necrosis. This resulted in exposure of both right index finger MCPJ and right thumb FPL tendon with additional first web space contracture. Surgical debridement created a complex and large palmar defect. This was covered by filleting of the non-functioning right index finger. A FTSG and a distal extensor apparatus flap based on the first dorsal metacarpal artery was used to cover the exposed right thumb proximal phalanx and FPL tendon. Two months later the wounds healed well with good range of movement and no complications. Conclusion Bowen’s disease of the palm is an extremely rare clinical entity and to our knowledge this is the first case report describing surgical reconstruction required for this rare pathology. There remains limited data on the conservative versus surgical management of BD. Our experience through this case demonstrates that, in patients with BD affecting the palm, early involvement of hand surgeons for consideration of surgical excision is crucial, preventing subsequent complications necessitating complex reconstruction.

Shoulder (3 abstracts)

Karim Latrach Tlemsani, Hamza Kefi, Sabeur Saadi, Khalil Amri, Mounira Khezami, Lotfi Nouisri

The Main Training Military Hospital Tunis, Tunisia

Objective The management of chronic irreparable tears in young patients under 65 years old remains a major challenge. Several procedures have been proposed, inter alia, tendon transfers. In massive rotator cuff tears, deltoid flap reconstruction has likely proved its efficiency in pain relief and function improvement in the shoulder. The purpose of this study to report our experience with management of irreparable rotator cuff tears in consecutive series of deltoid flap transfers performed between 1994 and 2007 with a mean follow-up time of 75 months. Patients and Methods In a retrospective study, we reviewed the charts of 27 patients younger than 65 years old at surgery with mean age of 54 years old. All paitents have exclusively performed deltoid muscle flap reconstruction for massive rotator cuff tears, between 1994 and 2007. The mean follow-up was of 75 months. Pre-operative and post-operative function was assessed according to Constant and Murley Score. Results At follow-up, 77% of patients considered the condition of their shoulder as better or much better compared with before surgery. Mean global Constant and Murley Score improved from 24,6 to 54,45 points. The subacromial space decreased from 8,9 mm to 4 mm at last follow-up. Of the 12 patients whose flap was examined by magnetic resonance imaging, 9 had no tear and a flap signal of muscle intensity. The mean flap thickness was 7,9 mm. Conclusion This long-term study demonstrated the efficiency of the deltoid flap for the treatment of full thickness massive tears of the rotator cuff, in term of pain relief and functional recovery. The flap provides persistent pain relief and good function and force.

Olga Gutkowska, Maciej Urban, Jerzy Gosk

Clinical Department of Traumatology and Hand Surgery, Wrocław University Hospital, Wrocław, Poland

Objective Anterior glenohumeral dislocation (GHD) affects about 2% of the general population during lifetime. The incidence of traumatic GHD ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17–96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation (IR) for 2–3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation (ER) can be considered an alternative. This work aims to compare the results of immobilization in IR and ER on the basis of current literature review. Methods A comprehensive literature search and review was performed using the keywords “glenohumeral dislocation”, “shoulder dislocation”, “immobilization”, “external rotation”, and “recurrent dislocation” in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases. Articles focusing on first-time traumatic GHD, reporting the results of conservative treatment of GHD with immobilization in ER, comparing the results of immobilization in ER and IR, having follow-up of at least 12 months for clinical studies, with a minimum of 10 patients in clinical studies were included in the analysis. Articles dealing with recurrent GHD, glenohumeral joint instability, operative management of GHD and case reports were excluded. Three cadaveric studies (28 shoulders), 6 imaging studies (129 shoulders), 10 clinical studies (734 shoulders), and 4 meta-analyses were identified. Results Literature analysis revealed better coaptation of the labrum on the glenoid rim (Bankart lesion) in ER in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies. Two metaanalyses demonstrated lack of significant difference between the two methods of immobilization (Liu et al., Vavken et al.), one found the results of immobilization in ER significantly better (Longo et al.), and one showed tendency towards better results in patients immobilized in ER (without statistical significance) (Paterson et al). The metaanalysis with the largest number of patients (663), demonstrated no superiority of immobilization in ER regardless of age, and in two groups stratified by age (≤30;>30 years). Several studies confirmed that increasing the degree of ER is associated with worse patient discomfort. Furthermore, the actual amount of ER achieved and maintained by orthoses was found to be less than anticipated, especially when they were applied by lay persons. Conclusions Analysis of the literature does not confirm the superiority of immobilization in ER over IR after GHD. This method can be considered an alternative, with its main limitations being: disparity between the optimal and patient-acceptable ER angles, patient compliance, inability of some braces to maintain the required amount of ER, and possible reduced effectiveness of the method in the presence of certain accompanying injuries (e.g., subscapularis tear). We do not recommend the use of ER braces in elderly patients due to the predominance of labroligamentous injury pattern connected with decreased effectiveness of such braces and lower tolerance of cumbersome orthoses in these patients. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in ER.

Wan-Sun Choi 1, Kwang-Hyun Lee 2, Bong Gun Lee 2, Joo-Hak Kim 3, Chang-Hun Lee 4, Sung-Jae Kim 5

1 Ajou Univerisity School of Medicine, Suwon, South Korea, 2 Hanyang University College of Medicine, Seoul, South Korea, 3 Myongji Hospital, Goyang, South Korea, 4 Eulji Medical Center, Eulji University College of Medicine, Seoul, South Korea, 5 Hallym University Dongtan Sacred Heart Hospital, Dontan, South Korea

Objective: Clavicle fracture is one of the common combined musculoskeletal injuries of severe polytrauma patients (Injury severity score (ISS) ≥16). We analyzed the factors that induce delayed displacement of fracture site during conservative treatment for clavicle fracture in severe polytrauma patients. Materials and methods: From January 2013 to April 2017, 178 polytrauma patients with ISS of 16 or more with a clavicle fracture at a single trauma center were enrolled. Of these patients, 81 patients who had initial displacement of fracture site of less than 100% of the clavicle diameter and underwent conservative treatment initially were included. The “delayed displacement” was defined as the increase of the displacement of fracture site over 100% of the clavicle diameter during follow-up. We analyzed the risk factors inducing delayed displacement of clavicle fracture by the regression analysis for demographic factors of patients, location of fracture site, presence of comminution, hospitalization in intensive care unit, ventilator care, initial consciousness level, combined upper extremity injuries, rib fractures of the ipsilateral side, brain injury and spinal cord injury. Results: A total of 31 patients with delayed displacement of clavicle fracture were found. The regression analysis showed that the statistically significant risk factor for delayed displacement of clavicle fractures was a comminution of fracture. Conclusion: Because conservative treatment for comminuted clavicle fracture in polytrauma patients can lead to delayed displacement, follow-up should be done at short intervals and the possibility of surgery should be considered.

Small Joint Arthritis (31 abstracts)

Isidro Jiménez, Alberto Marcos-García, Gustavo Muratore, Jonathan Caballero-Martel, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Proximal interphalangeal joint osteoarthritis is the second leading cause for hand pain after the thumb carpometacarpal joint. Arthroplasty is the mainstay of PIP arthritis surgery achieving good functional results but there are some absolute prerequisites including good bone stock, joint stability, supple skin coverage and functional tendons and furthermore, PIP joint arthroplasty may be associated with several complications and the salvage treatment remains a challenging clinical problem. Joint fusion allows to obtain an excellent control of the pain but the complete loss of mobility is debilitating and high price to pay specially in young or active patients Our purpose was to assess the clinical and functional outcomes after proximal interphalangeal joint denervation using a volar approach in the treatment of PIP joint osteoarthritis. Eight cases were surgically treated from June 2007 to June 2016. Demographic data, comorbidities, preoperative and postoperative Visual Analog Scale for pain and DASH questionnaire were assessed. Average age was 54 (range, 30–69). Average follow-up was 52 (12–116) months. Most affected finger was the ring finger in three cases. PIP joint range of motion improved from 52º preoperative to 79º at final follow-up. The pulp-to-palm distance at final follow-up was 7 millimeters (range, 0–16 millimeters). VAS for pain improved from 7.8 (5–10) preoperative to 1.3 (0–3) at final follow-up (p<0.001). DASH questionnaire improved from 45.8 (40–61.4) to 10 (2.3–20.5) at final follow-up (p<0.001). All patients returned to their daily and working activities in 4 (2–7) weeks. One patient reported postoperative digital paresthesia spontaneously solved at 3 weeks postoperative. Our study is a descriptive, non-comparative study and follow-up period is probably not long enough in all cases to assess the long-term results. This is a small series performing the denervation only in young or active patients with painful osteoarthritis and useful arc of motion. The benefits of the denervation are its simplicity and early postoperative recovery. It allows achieving good clinical results and, in case of failure; any more traditional and aggressive technique remains possible under good conditions.

Kjell Van Royen 1, Bart Kestens 2, Chul-Ki Goorens 1,2

1 Dept. of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Brussels, Belgium; 2 Dept. of Orthopaedics and Traumatology, Regionaal Ziekenhuis Tienen, Tienen, Belgium

Objective Proximal migration of the first metacarpal can be seen after total trapeziectomy. In this study, two poly-L/D-lactide scaffolds (Regjoint) were inserted to fill the void after total trapeziectomy. We hypothesized this spacer to prevent proximal migration of the first metacarpal without the need of an additional ligament reconstruction, allowing early mobilization and less demanding rehabilitation. Methods Ten thumbs in 9 patients were treated with a total trapeziectomy and insertion of a poly-L/D-lactide scaffold. Inclusion criteria were symptomatic combined primary TMC and STT osteoarthritis after failure of conservative treatment (8) and persistent painful post trapeziectomy status (2). All patients were female and mean age was 65 (range 50-80) years. Clinical and radiological evaluation was performed after 6 months and 1 year. Patient satisfaction, pain, QuickDASH score, mobility of the thumb and strength were assessed. Results After 1 year, 7 out of 10 patients were satisfied with the result. Pain according to the VAS decreased with 49% (p = 0.01). Overall function according to the QuickDASH score decreased with 46% (p = 0.02). Mean range of motion decreased compared to the non-operated side. Opening of the first web space decreased with 24% (p = 0.02), opposition decreased with 10% (p > 0.05) and retropulsion decreased with 20% (p > 0.05). Mean MP flexion decreased (p = 0.04) and mean MP extension increased (p > 0.05). Mean grip strength decreased with 5% (p > 0.05) compared to the non-operated side. Mean key pinch decreased with 48% (p = 0.05) and mean precision pinch decreased with 50% (p > 0.05) compared to the non-operated side. Radiological evaluation after 12 months showed a collapse of the scaphometacarpal distance of 45% (p = 0.01), refuting our main hypothesis. Moreover, osteolysis of the distal scaphoid pole and or proximal metacarpal was seen in 6 out of 10 cases. Because of the osteolysis, the use of the poly-L/D-lactide scaffold was discontinued in our practice. Conclusion In our limited series, total trapeziectomy with use of the poly-L/D-lactide scaffold provides significant pain reduction and improvement of overall function. However, the intervention does not restore the mobility of the thumb and results in a decrease of strength compared to the non-operated side. Radiographic evaluation shows significant collapse of the scaphometacarpal distance after 1 year and osteolysis of the scaphoid and or proximal metacarpal in more than half of the cases. Therefore, we do not encourage the use of the poly-L/D-lactide scaffold with total trapeziectomy before long term clinical and radiological follow-up of the osteolysis is available. To our knowledge, this series is the first to use the poly-L/D-lactide scaffold after total trapeziectomy for primary basal thumb osteoarthritis. Radiological results align with earlier reports of osteolysis after partial trapeziectomy with poly-L/D-lactide scaffold.

Kjell Van Royen 1, Chul Ki Goorens 1,2, Jean Goubau 1,3

1 Dept. of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB). Brussels, Belgium; 2 Dept. of Orthopaedics and Traumatology, Hagelandse Orthopedische Praktijk, Regionaal Ziekenhuis Tienen, Tienen, Belgium; 3 Dept. of Orthopaedics and Traumatology, Upper Limb Unit, Orthoclinic, AZ Sint-Jan AV Brugge - Oostende, AZ Sint Lucas, Brugge, Bruges, Belgium

Background Trapeziometacarpal osteoarthritis is common and various surgical techniques exist if conservative treatment fails. Osteoarthritis of the capitate and trapezoid is uncommon. We describe a case of a combined disabling osteoarthritis in both joints. Case Presentation A right-handed 63-year-old maintenance worker was referred for spontaneous pain at the left thumb base for 4 months. He experienced disabling pain at rest (VAS 7/10). Clinical examination showed tenderness over both trapeziometacarpal (TM) and scaphotrapezium-trapezoid (STT) joints. Interestingly, the patient also experienced tenderness at the base of the second and third metacarpal. QuickDash score was 29.5. Conventional radiography and magnetic resonance imaging confirmed a combined TM and STT osteoarthritis, but also an advanced osteoarthritis over the capitate-trapezoid joint. Conservative treatment did not provide any pain relief, and surgery was proposed to the patient. A trapeziectomy with ligament reconstruction and tendon interposition (LRTI) was performed, combined with a capitate-trapezoid fusion. An anterolateral Wagner approach was used to perform the trapeziectomy. Additionally, a dorsal incision was made over the capitate-trapezoid joint to remove the cartilage and insert autologous bone grafts. The joint was then stabilized using a headless compression screw which was introduced from the volar basal thumb approach. Subsequently a classic LRTI was performed, tunneling the hemi flexor carpi radialis tendon through the base of the first metacarpal. Postoperatively, the wrist was immobilized in a thumb spica for 6 weeks, followed by mobilization without power grip for another 6 weeks. Outcomes After 6 months follow-up, pain at rest decreased (VAS 3/10) and QuickDash score was 9.1. The patient was satisfied and prepared to undergo the same operation again. Opposition was 8 and retropulsion was 2. Opening of the first web space was 50°. Key pinch was 5kg, Precision pinch was 2.5kg and grip strength was 20kg (right side 28kg). Conventional radiography and computed tomography after 3 months showed correct screw positioning and bony bridge between the capitate and the trapezoid. Discussion Symptomatic capitate-trapezoid osteoarthritis is uncommon, neither isolated or in combination with a trapeziometacarpal osteoarthritis. Literature regarding pathology of the capitate-trapezoid joint is limited to incidental findings of carpal coalition. A review of the present literature does not report a symptomatic osteoarthritis of the capitate-trapezoid joint. One would not expect osteoarthritis in the capitate-trapezoid joint since the distal carpal row is very rigid and the intrinsic ligaments do not allow any intercarpal motion. In our case, osteoarthritis may be possibly induced or aggravated by chronic trauma during previous long term professional activities. One should keep in mind that any case presenting persistent pain after successful trapeziectomy and cuneiform osteotomy of the trapezoid should be investigated to exclude this type of unusual arthritis. It highlights the possibility of osteoarthritis in carpal joints other than the TM or STT joints in patients with basal thumb pain.

Osamu Soejima

Department of Orthopaedic Surgery, Fukuoka Sanno Hospital, School of Medicine, International University of Health and Welfare, Japan

Objective: The new surgical technique of ligament reconstruction suspension arthroplasty (LRSA) using double palmaris longus (PL) tendon graft with suture button has first been reported at JSSH, FESSH and ASSH meetings in 2017. The purpose of this study is to report the short-term surgical results of LRSA for treatment of advanced thumb TMC joint arthritis. Methods: 19 patients (21 thumbs) were treated using this technique since 2015 by a single-surgeon, 12 thumbs in 11 patients (6 males and 5 females) with 6-months minimum follow-up period were identified for this evaluation (follow up ratio: 85.7%). The average age at surgery was 65.6 years. According to the Eaton’s classification, 11 thumbs classified as stage III, and remaining 1 thumb as stage IV. Visual analogue scale (VAS), thumb range of motion, grip and pinch strengths and complications were reviewed. As an index of the first metacarpal subsidence, the trapezial space ratio, which is the height of the trapezial resection space divided by the length of the first metacarpal, was measured from the preoperative, postoperative, and follow-up radiographs and CT scans. All patients completed DASH and HAND-20 evaluations at the latest follow-up. All evaluations were made independently by different doctors and hand therapists. The mean follow-up period was 11.5 months. Results: VAS decreased from 15.6 to 6.7 (resting), and from 75.0 to 18.4 (working), respectively. The radial and palmar abductions improved from 52.8° to 65.3° and from 52.2° to 63.3°, respectively. The grip and the pinch strengths also improved from 18.8kg to 21.5kg and from 3.8kg to 4.1kg, respectively. DASH and HAND-20 scores improved from 33.0 to 21.3 and from 38.1 to 20.7, respectively. Radiographs demonstrated that the arthroplasty space was maintained, and no patient showed any evidence of an impingement or a fracture of the first and second metacarpal bases. No postoperative complications were noted at this short term follow-up period. Conclusions: From this study, LRSA technique preserved APL tendon as an extrinsic stabilizer and achieved good pain relief and recreated support of the base of the first metacarpal to resist proximal migration or radial subluxation. This technique also provided an improvement in strength and function early in the postoperative period without any complications. This technique holds promise, and merits further long-term follow-up studies. References: 1. Soejima O: JHS 42E, S19, 2017. 2. Soejima O: ASSH HAND-E (Top rated surgical videos), 2017.

Nicolas Dreant, Marie-Anne Poumellec

Pole Urgence Main, Nice, France

Purpose : The use of dual mobility is a propriety inspired by hip arthroplasty and recently introduced for first carpometacarpal joint total arthroplasty in the treatment of advanced stages of osteoarthritis. The aim of the study was to report the early functional results of a patient cohort treated with a dual-mobility thumb carpometacarpal joint prosthesis (MOOVIS®). Methods : A retrospective study was performed to assess the functional results of 32 patients treated for trapeziometacarpal advanced osteoarthritis (Eaton and Littler stage III) with 35 MOOVIS® prostheses. Preoperative and postoperative assessments included pain, range of motion and pinch and grip strenght. The average follow-up time was 24 months. Results : The mean pain score measured by a visual analogic scale was 8 preoperatively and 1 postoperatively. The mean preoperative Kapandji opposition score was 7 and counter-opposition score was 1; postoperative scores were 10 and 4, respectively. There was no significant difference in grip strength between the operative hand and contralateral hand evaluated after surgery. Final functional results were good: the mean Quick Disabilities of the Arm, Shoulder and Hand Questionnaire score was 15 and the mean Michigan Hand Outcomes Questionnaire score was 53. One metal hypersensibility but no dislocations or infections were observed in the series. Conclusions : Total joint arthroplasty with a dual mobility prosthesis appears to be a satisfactory solution in our series. The good functional results and the low level of prosthesis instability encourage us to recommend this technique for the treatment of advanced trapeziometacarpal osteoarthritis.

Kawther Raji 1, Anthony Barabas 2

1 Royal Papworth Hospital NHS Foundation Trust, UK; 2 North West Anglia Foundation Trust Hinchingbrooke Hospital, UK

Background: Medical texts normally recommend ligament reconstruction using the Eaton and Littler procedure. This procedure stabilises the trapeziometacarpal joint (TMJ) by reconstructing the anterior oblique ligament (AOL) using a strip of flexor carpi radialis (FCR) tendon passed from volar to dorsal through the base of the first metacarpal. Recent TMJ dissection studies have shown that the AOL is not the most important ligament in TMJ congruency and stability. Rather, these studies showed that the wider, thicker and stronger dorsal radial ligament complex (DRLC) is the prime stabiliser of the TMJ. Based on this understanding, we describe a novel procedure to reduce dorsal subluxation of the TMJ - by using the abductor pollicis longus (APL) tendon to reconstruct the DRLC. Technique: An incision is made across the anatomical snuffbox in line with the extensor pollicis brevis (EPB) tendon, as per a trapeziectomy. The dissection is made down to the TMJ capsule. The APL tendons are identified at their insertion onto the base of the 1st metacarpal, and exposed along their length crossing the anatomical snuffbox, back to the extensor retinaculum of the first dorsal compartment. There is invariably more than one APL tendon. The ulnar-most APL tendon is selected and divided proximal to the extensor retinaculum of the 1st compartment. This provides an approximately 5cm APL tendon stump which is pulled distally through the 1st dorsal compartment and freed up all the way to its attachment onto the base of the 1st metacarpal. This tendon stump is then divided into two equal sized strips, each still remaining attached to the APL insertion on the dorso-radial aspect of the first metacarpal. The soft tissues are stripped off the TMJ capsule in an ulnar direction until the intermetacarpal ligament (IML) is exposed. The ulnar APL tendon slip is passed under the EPB tendon, and then passed from distal to proximal around the IML and pulled taut. This manoeuvre pulls the base of the first metacarpal anteriorly and ulnarly relative to the trapezium. The APL tendon is then transfixed to the IML. Dissection proceeds in a radial direction around the TMJ capsule, beneath the remaining APL tendon slips. There are no strong radial ligaments on the radial aspect of the TMJ, therefore a 4mm bridge of TMJ capsule is raised, and the radial APL slip passed from radial to ulnar under the bridge and pulled taut. This leaves the trailing ends of the radial and ulnar APL slips running towards each other across the dorsal TMJ capsule directly overlying the DRLC, at the level of the joint. The two slips are then spiralled around each other, pulled taut and sutured to each other and to the dorsum of the joint capsule/DRLC. This reconstructs the DRLC, preventing dorsal subluxation of the 1st metacarpal base off the trapezium. Conclusion: The procedure has been performed on 8 patients, in one patient bilaterally. All patients except one reported decreased or no pain at their follow up, and improved pinch and grip strength.

Pascal Behm 1,2, Stephen J. Ferguson 2, Miriam Marks 1, Daniel B. Herren 1

1 Schulthess Clinic, Zürich, Switzerland; 2 ETH Zürich, Zürich, Switzerland

Objective In patients with osteoarthritis (OA) of the first carpometacarpal (CMC I) joint, the joint stability may vary from very well-controlled to lax joints. When performing trapeziectomy, alone or in combination with suspension and tendon interposition, the surgeon perceives individual differences in joint stability, which may influence his/her treatment decision. However, there are no quantitative data available on the stability of the CMC I joint after trapeziectomy. Furthermore, the relative contribution of the different surgical steps to the stability of the joint is unknown. Therefore, the objective of our study was to develop a device for intraoperatively measuring CMC I joint stability. Methods A measurement system was developed to provide continuous force measurement during a linear displacement of the CMC 1 joint. The system allows the hand to be positioned in a standardized pinch grip position. A conventional reposition forceps is attached to the base of the MC I and the forceps is in turn connected to a linear slide with integrated force sensor. The whole system is steam-sterilisable. The thumb ray is manually displaced by 10 mm towards the scaphoid and the counteracting force is measured over the entire displacement. The maximal measured force defines the apparent joint stability. The device was tested in a cadaver experiment to measure the CMC I stability after trapezium resection and interposition. Results CMC I joint stability could be successfully measured during the cadaver test. Interposition of fabric into the trapezial cavity resulted in a higher apparent stability. These initial measurements indicate easy handling of the measurement setup and proof-of-concept for measuring CMC I stability intraoperatively. Furthermore, a force displacement curve could be derived from simultaneously recorded fluoroscopy images. Conclusions The developed system allows the intraoperative assessment of the stability of the first carpometacarpal joint and provides accurate force data. It is planned to use the device in a clinical trial including 67 patients, in which the CMC I stability will be measured after each step of trapeziectomy with suspension-interposition arthroplasty. This will provide new insight into the patients’ initial joint stability, the increase at each surgical step and may assist the surgeon in defining the best surgical method.

Benjamin Degeorge, Louis Dagneaux, Julien Andrin, Cyril Lazerges, Bertrand Coulet, Michel Chammas

Lapeyronie University Hospital, Montpellier, France

Background : No surgical management is better than another regarding functional recovery for trapeziometacarpal joint osteoarthritis. Metacarpophalangeal hyperextension, directly due to the shortening of thumb height, appears to be a factor of poor prognosis. Hypothesis: MCP hyperextension can be corrected by implantation of a trapeziometacarpal prosthesis, as opposed to trapeziectomy and ligamentoplasty, and pinch strength is greater with TMP in this indication. Material and methods : Sixty-nine patients (41 TMP and 28 TL) were retrospectively evaluated. The following were evaluated: pain, mobility of the metacarpophalangeal joints, palmar grip and pinch strength. Thumb height was measured on radiographs as a post/preoperative ratio. Results : The mean follow-up was 20 months (6-38). The TMP group showed greater reduction of the metacarpophalangeal hyperextension in all hyperextension groups, especially hypertension >30°, compared with TL. The TMP group provided significant greater pinch strength in all the subgroups with preoperative MCP hyperextension. Patient with postoperative MCP hyperextension had a significant lower grip and pinch strength compared with patient without MCP hyperextension. Radiographic analysis showed that thumb height changes were related to the degree of preoperative hyperextension. Postoperatively, patients with postoperative MCP hyperextension had a significant lower thumb height than patient without MCP hyperextension. Discussion : Metacarpophalangeal hyperextension appears to be a factor of poor prognosis for surgical treatment of trapeziometacarpal osteoarthritis when it is not managed. TMP provides better metacarpophalangeal stabilization by restoring thumb length and would avoid surgery on the metacarpophalangeal joint. TMP may be recommended in patients having symptomatic trapezio-metacarpal joint osteoarthritis and MCP joint hyperextension.

Inga Besmens, Maurizio Calcagni, Thomas Giesen

University Hospital Zurich, Department of Plastic Surgery and Hand Surgery, Zurich, Switzerland

Degenerative changes of the distal interphalangeal (DIP) joints can be painful, disabling and disfiguring. Swanson spacers are primarily used in PIP and MP joints, but there are also many reports about their use at the DIP as an alternative to arthrodesis especially in high demand patients. The standard approach for Swanson spacer implantation at the DIP joint involves transecting the extensor tendon close to its insertion. This necessitates a six weeks period of postoperative immobilization, which is associated with a loss of joint motion. An alternative approach involves sparing the extensor tendons as already published. However, this approach is technically more demanding and is associated with higher risk of misplacement of the implant. We present a novel approach to the DIP joint with a more proximal division of the extensor tendon in zone 2 and only two weeks of postoperative immobilization. From 2015-2017 we implanted 8 Swanson Spacers in DIP joints in 4 patients with the new approach: After an H-shaped skin incision with proximal slightly longer legs over the DIP joint, the extensor tendon is incised in zone 2 just distal to the central slip insertion and is flipped distally. The Swanson spacer is then implanted in the standard manner. After positioning of the prosthesis, the extensor tendon is sutured back with two crossed sutures, one per slip. Postoperatively, the patients received a DIP splint in slight hyperextension for two weeks and started mobilizing the joint without protection after 2 weeks. The DIP joint range of motion was measured at 2, 6 and 12 weeks postoperatively We reviewed all our patients with a follow up of at least 3 months. At 12 weeks postoperative, we measured an extension lag between 0° and 20°. Median DIP flexion was 51°. Degenerative changes in the hand joints including the DIP joint are a common problem. Nowadays most patients have high functional expectations and opt against DIP arthrodesis. Optimizing the operative technique is very important to achieve the best possible function. Our postoperative results do not differ from the postoperative range of motion published in the literature for both tendon sparing and standard approach, but our technique is much easier and allow for a faster mobilization, further reducing the discomfort of the patient.

Mohamed Elsaid Abdelshaheed, Ahmed Abdel-Galil Khalil, Reda Abdallah Younis, Ahmed Mohamed Bahaa El-Din Moustafa, Samy Ahmed Mahmoud Shehabeldin

Faculty of medicine, Mansoura university, Mansoura, Egypt

Objective The proximal interphalangeal (PIP) joint plays an important role in both grasp and pinch. In terms of mobility and stability, an intact PIP joint plays an important role in isolated finger function as well as the function of the entire hand. Currently, there are only a few surgical management protocols: arthrodesis, arthroplasty without joint replacement and arthroplasty with prosthetic replacement. This study aims to evaluate the gap arthroplasty technique as an alternative method for PIP joint reconstruction and to identify its advantages and disadvantages. Methods This interventional prospective study was conducted in a university hospital setting. We performed PIP joint gap arthroplasty using a dynamic traction device system after resection of the ankylotic area. Results were evaluated after 6 months minimum follow up period based on ROM, pain relief according to the VAS, stability under manual stress, joint alignment according to radiographs and overall patient satisfaction according to a score we designed. Results After 17.23 ± 5.10 months mean follow up period, the mean flexion at the PIP joint was 66.15 ± 18.16°, the mean extension lag was 25.38 ± 8.77° and the mean active ROM was 40.77 ± 20.90°. VAS improved from 8 (ranging from 7 to 9) preoperatively to 1 (ranging from 0 to 2) postoperatively which was statistically significant (P value 0.001). Six joints (46.2% of cases) were stable under manual stress and three cases (23.1% of cases) showed PIP joint alignment in radiographs. The overall patient satisfaction was 4 (ranging from 3 to 5). Conclusions Gap arthroplasty is an easy and effective technique for the PIP joint, and it does not require expensive materials as do artificial joint procedures. However, further studies are needed to conduct a long term functional evaluation.

Francisco Cuadrado Abajo, Higinio Ayala Gutiérrez, Manuel Rubén Sánchez Crespo, José Couceiro Otero, Olga María Vélez García, María de los Ángeles de la Red Gallego, Fernando Javier del Canto Álvarez, Marta de Prado Tovar, Vanesa Martínez Cortavitarte

Marqués de Valdecilla Universitary Hospital, Santander, Spain

Background and Objectives Degenerative thumb carpometacarpal (CMC) osteoarthritis is one of the most prevalent pathologies in the hand but it affects rarely to young and active population. The most popular options for the treatment of this condition in such patients is the trapezoid-metacarpal arthrodesis. In spite of this, the carpometacarpal prostheses are becoming more relevant due to the reported favorable short-term results. The objective of this study was to assess the clinical and radiological results in a case report of a young and active woman who was initially treated with an arthrodesis that was not tolerated due to the need for more mobility of her thumb and was reconverted to a prostheses. Matherial and Methods We present a case of a 43-year-old woman, who works as butcher, and developed a degenerative 1st CMC osteoarthritis in her left hand, in the context of an idiopathic osteoarthritis. Physical examination: deformity at the base of the thumb, without metacarpal-phalangeal instability. Kapandji 9/10 with pain and the grinding test was positive. In plain radiographs a degenerative 1st CMC osteoarthritis (Eaton-Littler grade III) is diagnosed. As a first alternative to the patient, an 1st CMC arthrodesis was proposed, which was carried out in February 2016 using 2 K-wires and tension band (Lister’s technique). A radiological consolidation of the arthrodesis was observed at 2 months. At 3 months the patient reported a clear improvement in pain (visual analog scale 2/10) with a grip strength of 22 kilograms (kg) and a pinch of 4 kg (30 and 8 kg in the contralateral hand respectively) The thumb was fixated in 45º of radial abduction and 10º of palmar abduction position. However, the patient reported being unable to hold thick pieces of meat, affecting her work. Then, it was decided, as an agreed proposal, to reconvert the arthrodesis in a ISIS trapeziometacarpal prostheses in July 2016 (semiconstrained with a threaded, uncemented cup component, and uncemented metacarpal stem). Results The clinical result was satisfactory for the patient. The radial abduction was up to 45º and the palmar abduction was 45º. She does not report any pain during her work activity. The grip strength is 20 kg and pinch of 4 kg. The radiological results were good as well, with no signs of loosened components or prostheses luxation. Conclusions The reconversion of a 1st CMC arthrodesis into a prosthesis arthroplasty has proved to be an option in selected cases of manual workers in which the restriction of mobility of the 1st CMC joint affects their work activity. The clinical and radiological results of our case report have been satisfactory.

Veronica Jímenez Díaz, Migue Porras Moreno, Lorena García Lamas

Hospital 12 de Octubre, Madrid, Spain

The aim is to assess the long-term results of trapeziometacarpal arthrodesis using a quadrangular plate, regarding clinical, radiological and functional outcomes, as well as development of complications. From 2005 to 2015, 70 patients were treated at our institution for primary osteoarthrosis of thumb carpometacarpal joint performing a trapeziometacarpal arthrodesis. A total of 85 arthrodesis were carried out using a titanium quadrangular plate . The average follow-up was 60 months. Pre- and postoperative functional data were assessed at the outpatient clinics using DASH, MWS and VAS. All patients were asked for their ability to perform basic daily activities before and after surgery. All patients were also asked about satisfaction and their return to their jobs after surgery. Pre- and postoperative radiological data were also assessed. There were 59 females and 11 males with an average age of 55 years (range 44-60). Fifteen cases arthrodesis was carried out bilaterally. Preoperative average DASH score was 64 (range 50-85), postoperative average score was 25 (range 5-61). Regarding MWS, 51 patients obtained excellent results, 15 patients obtained good results and 4 patients referred poor results. The preoperative average score of VAS was 6 (range 5-10), which decrease to an average of 2 (range 0-3) after surgery; all those differences were statistically significant. All patients reported a mild loss of motion; however, all of them reported improvement to carry out daily activities. There were four cases of nonunion because of failure of fixation and two cases with dysesthetic scar. There was no development of osteoarthritis in adjacent joints. The use of quadrangular plates for arthrodesis of the trapeziometacarpal joint is a safety and reproducible technique with a low rate of complications. Arthrodesis decreases pain and improves function in patients with primary osteoarthritis of the thumb carpometacarpal joint

C. Martinez Andrade, M Cruz, O Escudero, MC Castro, JM Morell, F Castillo

Hospital Dos de Maig, Barcelona, Spain

The rescue of a fibrous interposition arthroplasty in the treatment ofCMC arthritis is a delicate situation, different techniques have been described, most of them using suspension systems such as the mini tigth-rope (Arthrex), on the contrary the use of prostheses is not it is widespread and most of the literature refers to clinical cases. We present a rescue case of Burton-Pellegrini arthroplasty with a Maia prosthesis (Lepine) with good clinical-radiological results Woman of 75 years of age, rizarthrosis surgery in 2004, fibrous interposition arthroplasty and metacarpo-phalangeal arthrodesis, correct clinical evolution until casual fall in August of 2014, radiological study discards fracture, treatment is performed with orthosis and physiotherapy. The patient does not improve, on the x-ray it is observed impaction between the scaphoid and the first metacarpal, it is not corrected with distraction of the thumb. The patient reported severe pain (8 on the VAS scale) and a decrease in the strength of the thumb pinch Surgery was performed in March 2016, Maia (Lepine) prosthesis placement placing the metacarpal component in the first metacarpal and the trapezium dome in the distal pole of the scaphoid. After immobilization for 4 weeks, the patient starts physiotherapy, in her last control, the patient reports a slight pain (2 on the VAS scale), performs correct opposition of the thumb (Kapandji 9), and has improved her thumb clamp strength. The radiological study and the CT objectify a correct placement of both components. The arthroplasty of fibrous interposition in a habitual technique in the treatment of theCMC arthritis with successful results, is infrequent the necessity of revision by failure being this revision surgery difficult. Normally the rescue is performed with suspension systems to recover the length of the thumb again and avoid the impingement between scaphoid and first metacarpal or between the bases of the first and second metacarpal. The use of prostheses is very unusual, having been described using the stem in the scaphoid and the dome at the base of the first metacarpal, we have not found in the literature reviewed the use of the dome in the scaphoid as in our case. The short time of evolution forces us to be cautious about this type of rescue surgery.

Simon Nicholson, Jill Arrowsmith

Pulvertaft Hand Centre, Derby, UK

Objective Surgical denervation of the small joints of the hand has failed to gain widespread popularity despite it’s numerous advantages over other treatments for arthritic pain. The present review discusses the anatomy, surgical techniques and outcomes of such denervation of joints commonly affected by arthritis, and highlights the benefits and drawbacks relative to other surgical options. Methods A review of existing literature following a Pubmed search using the keywords “(denervation OR neurectomy OR neurotomy) AND (finger OR thumb OR hand OR interphalangeal OR metacarpophalangeal OR carpometacarpal)” in either the title or abstract was performed. Eleven papers were felt to be of relevance, which included articles in English and French and described denervation of the distal and proximal interphalangeal joints, metacarpophalangeal joints and thumb carpometacarpal joint. Results A single study of distal interphalangeal joint denervation in 10 patients reported 7 patients achieved ‘good’ relief of pain and were pleased with results at minimum follow up of 4 months. In a series of 24 proximal interphalangeal joint denervations, the mean pain score reduced from 8 to 2 on a visual analogue scale, with ‘good improvement in pain’ seen in 22 cases at mean follow-up of 77 months. The mean range of movement increased from 57º to 67º. Meanwhile, Foucher reported improvement in pain by a mean 88% in 29 of 34 cases, and improved range of motion (mean 62º to 77º) in 7 at mean follow up of 17 months. Arenas-Prat performed nine denervations of metacarpophalangeal joints over 40 months. Three had complete relief of pain, and a further 5 had ‘significant improvement’ and were pleased with the outcome of surgery. Lorea’s approach to denervation of the trapeziometacarpal joint resulted in a mean reduction in pain of 84% (range 60-100%) by a mean of 5 months post-op. Twelve out of 14 patients were very satisfied, with global pain reduction of over 80%. Of the two results considered ‘bad’ (less than 80% improvement), only one was dissatisfied (60% reduction in pain); interestingly this was the youngest patient at age 30. Conclusions The benefits of small joint denervation are multiple: the procedures are technically simple, and many can be performed under local anaesthesia as day case surgery. Satisfactory pain relief can be achieved at a rate comparable to and sometimes better than that with other techniques, with few iatrogenic complications. There is no risk of implant-related complications such as breakage or migration, and the cost associated with implanted devices is eliminated. Denervation causes no interference with joint biomechanics or range of movement, and studies have shown movement to be no worse, and in some cases better, than pre-operatively. Pinch and grip strength are not lost, which may be the case with other techniques, and there is some evidence that these parameters may actually be improved following denervation.

L. Chris Bainbridge 1, Charles S. Day 2, Philip Sauvé 3, Sanjay Miranda 4, Paul Binhammer 5, Grey Giddins 6, David Lawrie 7, Jonathan Lee 8, Andrew Trenholm 9, Erin Brown 10

1 Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK; 2 Department of Orthopedic Surgery, St. Elizabeth’s Medical Center, Brighton, Massachusetts, USA; 3 Department of Orthopaedic Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Hampshire, UK; 4 Department of Trauma and Orthopaedics, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom; 5 Department of Plastic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 6 Department of Orthopaedics, Royal United Hospital, Bath, UK; 7 Woodend Hospital, NHS Grampian, Aberdeen, UK; 8 Department of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada; 9 Division of Orthopaedic Surgery, Dalhousie University and Queen Elizabeth Health Sciences Centre, Halifax, Nova Scotia, Canada; 10 Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada

AIM: We report the interim outcomes of a prospective, multicentre, feasibility trial of a synthetic cartilage implant for treatment of Eaton-Littler stage II / III first carpometacarpal joint osteoarthritis. METHODS: Fifty patients ≥18 yrs with VAS pain ≥40 and good bone stock were enrolled. The metacarpal base was exposed dorsally. The 8mm implant was placed in a precision reamed central cavity, stabilized by friction fit and rested 1-3 mm proud. The capsule was closed, a plaster short arm cast applied, and the thumb immobilised for 6 wks. General health was assessed at 14 and 42 days post surgery with x-rays at 42 days. General health, x-rays, ROM, pinch and grip strength, VAS pain, MHQ and QuickDASH were assessed at baseline, 3, 6 & 12 mos post surgery. Adverse events and medications were recorded. RESULTS: Outcome scores improved at 3, 6 and 12 mos post surgery. Clinically meaningful improvements in VAS pain, QuickDASH and MHQ scores were reported by 30/40, 39/40 and 24/39 patients at 6 mos, and 15/19, 18/19 and 13/18 patients at 1 yr, respectively. Grip and pinch strength were 2 std dev below age and gender matched healthy norms at baseline and improved to normal at 1 yr. ROM was maintained post surgery. Joint space and alignment were maintained over time on x-rays. There were no serious device-related adverse events and no implant failures. At mean follow-up of 7.6 ± 3.7 (range 1.5 – 12.5) months, 5/50 (10%) patients required secondary surgical intervention: 3 devices (6%) were removed and converted to trapeziectomy with suspension; 2 underwent supplemental fixation. The device implantation procedure was subsequently modified. CONCLUSION: The synthetic cartilage implant is a safe device with increased function and strength and reduced pain at 1 year.

Hideyuki Ota, Kentaro Watanabe, Yuki Fujihara, Atsuhiko Murayama

Department of Orthopedic Surgery, Nagoya Ekisaikai Hospital, Japan

[Objective] Many surgical procedures are available for the treatment of thumb carpometacarpal joint osteoarthritis (CMC-OA) such as arthroplasty, (i.e. trapeziectomy) with variations including ligament reconstruction, and tendon interposition (LRTI), arthrodesis and prosthesis. Procedures of LRTI have been popular, however, they require healthy tendons as donors and are technically complicated. Recently, suture button suspensionplasty (SBS) has attracted attention, yielding good clinical results. Therefore, we have developed a novel SBS using a couple of suture button devices (Mini TightRope, Arthlex, USA) following whole trapeziectomy. We report short-term clinical results of cases who underwent cross-coupling SBS at our institution. [Method] We reviewed 10 hands of 10 patients including 9 females and 1 male with an average age of 67 years. We evaluated the pre-operative Eaton stage, post-operative trapezial space height at the time just after surgery and at the final visit, range of motion of the palmar and radial abduction of the CMC joint at the final visit, pre- and post-operative pinch strength, and post-operative complications. [Result] Mean follow-up was 10 months (3 months – 24 months). The preoperative Eaton stages were II, III, IV in 2, 5, 3 thumbs, respectively. Arthrodesis of CMC joint was performed previously at the other clinic in one case of stage IV. Mean trapezial space height was 6.5 mm at the final visit (49% of post-operative space at the time just after surgery).Mean palmar and radial abduction were 46 degrees each. Mean pinch strength was 3.4 kg. In one case, a stress fracture of the second metacarpal occurred at 2 weeks after surgery, which was treated by casting. Improvement of all parameters was observed at the final visit. [Conclusions] Cross-coupling SBS has some advantages. First, it does not need a donor tendon for suspension. Second, it is simple technically compared to LRTI. Finally, it is less invasive than LRTI, and the patients can start rehabilitation just after surgery due to its rigid initial stability. Although the long-term outcome of SBS is not yet known, good short-term results can be expected. Therefore, we recognize that cross-coupling SBS is a good surgical option for CMC-OA.

Dong Ho Kwak, Yong-Suk Lee, Jin-Woo Kang, Seung Han Shin, Yang-Guk Chung

Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, South Korea

Objective The most main reason for thumb basal joint arthritis is instability of joint stabilizing ligament, especially because of Volar oblique ligament (VOL). Volar oblique ligament (VOL) is known as a primary trapeziometacarpal joint stabilizer. Eaton and Littler reported their technique of reconstructing VOL as a treatment of VOL reconstruction and stabilizing thumb basal joint. We evaluated clinical outcomes of VOL reconstruction applied for patients with stage I, II and even early stage III thumb basal joint arthritis. Method We analyzed 45 patients who had undergone surgery for thumb basal joint arthritis in our hospital from January 2010 to March 2017 and had a minimum 6 month follow-up. All patients except 3 were women and the mean age at diagnosis was 57 (range: 43-78) years. 14 patients were Eaton stage I, 23 were II, and 8 were III. Functional outcome were evaluated using New York Orthopedic Hospital Wrist Scoring Scale, which assessed ROM, grip power, radiologic findings, pain and hand function. The mean follow up period was 22.02 (6-69) months. Result The overall functional results were 20 very good, 21 fair and 4 poor. Two out of 8 patients with stage III osteoarthritis showed poor result. At last follow up, average grip power was 74.9% of normal side. The stability of volar oblique ligament-reconstructed basal joint were restored and maintained in 31 out of 45 joints. The arthritis was progressed in 7 joints, four out of 23 Eaton stage II and three out of 8 Eaton stage III joints. Conclusion Our results suggested VOL reconstruction is a reliable method for management of Eaton stage I and II osteoarthritis and can be applied even in early Eaton stage III osteoarthritis before performing salvage procedures.

Stefania Tanase 1, Jerome Jeudy 2, Alexandre Petit 2, Fabrice Rabarin 2, Yann Saint Cast 2, Guy Raimbeau 2

1 Central Military Hospital "Dr Carol Davila", Bucharest, Romania; 2 Centre de la Main, Trelaze, France

Objective: The purpose of this study was to evaluate the short-term clinical and radiographic outcome of a pyrocarbon interposition implant in treating posttraumatic little finger carpometacarpal arthritis. Methods: We treated five consecutive patients who presented traumatic destruction or symptomatic disabling post-traumatic arthritis of the hamato-metacarpal joints. According to the severity of the bone loss, two types of pyrocarbon interposition implants were used: Pi2 or Pyrocardan (Tornier, Montbonnot Saint Martin, France). All the patients were reviewed by an independent observer and were assessed through X-rays, physical exam and questionnaire. Results: The patients were reviewed at a mean of follow up of 25 months (12-54). All patients acknowledged a decrease in pain levels and were satisfied with the little finger aspect and CMC joint mobility. The grip strength at the time of the review was improved in all cases. No complications were reported. Radiographic evaluation showed no fractures or dislocations of the implant. Conclusion: Pyrocarbon interposition implant in treating little finger carpometacarpal arthritis is a simple and reliable technique for restoring CMC joint mobility without underlying pain.

Tetsuya Nemoto 1,2, Hajime Ishikawa 1, Asami Abe 1, Hiroshi Otani 1, Katsunori Inagaki 2

Department of Rheumatology, Niigata Rheumatic Center 1, Department of Orthopaedic Surgery, Showa University 2

[Objectives] The boutonniere deformity of the thumb is the most common deformity of rheumatoid thumb and it accounts for 50 to 74% of the involved thumbs. Metacarpophalangeal(MP) joint arthroplasty is indicated for the deteriorated MP joint with preserved soft tissue stability. Feldon introduced to use flexible hinge toe implant for the MP joint reconstruction because of its better mechanical strength compared to finger joint implant. We hypothesized rheumatoid thumb reconstruction using flexible hinge toe implant would improve the clinical outcomes and radiological findings. [Patients and Methods] Swanson implant arthroplasty for at the thumb MP joint was performed on the 68 cases (male 11, female 57) between November 2006 and December 2014. The average age was 64 yrs. old and the average follow-up period was 3 yrs. The duration of the rheumatoid arthritis at the time of surgery was 22 years. Combined with this MP joint arthroplasty, suspensionplasty at the CM joint (Thompson) was performed in 38 cases, arthrodesis at the IP joint in 20 cases, capsulodesis at the IP joint in 3 cases. Radiological assessments were performed in 68 cases, clinical evaluation was performed in 47 cases. We assessed range of motion, grip power, side pinch power, general health using visual analog scale (VAS) and DAS28-CRP. Wilcoxon rank sum test was used as a statistical analysis. [Results] A painless stability was provided to the thumb in most of the patients. In the radiological assessment, the pre- and the postoperative flexion angles at the MP joint were 45 and 17 degrees, and extension angles at the IP joint were 41 and 0 degree(s). In the clinical assessment, the average arc of motion was 21 degrees, with 44 degree in flexion and 23 degrees in extension. The average grip strength changed from 110 to 121 mmHg (p=0.130) and the average side pinch power changed 1.7 to 2.0kgwf (p=0.094), they were not a significant change, the patients were satisfied with their appearance of the thumb. General health using VAS improved from 40 to 28 (p=0.006) and DAS28-CRP was decreased 3.3 to 2.3(p>0.001). In one case, postoperative infection occurred and implant was removal of required. No implant fracture of the implant occurred. Joint stability and prehension pattern improved by arthrodesis or capsulodesis.

Jae-Hwi Nho 1, Ki Jin Jung 1, Hyun Sik Gong 2, Byungsung Kim 1

1 Soonchunhyang University Hospital, South Korea; 2 Seoul National University Bundang Hospital, South Korea

Introduction: In the 1st carpometacarpal(CMC) joint arthritis, surgical treatment is indicated in cases resistant to conservative therapy. Numerous procedures have been described for the treatment of such cases. Recently, Several studies have reported good results of Trapezial excision with or without ligament reconstruction and tendon interposition (LRTI). However, LRTI using FCR tendon is invasive than ligament reconstruction using suture anchor. The purpose of this study was to report the results of the patients with the 1st CMC arthritis who were treated with partial excision of trapezium and ligament reconstruction with suture anchor(JuggerKnot anchor, Biomet, Indiana, USA) in the 1st CMC arthritis. Methods: From 2014 to 2017, we treated 25 patients(pts) who had advanced 1st CMC arthritis with joint space narrowing and subluxation accompanying the collapse of the trapezium. The average age of the patients was 65.0 (range: 53~71, SD: 7.4) years. Hemi- excision of the lateral aspect of trapezium were performed. We inserted the anchor at the origin of volar oblique ligament of the trapezium, and inserted 1 more anchor at the base of 2nd metacarpal bone. After inserting 2 anchors, the 1st metacarpal base was fixed with 2 anchors to prevent subluxation. However, there were no interposition arthroplasties. Thumb spica cast was maintained for 6 weeks. We measured preoperative and postoperative clinical outcomes including pre- and postoperative VAS score, grip strength, wrist ranges of motion, and DASH scores 6 months after operation and the presences of complication. Results: Mean operation time was 35 minutes (range: 25~50, SD: 10.7). There were no notable complications at postoperative 6 months. There was a significant difference between the preoperative VAS score and the postoperative VAS score, that the preoperative VAS score averaged 7.1±3.3, however, the postoperative VAS score averaged 1.7±2.1 in these 35 patients( p value=0.000). All patients were evaluated in clinical outcomes including ROM, DASH score and Grip strength after postoperative 6 months. All patients considered their result as good or excellent outcomes including ROM, and improved the functional score. Conclusion: Partial excision of trapezium and ligament reconstruction with suture anchor could be an excellent option for the advanced 1st carpometacarpal arthritis. This method is simple and easy than the trapeziometacarpal arthrodesis or LRTI using FCR tendon. A new surgical procedure can be attempted with the improvement of the strength of the suture anchor.

Neela Janakiramanan, Sylvie Collon, David McComb, Stephen Tam

Victorian Hand Surgery Associates

AbstractrnObjectivernTo plot functional recovery following trapeziectomy and ligament reconstruction tendon interposition (LRTI) in patients with basal joint arthritis of the thumb.rnMethodsrnEligible participants were enrolled after trapeziectomy and LRTI were determined to be the best treatment in consultation with their treating surgeon. All patients underwent standard trapeziectomy and LRTI utilising flexor carpi radialis tendon passed through a drill hole in the base of the first metacarpal. Patients were immobilised for 2-4 weeks and then gradually weaned from splinting. rnA series of objective and subjective measurements were taken at baseline, three, six, nine and twelve months. These included Kapandji score, angles of palmar and radial abduction, grip strength and lateral key and tip pinch strength, a Disabilities of Arm, Shoulder and Hand (DASH) score, a Patient Rated Wrist Evaluation (PRWE) score and a pain score using a ten point visual analogue score. We also measured the trapezial space height and trapezial space ratio on pre-operative X-rays and post-operative X-rays at twelve months. rnThe primary statistical analysis was a repeated measures ANOVA, comparing each participant’s recovery trend over time.rnResultsrn55 participants were recruited into the study. Participants were predominantly female (82%) and elderly (mean age: 63) rnAll objective measures of thumb function improved over the twelve month follow up period. Mean Kapandji score improved from 8.3 to 8.6 (p=0.04); mean palmar and radial abduction angles improved from 44.2 to 52.3 (p=0.002) and 44 to 48.9 (p=0.04) respectively. rnMeasures of strength were universally lower at 3 months but had improved beyond baseline by 6 months and continued to improve to 12 months. Mean grip strength (in kg) improved from 17 at baseline to 23.9 at 12 months (p=0.1). Mean key pinch strength improved from 3.8 to 4.8kg (p=<0.001). Similarly, mean tip pinch strength improved from 3.2 to 4.5 kg (p=<0.001)rnPains scores dropped markedly between baseline and three month and then continued to improve until twelve months. Mean patient rated pain decreased from 7 at baseline to 2.4 at 3 months and then 0.9 by 12 months (p=<0.001)rnFor pre-operative factors, gender or the presence of pre-operative STT arthritis did not impact on functional recovery.rnConclusionsrnTrapeziectomy and LRTI results in statistically and clinically significant improvement in all objective and subjective measures of thumb and hand function. Most notably, there is a marked improvement in grip strength and tip and key pinch strength over twelve months, with final values approximating normative values for patients in that age group. Pain improved most rapidly, but all measures showed continual improvement until twelve months, and it is possible that thumb and hand function continues to improve past the point at which the study ended.

Thiago Tomazi, Peter Larsson, Samuel Christen, Jörg Hainich, Jörg Grünert

Kanton Spital Sankt Gallen, Sankt Gallen, Switzerland

PURPOSE: To present a surgical technique of volar plate interposition arthroplasty for posttraumatic arthrosis in proximal interphalangeal (PIP) joints. METHODS: During 2017 we performed the volar plate interposition arthroplasty technique in two patients, both showing posttraumatic destruction of the PIP Joint. The operations were performed by a single surgeon in a standardized procedure using a palmar approach and radial incision of the A3 Pulley. After retracting the deep flexor tendon to the ulnar side the palmar plate was divided at its proximal edge providing enough tissue to completely cover the basis of the intermediate phalange after folding it dorsally between the two parts of the joint. Fixation of the palmar plate to the dorsal capsule after preparation of the joint using the shoot gun approach is performed by using a PDS suture. Both Patients received an external fixator (Suzuki) afterwards. The surgical technique was intraoperatively documented with radiographs and photographs. Intra- and postoperative assessments included range of joint motion, joint alignment and stability under manual stress. Pain was assessed using a numerical analog pain scale from one to ten and the DASH Score (Disabilities of the Arm, Shoulder and Hand). RESULTS: The results were retrospectively reviewed after a follow-up period of 10 and 3 months. The surgical technique described can easily be reproduced and offers a surgical way to avoid arthrodesis in severe affected posttraumatic PIP joints, where implantation of a finger prosthesis is not adequate. It allows a significant increase in postoperative arc of motion and significant decrease in pain, especially under axial loading. The pain decreased significantly with an improvement in the numerical analog pain scale at the final evaluation, indicating a clearly positive subjective evaluation. CONCLUSIONS: According to our limited experience the surface replacement with volar plate interposition arthroplasty provides satisfactory results in terms of pain relief and range of motion restitution for the interphalangeal (PIP) joints with posttraumatic arthrosis. We propose this technique as a reliable therapeutic option for posttraumatic arthrosis in PIP joints in young patients in technical professions.

MO Ashraf 1, R Kanvinde 2

Ysbyty Gwynedd Bangor, Wales, UK

Purpose: The aim of the study is to establish the short term outcome for basal thumb arthroplasty using metal on metal uncemented prosthesis covered with tri-calcium phosphate coating. Methods: All patients treated with trapezio-metacarpal joint arthroplasty within the last 5 years in our practice were invited in the study. There were no exclusions. Patients underwent thumb mobility measurements using Kapandji thumb opposition score5 and measurement of thumb extension and abduction using goniometer. They had power assessments of grip and pinch strength including both end to side pinch and end to end pinch measurements using JAMAR dynamometer which is available in clinics. They were asked to fill out forms containing visual analogue score for pain and DASH score6 for functional assessment. Finally they were asked whether they are satisfied with the surgery and whether they will recommend the same surgery to other patients with the same condition. Results: There were eleven operated thumbs in 10 patients. Female to male ratio was 9:1. The mean age was 59 years (SD 7.3 years) with a mean follow-up period was 29.9 months (SD 16.3 months, range 9 – 65 months). The mean pre-op pain score was 9.5 (SD 0.7) on visual analog scale compared to 1.2 (SD 1.3) post operatively. Eight patients (72.7 %) were ‘very satisfied’, three (27.3 %) were ‘satisfied’ while no one was ‘dis-satisfied’ with the procedure. All of the patients (100 %) were happy to recommend the procedure to others with similar condition. The mean Kapandji score was almost equal on both hands with 9.5 (SD 1) on the operated side and 9.6 (SD 0.9) on the control side. The mean abduction 72.7 degrees (SD 6.8 degrees) on the operated side was marginally better than 70.9 degrees (SD 7.4 degrees) on the control side. Similarly, the mean thumb extension was marginally better on the operated side (70.9 degrees, SD 9.9 degrees) then the control side (69.5 degrees, SD 8.2 degrees) respectively. In females, the mean grip function in operated thumb was 16.5 (SD 6.4) compared to 17.1 (SD7.9) in the non-operated thumb. The mean end to side pinch or key pinch was 3.9 (SD 1.3) and 3.8 (SD 1.2) while end to end or tip pinch was 3 (SD 1.3) and 2.9 (SD 1.4) in operated and non-operated hands respectively. In the single male patient, the grip was almost similar in operated side (37.6) and non-operated side (38.6). The mean end to side or key pinch was 7.3 compared to 7.5 while end to end or tip pinch was 5 and 4.8 for the operated and non-operated side respectively. Conclusion: Trapeziometacarpal arthroplasty is a reliable procedure which gives good short term results. There was 8 point improvement in visual analog scale. Three fourths of patients were ‘very satisfied’ and one fourths were ‘satisfied’ with the procedure. All patients recommended the same procedure to others with similar condition.

Johanna Wirth, Eva-Maria Baur

Praxis für Plastische Chirurgie und Handchirurgie, Murnau, Germany

The main task of the thumb is a stable counter-grip against the long fingers. Instability in the metacarpophalangeal joint (MCP-J) often occurs in various stages of osteoarthritis of the thumb basal joint. In particular, dorsal instability which leads to hyperextension, but quite often also lateral and here especially ulnar instability, which clearly limits the stable counter-grip? To allow this again, additional stabilization of the MCP joint is sometimes required. In this case, we perform an arthrodesis of the MCP joint, in most cases simultaneously with the operation of basal thumb osteoarthritis. Resection arthroplasty is the gold standard in the treatment of advanced stages of basal thumb osteoarthritis, but there is little literature on management with concomitant instability / hyperextension in the MCP-I joint. We report our results of a retrospective study evaluating the effect of simultaneous arthrodesis in the MCP joint and resection ligamentous suspension arthroplasty in the basal joint of the thumb in terms of strength, function and satisfaction. Between 2006 and 2016, we performed 162 resection-suspension arthroplasties. 14 of those cases also received an arthrodesis of the MCP joint, mostly performed simultaneously. One patient had MCP-fusion as a secondary procedure; one patient already had arthrodesis of the MCP joint prior to resection-suspension arthroplasty. For comparison, a control group of patients who had only undergone resection-suspension arthroplasty during this period was examined. In all subjects, suspension was done with a distally based partial flexor carpi radialis tendon strip. For arthrodesis we either used the technique of tension band wiring or a plate osteosynthesis. All patients had a grade III-IV basal thumb osteoarthritis (acc. Eaton-Littler) refractory to conservative treatment. The follow-up was at least 12 months. For evaluation, we measured range of motion and any instabilities of the basal and MCP joint of the thumb and interphalangeal joint of the thumb. In addition, the strength of power grip and key grip was examined, as well as the pain scale (VAS), satisfaction after the operation and the function scores "QuickDASH Score" or "PRWHE" and the "Kapandji Oppositions Score". Radiologically, the proximalization of the first metacarpal bone was measured. By additional arthrodesis of the MCP-I joint, we found no improvement of function in patients with “only” hyperextension-instability. However, in thumbs with additional marked ulnar instability, stronger pinch-grip was obtained with arthrodesis, compared to resection-arthroplasty alone. In thumbs with basal thumb osteoarthritis requiring surgery, if there is additional marked ulnar collateral ligament instability, we recommend (simultaneous) arthrodesis of the MCP-I joint, to allow a stable thumb grip. Objective (function and strength) and subjective (VAS, satisfaction and scores) good results can be achieved.

MO Ashraf 1, R Kanvinde 2

Ysbyty Gwynedd Bangor, Wales, UK

Degenerative arthritis of trapeziometacarpal joint is a debilitating condition and commonly affects post-menopausal women. Various methods of conservative treatments are suggested including analgesics, physiotherapy, splints and intra-articular injections. While the effectiveness of injection therapy has been investigated, not much has been said about the technique of intra-articular injection. We propose a safe, accurate and effective technique for intra-articular injection of CMCJ of the thumb which should be performed in a surgical theatre under fluoroscopic guidance. Following technique is recommended; 1. Anatomical and radiological localisation should be performed and local anaesthesia should be given (Fig. 1). 2. From the dorso-radial side of the joint in a pronated hand resting on a flat surface, the needle is directed 45 degrees distally in-line with the thumb (Fig. 2). Radiological confirmation of placement of needle tip into the CMCJ is obtained (Fig. 3). 3. Once the tip of the needle is intra-articular, active distraction of thumb facilitates stabilisation and easier delivery of the injection. 4. Maximum quantity of 1 to 1.5 mls can now be given which causes increased discomfort to the patient. This is reassuring to the practitioner that the needle is in the correct place. 5. Once the injection is given, thumb is released and fluoroscopic image is taken which confirms distraction of the joint (Fig. 4). Pre- and post injection images should be saved. We have found this technique to be both effective and consistent in providing sufficient pain relief due to accurate delivery of intra-articular injection to the thumb CMCJ.

J. Tsehaie 1,2, J.T. Porsius 1,2,3, D. Rizopoulos 4, H.P. Slijper 2, R. Feitz 2, S.E.R. Hovius 1,2, R.W. Selles 1,3

1 Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center Rotterdam, the Netherlands; 2 Hand and Wrist Surgery, Xpert Clinic, the Netherlands; 3 Department of Rehabilitation Medicine, Erasmus Medical Center Rotterdam, the Netherlands; 4 Department of Biostatistics, Erasmus Medical Center Rotterdam, the Netherlands

Introduction Current guidelines for treatment of carpometacarpal (CMC) osteoarthritis (OA) advise to start with conservative treatment before surgery is considered. However, how the response to conservative treatment influences conversion to surgery is currently unclear. The aim of the present study was to study how the response to conservative treatment influences the probability that a patient converts to surgery. Methods In a multicenter prospective cohort study, 701 patients were included. They received three months of splinting and hand therapy for their CMC OA, while pain and functioning of the treated hand was measured with the Michigan Hand Questionnaire (MHQ) at baseline, six weeks and three months and conversion to surgery since the start of conservative treatment were recorded. Joint modelling was used to study the relationship between the response to therapy as measured by the MHQ scores and conversion to surgery. Due to the complexity of the output of the joint models, we visualized the joint model using nine hypothetical patients. Results The joint model showed that change in MHQ-pain score during conservative treatment significantly influences conversion to surgery (p < .001). When visualizing the joint model, we observed that 1) patients who ended with mild pain after three months had a very low probability of converting to surgery (2%), also when baseline pain was high, 2) patients with low pain at three months had lower conversion to surgery rates compared to patients with high pain at three months (2% vs 42% ), and 3) patients with increasing pain over time had higher conversion to surgery rates compared to patient who had high pain to start with even if the pain at follow-up was the same (49% vs 35 %). In contrast to MHQ-pain, change in MHQ-function score did not significantly influence conversion to surgery. Discussion This study found that a decrease in pain score during conservative treatment strongly decreases the probability of converting to surgery, while self-reported functioning of the hand was not associated with conversion. Our study indicates that reducing pain during conservative treatment strongly reduces the conversion to surgery while function has little influence.

Robert Mulh, Franek Dolšek, Tea Jedlovčnik-Štrumbelj, Boštjan Lah

General Hospital Novo Mesto, Slovenia

Objective: There are a lot of techniques for thumb basal joint arthritis treatment, which is very common pathology in our region. We tried to find out if RegJoint™ bioabsorbable disk spacer implant is good alternative for TMC osteoarthritis treatment. Methods: Operation technique is performed with a bloodless field, a dorsoradial longitudinal incision preserving superficial branch of radial nerve. Then we created the capsular flap with the distal base over a TMC joint, following complete resection of trapezium or the distal third. After that resection of the cartilage remnants of the proximal part of the first metacarpal is done. 3-4 weeks after the surgery patient are administered to physiotherapist. Forty-two patients were analysed, aged 49 -81 years. We observed patients 4, 12-15 weeks and 1 year postoperatively to measure progress with x-ray control, Kapandji's 10-point functional score, Mayo wrist score and QuickDASH score. Results: Forty-two patients were analysed: all patients were operated with our modified RegJoint™ implant arthroplasty technique with partial or complete trapeziectomy and 13 patients with additional tendon interposition. In addition to primary surgery we also performed: 4x surgical release of de-Quervain tenosynovitis, 4x carpal tunnel release and 2x trigger finger release. 6 patients had previously Menon's interposition arthroplasty on the same side and this technique was a second salvage procedure after Menon's interposition arthroplasty failure. Pre- and Post-operatively (after ~ 3 months) we performed a quickDASH score and average measures were pre-OP 43,5 and postOP 21,4. VAS (visual analogue scale) improved from 7,1 pre-OP to 2,6 post-OP. Kapandji's functional score also improved from 4-5 point pre-OP to 8-9 point post-OP. Pre- and post-operatively we performed Mayo wrist score which improved from preOP 45 to postOP 73,8. X-ray controls were made to evaluate the distance between base of first metacarpal bone and the trapezium residue or scaphoid. Conclusion: Using this technique the results are stimulative and comparable to the other known surgical techniques for TMC osteoarthritis operations. We can perform early mobilisation and result is good clinical outcome with quite low pain, stable (well-positioned) base of first metacarpal and low complication rate with simple, time friendly operation.

George Kasimatis, Konstantinos Kourkoutas, Nikolaos Liarakos, Panagiotis Kaldis, Nikolaos Vlachos, Panagiotis Giannakopoulos

Hand, Upper Extremity and Reconstructive Microsurgery Unit, Athens Medical Center, Athens, Greece

Objective: Arthritis of the 1st carpometacarpal joint (basal) of the thumb is the most frequent cause of pain and disability for middle-aged women. Among various causal factors, accessory bands of Abductor Pollicis Longus (APL) have been implicated in joint overload and instability, which progressively lead to basal arthritis of the thumb. Methods: We studied patients with chronic pain in the basal joint of the thumb which interfered with activities of daily living, who had undergone at least 2 intraarticular corticosteroid injections. Preoperative workup included plain radiographs (Face and stress views), pain assessment with the numeric rating scale for pain (NRS) and lateral pinch using B&L Engineering® Pinch Gauge. Tenotomy of the APL was undertaken, which included one or more accessory slips, in order to yield one narrow slip of APL. In the first 7 patients of the study no release of the 1st extensor compartment was performed, whereas this became standard procedure of the operation thereafter. All patients had their wrist immobilized in a thumb spica for the next 2 weeks. Results: Sixteen patients were included in the study (13 women, 3 men), with a mean age of 44 years (22-65) and the involved hand was the right one in 10/13 of them (80%). Radiographs were consistent with instability and mild arthritis (Eaton stage I,II) in 15/16 (94%), while moderate arthritis (Eaton III) was present in 1/16 (6%). Accessory slips of APL were found intraoperatively in all patients. NRS for pain improved a mean of 6 points (4-9) for activities of daily living. Lateral pinch improved in 15/16 patients, allowing them normal hand function, while 1 patient with Eaton III stage arthritis reported pain only upon overuse of the hand. Patients with instability did not worsen radiologically in their follow-up, whereas patients with arthritis did worsen, yet they remained pain-free with good function of the hand. All patients, irrespectively of their radiological stage, reported considerable improvement regarding their hand function and they declared they were happy with the operation. In 5 patients, tenosynovitis of the 1st extensor compartment was demonstrated (De Quervain’s) which required corticosteroid injection, while 2 of them necessitated a subsequent release of the relevant compartment. Conclusions: Tenotomy of the accessory slips of APL is a simple and reliable alternative solution for the treatment of instability and early stages of arthritis of basal joint of the thumb. However, although the period of immobilization is short, it should be noted that full recovery must be expected in 3 months’ time, when synovitis of the basal joint of the thumb subsides.

María José Ferreirós Conde 1 , Lorena Fontao Fernández 2, José Luis Fernández Luna 3

1 Alvaro Cunqueiro University Hospital, Vigo, Spain; 2 Santa Lucia University Hospital, Cartagena, Spain; ; 3 Emergency Service 061, Murcia, Spain

Introduction There were reviewed 4 cases with pain at the base of the thumb because of scaphotrapeciotrapezoid (STT) joint osteoarthritis treated by arthroscopic resection of the distal scaphoid pole from 2013 to 2017. Material and methods We are talking about 3 female patients affected by osteoarthritis of the STT, one of them bilateral. Three hands were left and one right, and surgical treatment was indicated when there were a failure of conservative treatment with AINES, infiltrations and physiotherapy. Arthroscopic resection of the distal pole of scaphoid was performed through ulnar and radial portals and finally radioscopic control. They began mobility in the immediate postoperative period. Results The results have been evaluated subjectively and objectively through Evans scale, DASH and pinch and clamp strength. Discussion and conclusions Our results are compared with those of the literature to the treatment of symptomatic STT joint osteoarthritis. Although a larger sample of cases would be necessary, it seems that arthroscopy may play a role in the treatment of scaphotrapeciotrapezoid joint arthrosis.

Seung-Han Shin, Keun-Young Choi, Yong-Suk Lee, Yang-Guk Chung, Seok-Whan Song, Hyoung-Min Kim, Jae-Young Lee

Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea

Among surgical methods for advanced trapeziometacarpal (TMC) arthrosis, arthrodesis may benefit high-demend patients such as laborers, because it preserves the osseous foundation of the thumb. We have achieved successful TMC arthrodesis in three patients by the combination of chevron osteotomy, percutaneous longitudinal K-wire, and K-wire compression staples. The staples were made by bending a K-wire of 1.6 mm or 1.8 mm diameter into a trapezoidal shape close to a rectangle. The cortical holes to insert the staple in the trapezium and the metacarpal base were drilled with a distance slightly narrower than the narrow width of the staple. No bone graft was used, and no complications specifically associated with the surgery other than asymptomatic slight pull-out of a staple were observed. Our combination can be a good option for TMC arthrodesis that has the advantages of small incision, common devices, and low cost.

Hiroko Shiraishi 1, Soya Nagao 1,2, Kana Kataoka 1, Yoshiaki Tomizuka 1, Masahiro Nagaoka 1, Yasuaki Tokuhashi 1

1 Nihon University School of Medicine, Tokyo, Japan; 2 Itabashi Medical Association Hospital, Tokyo, Japan

[Introduction] Yao, et al described and developed suture button suspensionplasty (SBS) for carpometacarpal joint osteoarthritis (CMC joint OA) of the thumb, and SBS have been one of the common procedure for thumb CMC joint OA. However, symptomatic implant, especially related to the button of the second metacarpal side was experienced in some cases. We modified SBS with TightRope FT (Arthrex Inc., Naples, FL; utilized anchor, #2 FiberWire and button) and could omit the skin incision above the second metacarpal shaft. We introduce procedure and postoperative outcomes of this modified SBS. [Procedure] Arthroscopic hemitrapeziectomy (or total trapeziectomy) with vertical traction by the traction tower is completed as usual manner. The guidewire is placed from the thumb metacarpal base to the second metacarpal metadiaphyseal junction as same as original SBS with horizontal traction fluoroscopically. The wire is overdrilled with a 3.5mm cannulated drill, and anchor is placed at second metacarpal metadiaphyseal junction. Finally, button is tightened as same manner of original SBS also. A short-arm thumb spica splint is provided for two weeks postoperatively. [Patients and Results] We have used this procedure in five female left hands for primary thumb CMC arthroplasty in those with Eaton stage III osteoarthritis. The age ranged of 57-74 years (mean age: 65.0 years). Preliminary result at one year are satisfactory without any complications such as metacarpal fracture and nerve injury while overdrilling. [Conclusion] Our modified SBS for thumb CMC OA seems to be reliable compared with original SBS.

Tendons (22 abstracts)

Arkaphat Kosiyatrakul, Kittinon Songchou, Suriya Luenam

Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand

Objective: To evaluate the efficacy of subcutaneous single injection digital block (SSIDB) for pain reduction in trigger finger corticosteroid injection. Methods: Ninety corticosteroid injection for trigger fingers were randomized to 3 groups. Group 1, the SSIDB with 2 ml of 1% lidocaine was performed prior to an intrathecal injection with 1 ml of 10-mg triamcinolone acetonide. Group 2, the SSIDB with 1 ml of 1% Lidocaine was followed by injection with 10 mg triamcinolone acetonide. Group 3, the ethylchloride spray was applied prior to intrathecal injection with the mixture of 0.5 ml of 1% lidocaine and 0.5 ml of triamcilonolne acetonide. The SSIDB was performed with No. 30 gauge needle. A No. 25 gauge needle was used to inject the triamcinolone acetonide solution. Baseline pain, pain during lidocaine needle insertion, lidocaine injection, steroid needle insertion and steroid injection were determined with a visual analog scale (VAS). Results: The VAS pain score during steroid needle insertion of 0.2±0.6 in group 1 and 0.5±1.0 in group 2 were significantly lower than the VAS pain score of 4.0±2.2 in group 3 (p<0.001). The VAS pain score during steroid injection of 1.6±2.6 in group 1 was significantly lower than 3.5±2.8 in group 2 (p<0.008) and 4.9±2.6 in group 3 (p<0.001). Pain from needle insertion and injection of anesthetic agent during SSIDB in group 1 and 2 were significantly lower than the pain from steroid needle insertion and injection in group 3 (p< 0.05 and p< 0.05). Conclusions: Subcutaneous single injection digital block with 2 ml of 1% lidocaine provided highly effective in reducing pain associated with injection of steroid for trigger finger.

Hyun Sik Seok, Seok Woo Hong, Jihyeung Kim, Kee Jeong Bae, Hyun Sik Gong, Goo Hyun Baek

Department Orthopedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea

Objective The aim of this study was to clarify efficiency of tenosynovectomy in A1 pulley release.in patients with trigger finger. Methods A total of 30 subjects (Male 11, Female 19, mean age 66.2 ± 5.9 years) with trigger fingers were selected. The A1 pulley release with tenosynovectomy were performed in all 30 participants. Flexor digitorum superficialis(FDS) and flexor digitorum profundus(FDP) tendons were exposed and marked to evaluate the excursion after A1 pulley release were performed. The subjects were instructed to flex the distal interphalangeal joint(DIP) with fixed middle phalanx position, and difference between extent of excursion of FDS and that of FDP were measured. After tenosynovectomy, same procedures were performed to evaluate difference between extent of excursion. The degree of proximal interphalangeal joint(PIPJ) contracture and the severity of pain determined by visual analog scale(VAS) on active functioning were measured to determine clinical outcomes before and after surgery. Results The mean differences of excursion of FDS and FDP tendon before surgery was mean 4.14 ± 1.45 and mean 6.05 ± 1.80 after A1 pulley release (P < 0.001). The extent of PIPJ contracture showed significant improvement (P < 0.001). The difference between VAS score also showed significant improvement before and after A1 pulley release (P < 0.001 ). Conclusions Performing sufficient tenosynovectomy in A1 pulley release was crucial to resolving the proximal interphalangeal joint contracture, and it could also improve clinical manifestation. Thus, the sufficient tenosynovectomy would be helpful for successful surgical outcomes.

Koji Moriya, Takae Yoshizu, Nato Tsubokawa, Hiroko Narisawa, Yutaka Maki

Niigata Hand Surgery Foundation, Japan

Objective: As early motion regimens after primary repair of divided flexor tendons have become more common, flexor tenolysis has decreased substantially. The purpose of this study was to examine patients requiring flexor tenolysis after primary tendon repair following early active mobilization (EAM). Methods: This study was a retrospective review of a case series. A total of 148 fingers of 132 consecutive patients with complete zone 1 or 2 flexor digitorum profundus (FDP) lacerations were treated using the Yoshizu #1 technique, followed by EAM, between 1993 and 2017. Digit mobilization featured a combination of active extension, and passive and active flexion within a protective splint, over the first 3 postoperative weeks. Of all patients, the hospital records of those requiring flexor tenolysis were examined. Results: Seven (4.7%) of 148 fingers needed flexor tenolysis (all in zone 2). According to Tang’s subdivisons of zone 2, there were 3 fingers with zone 2a, 2 fingers with zone 2b, 2 fingers with zone 2c. Of all seven fingers with flexor digitorum superficialis (FDS) tendon lacerations, six fingers were repaired and one was excised. The average time between primary flexor tendon repair and tenolysis was 14 weeks (range: 4–24 weeks). The follow-up period after flexor tenolysis averaged 9 months (range: 6–13 months). Two of seven fingers underwent flexor tenolysis early because of suspected flexor tendon rupture during postoperative EAM. The remaining five fingers underwent flexor tenolysis from 12 to 24 weeks after operation to improve the active range of motion (AROM). Surgery to treat flexor tenolysis was performed using a combined wrist and digital block after application of a pneumatic tourniquet via a Brunner incision. Neither the A4 nor A2 pulley was entirely excised. Adhesions were usually found between the repaired FDS and FDP tendons, but never extended proximal to the repair site. All adhesions were categorized as moderate. Postoperatively, two fingers with early flexor tenolysis remained on the EAM protocol; the remaining five fingers (with late flexor tenolysis) followed the Foucher-type rehabilitation protocol. The AROM of the proximal and distal interphalangeal (PIP and DIP) joints at follow-up averaged 123° (range: 57–180°). Excluding the two fingers that underwent early flexor tenolysis, the average preoperative AROM of the PIP and DIP joints was 82° (range: 30–130°), increasing to 111° (range: 57–135°) at the final evaluation. We recorded no tendon rupture or recurrent adhesion causing loss of active motion during follow-up. We noted no postoperative complication (infection or digital neurapraxia). No patient required repeat tenolysis. Conclusions: No prior article has explored the need for flexor tenolysis after an early motion protocol. This study indicates that about 5% of patients undergoing primary flexor tendon repair following EAM may require flexor tenolysis. We found that a sudden decrease of AROM in the early postoperative period may be caused by adhesions, and thus not rupture. Additionally, we believe that the area of adhesion is limited by the EAM protocol applied.

Konstantinos Tolis, Sarantis Spyridonos

Hand Surgery, Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece

Objective : Flexor tendon pulley injuries are rare. Surgical restoration once diagnosed is a challenging procedure mostly due to their complex anatomy and function. Up to now surgical operations are divided in two categories : “looped” are considered those techniques, which encircle the phalanx and “non-encircling” those that do not. We present a new “non-encircling” technique for the reconstruction of A2 pulley injury, with the use of an adjacent non-injured A1 pulley, in two cases. Methods: Reconstruction of the A2 pulley was performed during the last 2 years in two cases. A 68 years old woman was diagnosed intraoperatively with A2 pulley deficit during the second procedure of a two – stage flexor tendon reconstruction at her right middle finger. The second case involved an A2 pulley deficit in a 35 years old man, who has been operated previously for rupture of the both flexors of the middle finger, one year before presentation to our department. Both operations were performed under brachial plexus anesthesia and tourniquet. A Brunner was used to expose the lacerated tendon. Surgical exposure revealed deficit of the A2 pulley due to previous operations, which performed in other orthopedic centers. For the female patient the A1 pulley from the injured middle finger was harvested, while on the male patient that from the ring finger, without using a new incision. The graft was placed in its new place with the use of absorbable sutures and mini Mitek anchors (Depuy-Jonhson&Johnson). A dorsal plaster splint for rest and protection was placed for 4 weeks. Results: Passive and active protective physiotherapy was admitted immediately after the operation. Sutures removed at 15 days postoperatively and the splint at 4 weeks postoperatively. No signs of bowstringing at the middle finger were reported at 1 year follow up. Discussion: Flexor pulley reconstruction is a challenging surgery. The use of adjacent A1 pulley as an autograft is a safe, fast and simple method to perform. The fact that it is a non encircling pulley reconstruction method favors its use for better functional results, while preserves surrounding soft tissues and enables better healing.

Michno Dominika, Konczalik Wojciech, Ramman Saif, Akhavani Mohammed

Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK

Objective: Case report of a complication of local corticosteroid therapy which has not been previously reported in the literature. We describe a rupture of a previously repaired extensor pollicis brevis which occurred spontaneously three months after the administration of triamcinolone into the first dorsal extensor compartment of the recently injured wrist. Methods: A 29 year old male carpenter presented to the hand therapists with De Quervain’s Tenosynovitis three months after sustaining a circular saw injury which resulted in transection of both tendons in the first extensor compartment of the affected wrist. The inflammatory symptoms were deemed severe enough to warrant triamcinolone injection into the site of previous repair and despite initial improvement the patient re-presented to clinic twelve weeks after steroid administration with spontaneous weakness of thumb extension. The extensor pollicis brevis could not be palpated clinically and subsequent ultrasonography confirmed tendon rupture in the vicinity of the previous injury. Results: Intra-operative findings confirmed rupture of the extensor pollicis brevis at the site of previous repair with gelatinous degeneration of the tendon stumps which required debridement prior to re-approximation. The patient made a good recovery following this intervention and was able to return to work as a carpenter three months after surgery. Conclusions: Our case suggests that corticosteroid therapy may negatively impact the healing process of a recently repaired tendon and reduce its tensile strength resulting in spontaneous rupture. It also highlights the importance of adopting a more conservative approach in patients with a background of traumatic hand injuries who present to clinic with inflammatory symptoms of the hand and wrist affecting a previously repaired tendon. In these instances, we recommend abstaining from local corticosteroid administration altogether and instead managing these patents with splinting, targeted physiotherapy or tenolysis.

Masahiro Miyashita, Masataka Yasuda, Kenta Minato, Shunpei Hama

Baba Memorial Hospital, Osaka, Japan

To investigate 5 cases of spontenous flexor tendon rupture which was operated surgically at our hospital. We used electrical medical charts to indentify flexor tendon rupture cases. There are 26 cases identified between January 2012 and September 2017 at our hospitals. Among them, there were 11 cases of closed tendon ruptures, and 5 cases 6 fingers of spontaneous tendon rupture which had no clear causes to damage tendons such as plates or fractures. Three fingers were little, 1 finger was ring, and there were 2 thumbs. Four fingers were ruptured at Zone 3, 2 thumbs were ruptures at zone2. All fingers had flexor digitorum profundus (FDP) or flexor pollicis longus (FPL) ruptures, and 3 fingers had flexor digitorum superficialis (FDS) ruptures. Two fingers of 1 case had fresh distal radius fracture, and 1 case had long-term steroid medication due to renal transplantation. Another cause such as osteophytes, calcifications or fractures of hamate hook were not observed in all cases. We investigated background of patients, injury reversals, and surgical methods, then discussed about the pathology of ruptures. Average age at surgery was 67.4 years (53 - 80 years). Average follow-up period was 7.8 months (5 - 12 months). Waiting period from injury to surgery 328 days (5 days - 4 years). There were 1 male and 4 women. Four cases were right-side affected, one case was left-side affected. Four cases had dominant-side affected, and 1 case had nondominant-side affected. At the time of injuly, all patients had mild pain, but no one had sharp pain, hematoma, or swelling. All patients visited hospitals complaining disability of finger flexion. There were only 2 cases which has ruptures under the load by sports activities or works at the time of injury, and other 3 cases has no clear cause of injuries. About surgical methods, we performed tendon transplantation for 3 fingers, tendon graft for 1 finger, end to end suture for 1 thumb and IP arthrodesis for 1 thumb. Nineteen percent of flexor tendon ruptures at our hospital had no cause such as obvious trauma or attrition rupture. We thought there were related factors such as existence of fragile part due to poor blood circulation or shearing force due to lumbricales muscle or tendon-junction.

Noppadon Panjawatthana

Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand

Background Trigger finger, common disease in hand, which life time risk is 3%. There were several approaches to treating patients but lacked empirical evidence of primary conservative treatment. Current conservative treatment to trigger finger are topical steroid injection, splinting and physical therapy, however, have not been studied research to compare them. Objectives To compare the effect of combined steroid injection with finger splinting, steroid injection and splinting alone with disability of the Shoulder and Hand (DASH score), Green grade, and success rate. Research methodology This study was a collection of patients who were isolated idiopathic trigger finger and green grade 1, 2 and 3. All 60 participants were randomly assigned to the 3 treatment groups, by block-based randomization; group 1, treated with steriod injection; group 2, received only splinting and group 3; treated combined, each group contained 20 participants. Then the participants will be monitored, practical advice and practice of physical therapy in the same way. DASH score and Green grade were assessed, before treatment and after treatment at week 3, 6 and 12, as well as the success rate at week 12. Research result Participants in the three groups were no significant different in gender, average age, dominant hand, affected hand and finger, duration of symptom, initial DASH score, and green grade before admission. At week 12 showed a combined group, the DASH scores were lower than those of other groups (p = 0.01). Moreover, the splint group and steroid group were not significantly different at week 12 as well (p = 0.38). Research summary Treatment of trigger finger, severity of the disease in Green grade 1, 2 and 3, should be used in combination with steroid injection and splinting. For patient who denied injection, splinting is an alternative choice that no significant different outcomes.

Tamer Ali, Jacqueline Fowler

Royal Devon and Exeter NHS Foundation Trust, UK

Aim We present a retrospective study looking at all flexor tendon injuries repaired at the Royal Devon and Exeter NHS Foundation Trust over the past 10 years from the 1st of January 2006 to 31st of December 2015. We looked at the type of repair used, our rupture rates and the (Total Active Motion) TAM outcomes compared to the standards described in the literature for divisions greater than 30%. We also looked at 100% Zone 2 injuries between 2012 and 2015. Methods Hand therapy notes for all flexor tendon injuries were reviewed that involved flexor tendon injuries greater than 30% in Zones 1-5 from the period of 1st of January 2006 up to 31st of December 2015. Excluded from our study were polytrauma patients, re-repairs, tendon reconstructions, Zone 6 and muscle belly injuries as well as flexor pollicis longus repairs. Patient details and the data was collected from the patients’ notes, Microsoft Access® and reviewed in Microsoft Excel®. Accurate informative data for Zone 2 repairs were only available from 2012 onwards. Results There were a total of 503 patients with 667 injured digits. A total of 941 tendon repairs took place over a 10 years period at the Royal Devon and Exeter Hospital. Of those were 396 flexor digitorum superficialis repairs and 545 flexor digitorum profundus repairs. Zone 2 repairs between 2012 and 2015 accounted for 131. The most common repair by far was a Modified Kesseler repair and there was a fairly equal number of 2 strand versus 4 strand repairs and nearly all repairs included an epitendinous repair. Unfortunately, in 122 repairs, the type of repair was not stated in the operation note or the hand therapy notes. Our total ruptures over the 10 year period were 53 ruptured tendons out of a total of 940 tendons repaired, putting our rupture rate at 5.6%. Conclusion The reported rate of flexor tendon rupture is varied in the literature. Tang et. al report the usual rupture rate for digits is 4-10%. As part of adhering to guidelines and best practice, we decided to look at our tendon repairs and our rupture rates over a 10 year period with the aim of improving and minimizing our complications. Our study did not find a significant difference in rupture between a 2 and a 4 strand repair however we accept that the modern gold standard is a 4 strand repair. We did not look at the type of suture used however our trust have only been using Ethicon® sutures for the past 10 years and we can safely say that either Prolene or Ehibond were used for the tendon repairs. It is of note that the rupture rate steadily fell every year from 2006 to 2015 when tabulating our results.

Mohammed Tahir Ansari, Swapnil Singh

All India Institute of Medical Sciences, New Delhi, India

Background: To avoid potential risk of APL and EPB subluxation after first compartment pulley release, pulley reconstruction has been proposed recently. Here we are presenting result of outcome in patients after pulley reconstruction for patients with de Quervain’s disease. Objectives: To assess the functional outcome of pulley reconstruction in patients of de Quervain`s tenosynovitis. Material and methods: A retrospective analysis was performed in 15 patients who were operated from Jan 2016 to Jan 2017. All the patients were operated under wide awake local anaesthesia and no tourniquet. A Z incision was given to release pulley followed by its reconstruction. The outcome assessment was done post-operatively with Quick DASH score, Mayo wrist score and VAS score at 3 month and dynamic ultrasound evaluation was done to assess volar subluxation of tendons. Results:Mean Quick DASH score was 8.7 while VAS score was 1.1 at 3 patients. Outcome was excellent according to Mayo wrist score. Re-surgery was not required in any patients. One patient had neuropraxia which recovered subsequently in 3 month. Not a single patient had subluxation of tendons. Conclusion: Pulley reconstruction is an effective and technically safe to perform for excellent outcome in patients with de Quervain’s disease.

Pierfrancesco Pugliese, Pier Paolo Pangrazi, Francesco De Francesco, Michele Riccio

Department of Reconstructive Plastic Surgery - Hand Surgery Unit, Ancona Teaching Hospital, Italy

Introduction: Traumatic hand injuries commonly involve tendons especially those concerning the dorsal region. Complete extension of the thumb and activation of the Extensor Pollicis Longus tendon (ELP) is fundamental to ensure maximum hand function. Many ELP repair techniques are described in literature. The authors herein present an alternative technique using the Brachioradialis Tendon (BR) to restore the ELP function following an acute dorsal trauma, characterized by loss of traditional donor sites. Methods: 8 patients with injuries of the EPL tendon in zone 8 from 2012 to 2015 were studied. Each patient presented extensive skin and muscle mass loss with composite wounds, involving tendon lesions of the Extensor Indicis Proprius (EIP). Surgical Technique: Local debridement was performed and unscathed tissue was assessed, before performing a Pulvertaft Tenorraphy between the ELP stump and the BR tendon. Free or local flap coverage was applied to the tendon reconstruction and physical therapy was administered in early postoperative days. Results: Thumb extension was restored in all patients with satisfactory extension recovery of the distal phalanx as well as pinch grip. Five of the eight patients achieved excellent extension of the distal phalanx; good functional results were observed in two cases and in one case satisfactory results were achieved. Patient satisfaction and thumb range of motion were evaluated on the long term using the Geldmacher assessment and the Kapandji scale was used to compare the opposite unaffected side. The overall results were rated as excellent, good, fair, or poor according to the Quick DASH Scale. Conclusions: The BR unit appeared to be an eligible and suitable donor site for the reconstruction subsequent to ELP lesions. The BR tendon was suitable to treat all cases, in particular in injuries occurring proximal to the Lister’s tubercle, due to its appropriate length for tenorraphy albeit with a short distal head. The authors consider BR a valuable resource for the ELP tendon reconstruction as an alternative to traditional tendon donor sites.

Landino Cugola, Enrico Carità

Clinica San Francesco, Verona, Italy

De Qeurvain's disease often requires surgical release. The classic procedure, simple release of the radio-styloid pulley, can be sometimes complicated by the shifting of tendons on the radio-styloid process, caused by wrist movements. In this case the pulley has to be reconstructed. During operation we have to check tendons subluxation by the wrist flexion and adducting the thumb. Without tendon subluxation in unnecessary to do pulley reconstruction. A trick to avoid shifting: to open the pulley by dorsal incision, while skin incision has to be volar to avoid of the scar to underlying tendons with disgracious aestetique. We present types of incisions and how to do pulley reconstruction and possible complications with simple pulley incision and/or reconstruction of the first dorsal compartment.

Mohammad Haddara 1,2, Brett Byers 2, Louis Ferreira 1,2, Nina Suh 2

1 Department of Biomedical Engineering, University of Western Ontario, London, ON, Canada; 2 Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, ON, Canada

Objective: Injury to A2 and A4 flexor tendon pulleys are not uncommon and are known to cause tendon bowstringing with subsequent range of motion (ROM) deficits of the affected finger. The purpose of this study is to characterize the effects of sequential A2 and A4 pulley sectioning and reconstruction on joint ROM and tendon load. Methods: Fourteen digits comprised of the index, long, and ring fingers were tested from five cadaveric specimens on a validated novel in-vitro finger motion simulator devised to actively achieve full finger flexion and extension. The simulator is designed to measure tendon forces, joint ROM, and tendon excursion under load or excursion control using a closed-loop feedback system. The effects of partial and full sectioning of the A2 and A4 pulleys, and their reconstructions with wrist in neutral, 30-degree flexion, and 30-degree extension were analyzed using a 2-way repeated-measures ANOVA. Results: With the wrist in neutral, full sectioning of both A2 and A4 pulleys reduced MCP ROM and FDP tendon load by 9.17.1 (p=0.016) and 2.3±1.9N (p=0.029), respectively. With the wrist flexed, cutting both A2 and A4 reduced MCP ROM (p=0.002), as well as FDP tendon load (p=0.006). The MCP joint lost 7.4±6.3° of ROM (p=0.009). FDP tendon load was reduced by 3.6±3.5 N (p=0.034) and restored to within 0.5 N of the intact state by their subsequent reconstruction (p=0.034). With the wrist extended, cutting both A2 and A4 reduced MCP ROM (p=0.006), as well as FDP tendon load (p=0.001). The MCP joint lost 7.2±7.3° of ROM (p=0.024), and reconstruction restored MCP ROM to within 2° of the intact state (p=0.014), while FDP tendon load was reduced by 3.5±1.7 N (p<0.001). DIP and PIP ROM were not significantly altered. When both pulleys were fully reconstructed, there was a loss of 1216.1 (p=0.049) in MCP ROM in wrist neutral compared to wrist flexed, as well as a 17.516(p=0.004) loss in MCP ROM in wrist neutral compared to wrist extended. Conclusion: In all wrist positions, cutting A2 and A4 pulleys reduced MCP ROM, as well as FDP tendon loads. PIP and DIP joint ROM was not significantly affected. Pulley reconstructions restored these metrics within no significant difference compared to the intact state, reinforcing their utility by not only reducing bowstringing, but by restoring natural joint biomechanics and tendon loads. The new simulator has provided additional tendon load information to compliment the state of knowledge on joint ROM in the context of pulley reconstructions.

Samir Zeynalov 1, Eren Cansü 1, Ural Verimli 1, Abdulveli İsmailoglu 2

1 Marmara University Istanbul, Turkey; 2 Acibadem University Istanbul, Turkey

ABSTRACT INTRODUCTION AND PURPOSE: Success of surgical treatment of extensor tendon injuries is related to the properties of the repair technique used, as well as the postoperative rehabilitation program applied. Early motion after tendon repair accelerates tendon healing and prevents adhesion formation. The purpose of this study was to investigate the effects of postoperative immediate active mobilization on repair site after repairing extensor Zone IV tendon with 3 various suture techniques. MATERIALS AND METHODS: The study was conducted on 9 fresh-frozen cadaveric upper extremities amputated from mid-shaft of humerus. While the extensor tendon was in place, Zone IV tendon was measured for length and for the amount of weight needed to flex and extend the finger to simulate active flexion and extension. This amount of weight was applied after cutting and repairing the tendon and tendon length remeasured. Three different suture techniques were used for repair: Double-Modified Kessler, Double Figure of Eight and Running Interlocking Horizontal Mattress with 3-0 PDS® have been applied. Each finger was flexed and extended for 200 times respectively through the tendon axis without any sudden loading. After each cycle of 20 motions, any gap formation was checked, and the first moment of gap formation and the moment of 2 mm gap formation were recorded. 2 mm gap formation was accepted as the failure criterion. If no gap formation is recorded, the tendons shall flexed and extended 50 more times by applying twice as much weight and the gap in the repair zone shall be recorded. RESULTS: We did not detect any failure in any of the suture techniques after applying repetitive motions on the repaired tendons. None of the tendons had measurable gap formation. Additionally, twice as much weight was applied to flex and extend the tendons without gapping for 50 times. As a result, any failure or gap was not detected. The average postoperative extensor tendon shortening was 6.7 mm in Modified Kessler, 5.9 mm in Figure of Eight and 5.1 mm in Running Interlocking Horizontal Mattress method. No statistically significant difference among these values was identified. DISCUSSION: A number of suture techniques for extensor tendon repairs have been broadly studied while no golden standard suture technique has yet been defined. In this study we compared 3 various suturing techniques used in extensor tendon repairs. We studied the changes in repair site resulting from immediate active mobilization and the effects of suture techniques on tendon shortening. We concluded that these suture techniques are resistant in vitro for starting postoperative immediate active motions. We did not identify any statistically significant difference in the impact of the applied suture techniques on the tendon shortening. CONCLUSION: The results suggest that all 3 techniques applied are reliable for starting immediate active motion after extensor tendon Zone IV injuries. This is an in vitro study and in vivo and clinical studies are needed for further support.

Rehnuma Hossain, Shekhar Srivastava

University Hospitals Coventry and Warwickshire, Coventry, UK

Objective: Within the UK, most flexor tendon injuries are within the two weeks. However, there are patients who present beyond that time period, and are often not given the option of primary repair, as it is deemed “too late”. We present our experiences at one unit in a major trauma centre over the past five decades of delayed primary repair of flexor tendons. Methods: We present a series of seven consecutive patients who had primary flexor tendon repair carried out in our unit in Coventry and discuss their outcome. A thorough systematic review did not provide any papers on this subject. Results: Our consecutive group of 7 patients, aged 24 – 77 years presented from 14 days to 78 days later with the median being four weeks. There was a variety of mechanisms of injuries, though most occurred in zone 1. We found that the little finger was the most common digit to present late. In all cases the wound was healed or unidentifiable and the joints were mobile. Exploration of finger showed that in all these cases tendon ends could be dissected and stretched to effect a primary repair using conventional techniques. We used a four strand repair in some cases while some patients had repair by Kessler technique. The tendon ends held sutures as normal. Following repair active mobilisation was used in all cases. No repairs ruptured during therapy. 5 patients in this series obtained good to excellent results. One patient is still undergoing therapy and indications are that she will get a fair to good result while another patient had just had her repair carried out. It is to be noted that four of these patients had zone 1 injury, where good to excellent results are fewer when compared to combined results of all zones. One patient with a zone 1 injury refused the offer of a tenolysis in an attempt to improve her DIP flexion. Conclusion: We recommend that all patients presenting with flexor tendon injury as late as 3 months be explored soon after their presentation to see if a primary repair is possible. In many cases it will be possible to repair the flexor tendon primarily while in very late cases it may be necessary to insert a silastic rod as a first stage of 2 stage tendon reconstruction although we were not required to perform this in any of our cases in this cohort. Additional measures to facilitate a primary repair will be discussed.

Sarah Tolerton 1, Raymond Jongs 2, Belinda Smith 1, Mark Hile 1

1 Department of Hand Surgery & Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia; 2 Department of Physiotherapy, Royal North Shore Hospital, Sydney, Australia

Title: Extensor Tendon Excursion at the Proximal Phalanx: Clinical Application to Rehabilitation Programs Objective: Current rehabilitation programmes for extensor tendons have been extrapolated from flexor tendon studies and are largely based on intuition, good judgement and experience rather than scientific evidence. The aim of this study is to measure the relative motion of the extensor tendon over the phalanges when the finger is moved from one posture to another to determine the combination that generates the greatest extensor tendon excursion. Methods: Ten fresh-frozen cadavers were dissected. Markers were placed in the index, middle, ring and little phalanges and extensor tendons in relation to the interphalangeal joints. Relative motions of the extensor tendon to the phalanges through five commonly prescribed hand postures (extension, table top, straight fist, hook fist and full fist) were measured. Results: Statistical analysis determined the extensor tendon excursion throughout the prescribed hand postures and compared different combinations of postures. Further analysis and correlation with the soft tissue and bony dimensions of the cadaver fingers allowed comparison with existing mathematical models. Conclusion: Using a cadaver model, we determined the optimal combination of finger postures for extensor tendon excursion relative to the underlying phalanges. Knowledge of the most effective extensor tendon gliding exercise will allow evidence based decision making for hand surgeons and therapists to simplify exercise programs for patients. This will increase compliance and ultimately improve outcomes following trauma and surgery.

Andreas Gohritz 1,2, Jan Fridén 1, Dirk J. Schaefer 2

1 Hand Surgery, Swiss Paraplegia Center, Nottwil, Switzerland; 2 Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, University Hospital, Basel, Switzerland

In case of a short distal recipient stump after extensor pollicis longus (EPL) tendon rupture, transfer of the extensor indicis proprius (EIP) tendon using a conventional Pulvertaft tendon-weaving technique may be difficult or impossible. The purpose of this paper is to provide a technical tip to manage this rare, but clinically important scenario of a very short distal EPL recipient tendon. A side-to-side tendon suture (SSTS) was used for EIP transfer to restore thumb extension in 3 patients who had sustained a distal rupture of their extensor pollicis longus near the interphalangeal joint. The SSTS was performed with an overlap of 2 cm in 2 patients and 2.5 cm in one patient. Stable SSTS was achieved which allowed early active mobilization and resulted in good functional recovery of thumb extension after a mean follow-up of 8 months. In conclusion, extensor indicis transfer using SSTS is a reliable and technically simple escape plan in a distal rupture of the EPL near the interphalangeal joint. It provides very stable tendon-to-tendon attachment with high loading capacity and good gliding qualities.

Yoshimasa Tomita 1, Hideyuki Hirasawa 1, Yu Sugawara 1, Ryohei Matsuo 1, Akira Sakurai 1, Yuuta Asanuma 1, Kouju Hayashi 1, Shinnosuke Hada 1, Fumihiro Mukasa 1, Keiichiro Kumagai 1, Yuka Igeta 3, Katsutoshi Noike 2, Kouichi Kusunose 1

1 Department of Orthopedic and Hand Surgery, Tokyo Rosai Hospital, Tokyo, Japan; 2 Department of Orthopaedic Surgery, Mejiro Hospital, Tokyo, Japan; 3 Department of Hand surgery, Strasbourg University Hospital, Strasbourg, France

Trigger finger is one of the most common problem that treated by hand surgeon. At first conservative treatment with corticosteroid injection usually done. This conservative treatment has sometimes the recurrence of the symptom and the risk of tendon rupture to inject it in many times. (Purpose) We developed a new designed knife for minimum invasive surgery of Trigger finger. The purpose of this study is to confirm the availability and safety for this treatment. (Materials and Methods) This knife is composed by a small blade and a two-piece guide with an introducer of tendon sheath with protect the flexor tendon and land mark of the position of the blade to protect the tissue around it. It presents a specialized shape to cut A1 pulley that manufactured a prototype for this study. Twenty-five fingers of five cadaveric hands were investigated the anatomical location and to make sure the availability and safety to cut A1 pulley. (Result) The anatomical location of proximal end of A1 pulley from palmar digital crease was 5mm in thumb(4~6mm), 22mm in index and ring finger(21~23mm), 23mm in middle finger(21~23mm), 18mm in little finger(17~19mm). The average length of each A1 pulley was 5mm in thumb(4.5~5.5mm), 12mm in index(11~13mm), middle(11~14mm) and ring(11~12mm) finger, 10mm in little finger(9~11mm). The average distance of Neurovascular bundle around the both side of A1 pulley was 9mm in thumb(8~10mm), 9.5mm in index(9~10mm) and ring(9~10mm) finger,10.5mm in middle(10~11mm), 9mm in little finger(8~10mm) The A1 pulley was completely cut in all fingers, and the injury of neurovascular bundle and palmar arterial arch was not recognized. A shallow injury of the flexor tendon was revealed ten fingers in all. (Conclusion) １．We developed the new designed knife for trigger fingers, and investigated the complications with the cadaveric hands. ２． The A1 pulley were cut completely in all cases. ３． Ten tendons had the injury of a surface and longitudinal tear.

Min Kai Chang 1, Yiwei Zeus Lim 2, Yoke Rung Wong 2, Shian Chao Tay 1,2,3

1 Duke-NUS Medical School, Singapore; 2 Biomechanics Lab, Singapore General Hospital; 3 Department of Hand Surgery, Singapore General Hospital

Objective: Cyclic testing of flexor tendons aims to simulate post-operative rehabilitation and is more rigorous than static testing. However, there are many different protocols, making comparisons difficult. We reviewed these protocols, compared the parameters, and suggested two protocols that closely simulate passive and active mobilisation. Methods: Literature search was performed to look for cyclic testing protocols used to evaluate flexor tendon repairs. Preload, cyclic load, number of cycles and frequency were categorised. Results: 35 studies with 42 different protocols were included. 31 protocols were single-staged, while 11 protocols were multiple-staged. 29 out of 42 protocols used preload, ranging from 0.2 to 5N. Preload of 2N was used in most protocols. The most commonly used cyclic load was between 11-20N. Cyclic load with increment of 10N after each stage was used in multiple-staged protocols. The most commonly used number of cycles between 100 to 1000. Most protocols used a frequency of less than 1Hz. Conclusions: We propose two single-staged protocols. Protocol 1: cyclic load of 15N to simulate passive mobilization with preload of 2N, number of cycles of at least 2000, frequency of 0.2Hz.; Protocol 2: cyclic load of 38N to simulate active mobilization, with the same preload, number of cycles, and frequency. Clinical Relevance: This review consolidates the current understanding of cyclic testing. This may help clinicians and investigators improve the design of flexor tendon repairs, allow for comparisons of different repairs using the same protocol, and evaluate flexor tendon repairs more rigorously before applying on patients.

Hiroyuki Ohi

Hand & Microsurgery Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan

Purpose: Tendon grafting to the digital sheaths of the hand sometimes dose not good results. One factor affecting the results may that the grafts are usually from extrasynovial tendons such as palmaris longs or plantaris tendon. The aim of this study was analysis the outcomes intrasynovial tendon grafting harvested from toe flexor for secondary flexor tendon reconstruction. Methods: From 2010 to 2015, I treated 7 patients. The intrasynovial tendon harvested from the second or third toe. Three digits were two staged tendon reconstructions. The tendons were sutured into the appropriate FDP tendon proximally using a Pulvertaft weave; the distal end of the graft was direct suture to the base of the distal phalanx. The operations were performed by only one surgeon. Postoperative rehabilitation was active flexion and extension exercise with dorsal extension block splint. Results: The finger TAM was 92.0%(78.5-100%), the recovery rate was 94.2%(80.6-100%). The tenolysis did not underwent. One patient failed at the proximal suture site in the palm associated with infection at 3 weeks. Three months later, I transferred the ring flexor tendon to the proximal stump of the grafted tendon in the palm. All patients had residual limited flexion of the donor toe. However, gate was apparently normal. Conclusions: This technique is feasible and gives a good result.

Min Kai Chang 1, Sanchalika Acharyya 1, Yiwei Zeus Lim 2, Shian Chao Tay 1,2,3

1 Duke-NUS Medical School, Singapore 2 Biomechanics Laboratory, Singapore General Hospital 3 Department of Hand Surgery, Singapore General Hospital

Background: The single looped suture modified Lim/Tsai technique is widely used for flexor tendon repairs. It has been shown to possess better biomechanical properties and require less repair time per tendon as compared to the double looped suture original Lim/Tsai technique. However, there is no clinical data on the modified technique. Methods: The retrospective study included zone 2 flexor tendon repairs made using the modified Lim/Tsai technique from January 2008 to December 2014. Clinical outcome was assessed using the revised Strickland and Glogovac criteria, which categorises repairs based on the total active motion of the repaired digit. Results: Sixty-two patients with 74 digits were included. The overall mean total active motion was 122o. The overall satisfactory outcome of the modified Lim/Tsai technique was 81.1%. The rupture rate of the modified Lim/Tsai technique was 2.7%. Outcomes were negatively influenced by subzone 2C and crush/saw injuries, but not by concomitant neurovascular injuries. Conclusions: Based on this retrospective study of patients with zone 2 flexor tendon injuries, the clinical outcomes of modified and original Lim/Tsai techniques are comparable. As such, there is no clinical evidence favouring one over the other.

Claudia Lamas-Gómez, Laura Velasco-González, Marta Almenara-Fernández, Ariadna da Ponte-Prieto, MC Pulido-Garcia, Aranzazu González-Osuna.

Hand Unit and Upper Extremity. Department of Orthopaedic Surgery. Universitat Autònoma de Barcelona.

Objectives: Isolated laceration of the flexor digitorum profundus (FDP) tendon appears habitually when the section is in zone I and sometimes in zone II. In some cases, due to a delayed diagnosis or to a fail of the primary suture, the reparation is performed some weeks after the injury. In most of these cases, the intact vincular system prevents the retraction of the FDP tendon and this can be repaired as would be done in a primary repair. Finger in which the vincular system was not disrupted had greater final total active motion than had those without intact vincula. The objective of the study was to explain our experience and outcomes in the delayed treatment of the lacerations of the FDP tendon without tendon retraction due to the presence of the intact vincular system. Methods: Between 2005 and 2016, eight patients were operated with delay reparation of the FDP tendon without retraction of the same in zone II. The injury was diagnosed clinically and with MRI. The injury was localized in the proximal interphalangeal (PIP) joint in 5 cases and in middle phalanx in the other 3. Surgery treatment and outcomes were analysed. Visual analog scale, range of motion and Disabilities of the Arm, Shoulder and Hand (QuickDASH) score were evaluated at the final of the follow-up. Results: There were 8 patients with FDP tendon lacerations. There were 5 men and 3 women with a mean age of 27 years old (29-54). Reparation was performed after 3.3 weeks (3-5). The initial injury was located in zone I in 3 cases and in zone II in 5 cases. The lacerations were in the index finger in three cases, long finger in 2, and little finger in 3. Minimun follow-up was 12 months. Ochiai et al. classified three types of distribution of VLS (vinculum longum superficialis) and five types of distribution of VLP (vinculum longum profundus). The five types of distribution of VLP were determined to be the distal, middle, mixed, proximal, and absent. The intraoperative findings found the intact VLP in all cases that avoided the proximal retraction of the FDP. The middle type of VLP bridge between the profundus tendon and vinculum breve superficialis through the decussation of the superficialis tendon. Its blood supply came from the proximal transverse digital artery. This type is the most common type in our cases. A modified Kessler suture was performed in all cases. All patients had good functionality measured with the DASH score at the final of the follow-up. Conclusions: The integrity of the VLP could be one reason of the lack of retraction that occurs sometimes in FDP tendon injuries. When it occurs and the diagnosis is delayed, tendon suture can be performed like an acute primary repair. In cases of intact VLP, the vincular blood supply in combination with the synovial fluid nutrition maintain tendon viability and permits tendon healing after tendon repair.

Seung-Bum Chae

Daegu Catholic University Medical Center, Daegu, South Korea

purpose: To evaluate the usefulness of the Wide Awake Local Anesthesia No Tourniquet (WALANT) technique for extensor indicis proprius (EIP) tendon transfer. Methods : From Jan 2014 to Jan 2016. We selected the patients with chronic extensor pollicis longus rupture who underwent EIP transfer surgery with WALANT(wide awake local anesthesia no tourniquet). We evaluated the patient’s postoperative pain using VAS scores, functional outcomes(DASH scores) and measured the ROM of the affected hand at the final follow-up session And we compared total cost between WALANT operation and ordinary regional anesthesia. Results : There were 12 patients (8 males and 4 females) with a mean age of 57.1 years. The postoperative mean VAS score was 1.3. The mean functional score(DASH) was 17.4. The mean Metacarpophalangeal joint ROM was 56° in distal phalange, each flexion and extension was 81°, 7.1° Mean Pinch power was 91% of unaffected side. Mean grip strength was 91% of unaffected side. Conclusion : Wide-awake approach has allowed the surgeon to know how much tendon tension on tendon repair site and tendon transfer site. The wide-awake approach makes surgeon do tendon surgery much easier and more reliable

Trauma (in general) (61 abstracts)

Isidro Jiménez 1, Martine Dury 2, José Medina 1

1 Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain; 2 Chirurgie de la Main, SOS Main Strasbourg. Rhéna Clinique de Strasbourg, Strasbourg, France

Axial carpal dislocations and fracture-dislocations remain difficult to understand and to treat. The outcome is directly related to the injury pattern and long-term results are not good in most cases. A 39-year-old, right-handed male was admitted to our hand emergency department after his left hand was caught between 2 rollers for 10 minutes until he was freed. He presented a cutaneous detachment of the ulnar side of the wrist and hand and a divergence between the axes of second to third and fourth to fifth metacarpals Initial x-ray showed a loss of carpal height (Youm and McMurtry index), disruption of the Gilula’s and carpometacarpal lines, volar dislocation of the capitate with the third metacarpal regarding the hamate and volar subluxation of the trapezium regarding the scaphoid. He was diagnosed of an open axial carpal dislocation type B (perihamate-peripisiform) and type E (peritrapezium) of Garcia-Elias. Under regional anesthesia and arm tourniquet we found an avulsion of the crest of trapezium, section of the second commissural artery but no tendino-nervous injuries. Under flouroscopic control, reduction of capitate and carpometacarpal dislocations and trapezial-metacarpal stabilization was performed and secured with K-wires. Microsurgical suture of the artery, fasciotomy of interosseous muscles, and opening of Guyon’s tunnel. Dorsal splint and “buddy taping” between the third and fourth fingers was applied. 14 days after the trauma, a full thickness skin graft was required for the volar-ulnar skin coverage and a dynamic splint was placed. Physical therapy began 5 weeks after surgery and K-wires were progressively removed. Last K-wire and “buddy taping” were removed at 10th week. Four months after, 20° wrist extension and 40° flexion with a deficit of thumb opposition and 26kg grip strength on his left hand and 62kg on his right (Jamar). X-ray showed a minimal disturbance of the second Gilula’s line and a lunotriquetrum ligament diastasis. At year and a half, thumb opposition deficit persisted, grip strength was 32kg on his left and 60kg on right. X-ray showed an area of lunohamate joint narrowing. At 4-year follow-up, he had thenar eminence flattening with a Kapandji score of 7, 70° wrist extension and 78° flexion. He referred hypoesthesia in the cutaneous detachment area and mild pain during cold weather. Strength of 38kg on his left and 59kg on his right. X-ray showed signs of osteoarthritis with lunohamate joint narrowing area. He was satisfied and continued doing the same work as before. Axial carpal dislocations and fracture-dislocations remain a challenge and remains unclear what the predictors of long-term outcome are, although it seems to relate to injury pattern, soft tissue damage, and the surgeons ability to regain carpal alignment Most of these injuries may be classified as ulnar or radial axial dislocations but there are some lesions that do not follow a single pattern as occurred in this case; therefore, we believe that adding a type G (mixed pattern) which include the association of different patterns to the classification of Garcia-Elias could be useful not in changing the treatment but probably indicating a worse prognosis.

Young Ran Jung, Young Keun Lee, Tae Gyun Kim, Jun Mo Lee

Department of Orthopedic Surgery, Chonbuk National University Hospital, Jeonju, South Korea

Abstract Objective: Composite tissue defect at the dorsum of hand is a challenging problem for reconstruction. Restoration of extensor tendons by staged reconstruction is rarely described in medical literature. Here, we report the successful treatment of composite tissue defect at the dorsum of hand by staged extensor tendon reconstruction with free tendon grafts and ALT free flap. Method: A 34-year-old man appeared with composite tissue defect on the dorsum of his left hand as a result of a car accident. A 14x9 cm sized composite tissue defect with LIF ~ LRF EDC tendons segmental defect and 5th EDC tendon rupture were found. An initial operation was debridement of necrotic tissue, multiple K-wires fixation for MP jts and 5th PIP jt. and 5th EDC tendon repair. 3 days after the initial operation, 14x9 cm sized fascio-cutaneous type ALT free flap was used to cover the defect. 3 months after the ALT free flap, Hunter-rods insertion was performed for the reconstruction of LIF, LLF, LRF EDC tendons. 3 months after the Hunter-rod insertion, EDC reconstruction was performed with PL free graft for LIF and with 4th FDS free tendon graft for LLF & LRF. Result: At 6-month follow-up after reconstruction and rehabilitation with dynamic splint, the patient had normal finger ROM. Conclusion: We suggest that staged extensor tendon reconstruction with coverage of ALT free flap for the treatment of composite tissue defect of the dorsum of hand can be a useful procedure.

Young Ran Jung, Young Keun Lee, Tae Gyun Kim, Jun Mo Lee

Department of Orthopedic Surgery, Chonbuk National University Hospital, Jeonju, South Korea

Purpose : The purpose of this study was to report radiological and functional results of the patients with antegrade metacarpal intramedullary nailing using K-wire for the treatment of metacarpal fracture. Materials and methods : We retrospectively reviewed the records of 30 patients with metacarpal fracture who had undergone operative treatment from 2010 ~ 2016. The average follow-up period was 8 months. Bone union was assessed using serial plain radiographs. At final follow-up, functional outcome was evaluated using the grip power, pinch power, quick-DASH sores and VAS scores for pain. Results : All fractures completely united. The average union time was 7.4 weeks. In last follow-up radiograph, preoperative angulation was corrected from average 32.7° to average 8.8°. Average grip power and pinch power were 32kg, 16.3kg respectively, and average VAS was observed 1.07 at the final follow-up. The average Quick DASH score was 2.05. Conclusion : Antegrade metacarpal intramedullary nailing using K-wire could be one of the most useful methods for the treatment of metacarpal fracture because of its simple procedure and good functional results. Key words : Metacarpal fracture, intramedullary nailing, K-wire

Ojas Pujji, Eva O'Grady, Dominic Power, Jill Webb

The Hand Plastic Peripheral Nerve Group, Birmingham, UK

Objectives - Fingertip injuries are a major component of hand trauma workload. A new low-adhesion medicated foam PolyMem (PM) dressing has been recently introduced to our unit. This pilot study was undertaken to establish current practice, feasibility and to define primary and secondary outcome measures for a randomised controlled trial (RCT) of post-op fingertip dressings. Trial protocol is being developed by the Hand, Plastic, and Peripheral Nerve research group at the Birmingham Hand Centre (BHC). Methods - The study design was peer reviewed and approved by the audit department. Patients over 16 years of age having surgical management of fingertip injuries at the BHC were included. At first change of dressing the patient was asked to fill a pain questionnaire using a visual analogue scale (VAS). Results - Data was collected in 52 patients during the study period. Most common operative dressing used at the BHC for dressing was Mepitel 70% (n=36), and PolyMem 2% (n=1). Most common dressing used at 1st change of dressing was Cosmopore at 46% (n=24), and PM 12% (n=6). Mean VAS for pain since operation and pain on removal for Mepitel was 15 (n=34), PM 17 (n=1). Mean VAS scores for pain on application was and Cosmopore 3 (n=24), PM 6 (n=6). VAS scores were completed sub-optimally by patients. Comments regarding exudate collection in PM dressing prompted use of a 4-point nominal Adhesion Scale. Conclusions - The pilot study has demonstrated current practice at the BHC and recorded pain scales for first dressing changes. Guidance for VAS recording needs to be more clearly defined and standardised for the purpose of a future study. Dressing adhesion scores and Global Patient Satisfaction Scores will be piloted in the next phase of protocol development.

Thomas Henne

Kreiskrankenhaus Osterholz-Scharmbeck, Germany

Introduction: Hypertrophic scars are a therapeutic problem. A Gold-standard does not exist. We present a new approach for treatment of a hypertrophic scar by excision, closing the wound by a local advancement mesh flap followed by negative pressure wound therapy ( NPWT ). Patient: 24 years, male, healthy; decollement injury of the back of the right hand 2011, state after 2 operations with mesh graft 10/2011 and 12/2011 with the result of a hypertrophic scar, causing functional ( itching and repeated skin ulcerations ) and aesthetic complaints. Method: After lots of paperwork the scar was excised. The skin distal of the wound was mobilized and scarified by scalpel. The so created mesh was used to close the wound followed by NPWT with a white sponge and 120 mm continuous suction for 2 weeks. Hand and forearm were immobilized by a splint. After removing of the stitches the patient was wearing a compression glove for 3 month. Result: After therapy the patient is symptom free and content. The skin on the back of the hand is mobile over the tendons and has sensibility. The histologic examination of the excised specimen confirmed the diagnosis of a hypertrophic scar. Advantages of the method: Flap without donor site defect, remaining sensibility Disadvantages: long time of therapy, definitively cooperative patient necessary, lots of paperwork Limits: defect size in relation to mobilizable skin. Conclusion: The used single components as local flap, mesh graft and NPWT are known, but in this combination for treatment of a hyertrophic scar new and successful.

Daniele De Spirito

Ospedale Regionale di Lugano, Lugano, Switzerland

Objective Isolated loss of sterile nail matrix is a rather uncommon lesion but, when occurs, it represents a difficult reconstructive challenge. The purpose of this paper is to show our original dorsal advancement flap to easily solve the problem. Methods By means of two dorsal longitudinal incisions a flap is raised on the thumb, leaving in continuity the dorsal skin and the residual nail matrix. The dissection is carried out beneath the nail matrix and beyond the insertion of the extensor tendon. The significant forward movement of the flap allows all the exposed bone to be completely covered. Results Both patients we treated with the described technique rapidly healed with no complications such as flap suffering or infections. They also had a rapid and complete recover of function with no joint stiffness. Conclusions Since isolated nail bed loss in the thumb is a rare lesion, we have employed the described dorsal advancement flap just in two cases so far. Nevertheless in both cases the flap, which is quick and easy to perform, demonstrated to be very reliable. It also does not require complex procedures or further surgical fields. In those peculiar situations it now represents our first choice in reconstruction of the thumb.

Ana M. Far-Riera, Carlos Perez-Uribarri, Matías José Esteras Serrano, Isabel María Ruiz Hernández

Hospital Son Llàtzer, Palma De Mallorca, Islas Baleares, Spain

1.- Introduction Trapezium-metacarpal dislocations are infrequent lesions. Its treatment continues in controversy. In most cases the dislocation is dorsal, by a mechanism of axial compression in flexion of the thumb. The clinical deformity and the TMC pain guide us to the diagnosis, which we will confirm through x-ray. They are classified as acute or chronic dislocations. There is no consensus in the management of acute injury. Some authors propose an early stabilization by ligamentous reconstruction, while others advocate a closed reduction and immobilization. If a stable joint is obtained after reduction, it is immobilized in a Zancolli cast and visited weekly. In case of instability, pinning with two k-wires with or without ligamentous repair, or a tendon reconstruction are the surgical options. In chronic symptomatic lesions open surgery and ligamentous reconstruction are recommended. We have not found any recommendation for instability after the failure of closed stabilization. 2.- Aim Treatment proposal for acute instability of trapezium-metacarpal joint dislocation after failure of closed stabilization. 3.- Material and methods We present a case of a 15-year-old male who suffered a post-traumatic TMC dislocation self-reduced 4 weeks earlier. X-rays shown a dorsoradial subluxation. Patient is unnable to perform key pinch. A closed reduction was performed and remained immobilized for 6 weeks. After removal of kischner wires and immobilization the joint remained unstable. Then an open reduction and reconstruction by Eaton plasty with FCR was performed. 4.- Results The surgical technique is illustrated. At 6 months the patient presents a non-painful, symmetric mobility, maintaining a correct reduction on the x-ray. 5.- Conclusion The treatment of acute TMC dislocations continues in controversy. A stable dislocation after closed reduction can be treated with immobilization with or without percutaneous stabilization. There are authors who propose an early reconstruction of the ligament. In our case, with a "subacute" presentation, closed stabilization did not solve the problem, and we had to resort to a reconstruction with FCR plasty to achieve a stable joint. Although both techniques are useful in acute injury, in delayed presentations it may be preferable to propose a ligamentous reconstruction.

Hirofumi Imai 1,2, Masatoshi Takahara 1, Mikirou Kondou 1

1 Izumi Orthopedics Hospital, Miyagi, Japan; 2 Minamisannriku Hospital, Miyagi, Japan

Objective： To compare the results of metaphyseal ulnar shortening osteotomy (MUSO) and diaphyseal ulnar shortening osteotomy (DUSO) for the treatment of ulnar impaction syndrome. Methods： From 2011 to 2016, we underwent MUSO in 8 patients (8 wrists) and DUSO in 6 patients (7 wrists). The results were investigated and compared, including pain Visual Analog Scale (VAS), Hand20, patient-rated wrist evaluation (PRWE), wrist and forearm range of motion (ROM), grip strength rate with unaffected side, ulnar variance (UV), and terms of cast immobilization and bone union. Mean follow-up period was 20.5 months (range: 3~60 months). Results： Mean pain VAS in MUSO and DUSO was 7.0 (range: 4~7) and 7.3 (range: 5~10) before surgery (p=0.81), 4.5 (range: 3~7) and 3.75 (range: 3~5) 3 months after surgery (p=0.41), and 3.0 (range: 0~6) and 3.7 (range: 0~6) final follow up (p=0.65). Mean Hand20 was 44.1 (range: 18~61) and 35.8 (range: 12~78) before surgery (p=0.57), 40.5 (range: 25~68) and 40.1 (range: 27.5~56.5) 3 months after surgery (p=0.69), 22.3 (range: 0~68) and 39.1 (range: 16~55) final follow up (p=0.26). Mean PRWE was 63.1 (range: 33.5~76.5) and 50.0 (range: 24.5~65.5) before surgery (p=0.38), 45.9 (range: 30.5~ 74) and 45 (range: 29~54) 3 months after surgery (p=0.93), and 23.4 (range: 0~49) and 38 (range:17~73) final follow up (p=0.15). Mean wrist flexion/extension ROM was 149 degrees (range: 75~180) and 140 degrees (range: 95~180) before surgery (p=0.68), 159.6 degrees (range: 90~180) and 162 degrees (range: 95~180) 3 months after surgery (p=0.89). Mean forearm pronation/supination ROM was 169 degrees (range: 140~180) and 176 degrees (range: 155~180) before surgery (p=0.52), 135 degrees (range: 90~180) and 169 degrees (range: 140~180) 3 months after surgery (p=0.02), 173 degrees (range: 170~180) and 173 degrees (range: 160~180) 6 months after surgery (p=0.93). Preoperative grip strength rate was slightly higher in MUSO (mean: 78%, range: 37~102) than DUSO (mean: 59.2%, range: 31~85) (p=0.08), 57 % (range: 40~102) and 61 % (range: 39.5~70) 3 months after surgery (p=0.73), 77 % (range: 73~90) and 70 % (range: 59.5~86.8) 6 months after surgery (p=0.66). Mean preoperative UV was +1.91 mm (range: +1.0~3.0) and +2.53 mm (range: +0.5~4.0) (p=0.30) and after surgery +0.48 mm (range: -0.5~+1.0) and -0.11 mm (range: -2.5~+2.5), (p=0.49). MUSO had the significantly shorter term of cast immobilization after surgery (mean: 24.2 days, range: 17~29) than DUSO (mean: 29.2 days, range: 24~35), (p=0.03). Mean period of bone union was slightly shorter in MUSO (mean: 3.5 months, range: 3~4) than DUSO (mean: 4.3 months, range: 3~7), (p=0.16). Both groups improved with no significant differences finally. 3 months after surgery pronation/supination ROM was significantly decreased in MUSO, but 6 months after surgery those had recovered. In MUSO, mean grip strength rate was slightly decreased after 3 months compared with preoperative (p=0.19), but recoverd at 6 months. Conclusion： Although MUSO were temporarily associated with decrease of pronation/supination motion and grip strength, recoverd at 6 months. The results from this study suggest that MUSO has advantage to bone union and an effective alternative to DUSO for ulnar impaction syndrome.

Jikang Park, Sangwoo Kang, Jungkwon Cha

Chungbuk National University Hospital, Cheongju, South Korea

Why not try a direct anatomical reduction of bony mallet finger? (A modified Intrafocal pinning technique) Background: The purpose of this study was to describe and evaluate a modified intrafocal pinning technique for the treatment of bony mallet finger. Methods: We reviewed 18 patients (14 men, 4 women) with closed bony mallet finger who were treated with a modified intrafocal pinning technique. The mean joint surface involvement was 40.5% (range: 25–48%). The mean time from injury to surgery was 14.5days, and average follow-up was six months (range, 3-10 month). The functional outcomes were graded using Crawford’s criteria. The results: All fractures achieved an anatomical reduction and union at an average of 6 weeks after surgery. The mean extension lag was 2.8, and active flexion of the distal interphalangeal joint was 72 degrees. According to the Crawford rating scale, 12 were excellent, and six were good. There were no pin site infections, nail deformity, or dermal necrosis. Conclusions: Our modified Intrafocal pinning technique is a useful treatment option in bony mallet finger to achieve an anatomical reduction and provides good clinical results.

Hirotada Matsui, Hideki Tsuji, Yoshiaki Kurata

Sapporo Tokushukai Hospital, Japan

Objective: We invented a flap called the bipedicled volar advancement flap (BVAF). This study aimed at introducing an operative technique for BVAF, and comparing its clinical outcomes with those of oblique triangular flap (OTF). Methods: The operative technique for BVAF is designed at the proximal interphalangeal (PIP) joint level. Mid-lateral incisions are made on both sides of the finger. The dorsal branches of the digital artery are then dissected on both sides. This island flap is connected by both digital arteries and nerves. A skin graft covers the flap's donor site. We retrospectively analyzed the results of BVAF in 11 fingers from 9 patients; OTF was applied to 10 fingers from 9 patients for comparison. Two flaps were used for amputations, claw-nail deformities, and skin defects of the fingertip. Outcome measurements included flap elongation, range of motion (ROM), the Semmes–Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) score, and complications. Results: The mean age of patients and the follow-up period in the BVAF and OTF groups was 33.7 and 44.4 years and 7.7 and 8.7 months, respectively. All flaps were engrafted. The average flap elongations were 10.8 and 7.5 mm. A patient who underwent BVAF experienced temporary numbness. In the final follow-up assessment, there was no significant difference in the ROM, SWT, and DASH scores between the two procedures. The average metacarpophalangeal (MP)/proximal interphalangeal joints (PIP)/distal interphalangeal (DIP) joint extensions in BVAF and OTF were 20.5°/-4.1°/-3.2° and 15°/-0.5°/-8.0°, respectively, whereas the average MP/PIP/DIP joint flexions in BVAF and OTF were 85.9°/91.4°/37.7° and 87.5°/94.0°/51.5°, respectively．The SWT of BVAF was 6 blue and 5 green, whereas that of OTF was 7 blue and 3 green. The average DASH score of BVAF and OTF was 12.0 and 14.2 points, respectively. Conclusions: The advantage of BVAF is the easier and reliable surgical procedure and larger movement distance than that of OTF. It is possible to perform volar flap advancements of up to 15 mm. Moreover, there was no dorsal skin necrosis of the distal phalanx in our study. The disadvantage of BVAF is that it requires a skin graft. The indications for BVAF include multi-finger injuries and volar skin defects smaller than 15 mm. We believe that BVAF is a useful method in fingertip reconstruction.

Hideyuki Mizushima

Sakai city medical center, Sakai, Japan

Objective Replantation cannot be performed in all cases of fingertip amputation, and in such cases, a pedicle flap is sometimes used to cover the skin and soft tissue defect. Kutler described a technique of bilateral V-Y advancement flap for reconstructing fingertip amputation in 1947. In this study, we show an newly developed bilateral V-Y advancement flap (modified Kutler method) and evaluated the outcomes of this local flap. Materials and Methods Materials: We reviewed 21 cases (men, 21; women, 1; average age, 47 years) of amputation of the fingertip from July 2009 to February 2016. The injury sites were as follows: thumb (1), index finger (6), middle finger (7), ring finger (4), and little finger (3). Nineteen cases were injured in crush, and 2 were in clean cut. The average follow-up period was 188 weeks. Sensory disturbance and pain were examined at the final follow-up. Methods: Inverted triangular flaps, the apex of those were placed on distal interphalangeal joint, were designed in radial and ulnar side of amputated finger. The volar incision was slightly undermined but left attached to subcutaneous tissue, and the dorsal incision was made to periosteum in both flaps. Both dorsal incisions were connected anterior to distal phalanx and volar subcutaneous tissue which include two flaps was separated from distal phalanx. Because of this maneuver, mobility of both flaps was greater than original Kutler method. Results All flaps survived. numbness, hypersensitivity, or hypesthesia remained in 8, 5 and 10 cases respectively. And pain due to an attack remained in 1 case. Coldness remained in 5 cases. Affected finger were useful in 18 patients and not useful in 3 patients. Of three cases, one was not useful because of pain, one was of hypersensitivity, and remained one was of hypesthesia. Conclusion Our modification allowed much greater mobility of the bilateral V-Y advancement flap than original Kutler method. But in this study, the incidence of numbness, hypersensitivity, or hypesthesia after operasion were higher than expected. Otherwise, this flap is very useful method for fingertip injury because affected fingers were useful in most of patients.

Konstantinos Tolis, Panagiotis Kanellos, Konstantinos Raptis, Markos Liontos, Maria Ladogianni, Sarantis Spyridonos

Hand Surgery, Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece

Objectives: A partial or complete rupture of the ulnar collateral ligament (UCL) of metacarpophalangeal joint is the commonest injury of the thumb’s base. We present the first reported case of an acute bilateral, traumatic rupture of the UCL of the thumb and its treatment. Methods: An amateur female skateboarder was evaluated at the emergency department, after a sustained a fall in a ski slopes. She reported pain 5 days post-injury on both her thumbs. Clinical examination revealed pain at the ulnar side of the thumb’s base, bilaterally, and instability during valgus test, after injection with xylocaine (Oberst anaesthesia). On simple postero-anterior radiographies a detached fracture of the ulnar side of the thumb’s proximal phalanx was observed, bilaterally. Diagnosis was complete rupture of the UCL on both thumbs. The diagnosis was confirmed with Magnetic Resonance Imaging. Under general anesthesia an open reduction and stabilization of the fractures with Kirschner wires was performed for both thumbs. A plaster spica was placed for protection. Results: The plaster spica and the K-wires were removed simultaneously at 4 weerks and the patient began an intensive, gradual kinesiotherapy program. At 6 months postoperatively the patient reports mild on the ulnar side of both thumbs, the valgus stress test is negative and the metacarpophalangeal joints regained full function bilaterally. Conclusions: A complete rupture of the UCL of the thumb is a major cause for thumb instability. The incidence in the bibliography is almost 86% when considering injury of the thumb’s base. It is a usual injury amongst skiers and rarely when considering snowboarders. The use of K-wires for stabilization of the UCL, when detached with a bone fragment, is an effective and costless method of surgical treatment.

Yu-Te Lin 1, Charles Yuen Yung Loh 2, Shwu-Huei Lien 2, Chih-Hung Lin 3, Fu-Chan Wei 2

Chang Gung Memorial Hospital, 1 Keelung, 2 Linkou, 3 Chiayi, Taiwan

Introduction: Claw deformity of the transferred second toe is quite common since no intrinsics been repaired. In this article, the experience of simultaneous intrinsic reconstruction during the second toe transfers is reported. Materials and Methods: Seven 2nd toe transfers were performed in 5 metacarpal-like and metacarpal hands. Double second toe transfers were performed in two cases. Stiles-Bunnell tendon transfer was incorporated into the toe transfers for the intrinsic reconstruction. Toe lumbrical tendons were included in the 2nd toe harvest and were repaired to the Flexor Digitorum Sublimis of the same recipient digit. Results: The active motion of the PIPJ were 61°±9.5° and 36°±6.4° in the 2nd toes transferred to the middle and ring fingers. The extension lag overall was 19.9°±9.9°. The transferred toe PIPJs had minimal extensor lag with the MCPJ in flexion position. The total active motion was 150.3°±32.1°. The flexion sweep of the toe was improved by the intrinsic reconstruction. Conclusion: From the results seen, simultaneous intrinsic reconstruction appears to enhance the dexterity and hence function of transferred toes.

Inga Besmens, Mario Scaglioni, Maurizio Calcagni, Thomas Giesen

University Hospital Zurich, Department of Plastic Surgery and Hand Surgery, Zurich, Switzerland

The necessity to reconstruct the thumb in complex hand injuries is well accepted, but in some cases, the thumb is lost or cannot be replanted. In multidigital amputations the thumb can also be reconstructed through the heterotopic replantation of another finger. In this case the index finger was still vascularized through the first dorsal metacarpal artery (FDMCA) and was the only possibility available. We report on its successful primary pollicization using only the dorsal vascular supply. A 82-years old patient suffered a traumatic multidigital in zone 2 with a circular saw. The index finger was sub-amputated and still attached through a dorsal skin bridge and the extensor tendons. At inspection, the index finger was still vascularized through the FDMCA. The thumb was the only digit not available for replantation. We transferred the index finger to the thumb without any microvascular anastomosis, relying only on the remaining dorsal skin bridge with the inclusion of the first dorsal metacarpal artery. Digits III, IV and V were replanted. The neopollex survived completely with no further operations. The replanted fingers survived as well. The patient achieved a satisfactory function of the hand for daily activities and his hobby (constructing little wire sculptures). He regained grasp function with a maximum opposition of Kapandji 8. The FDMCA consistently arises from the radial artery in the first intermetacarpal space and then divides into a radial branch to the thumb, the intermediate branch to the first web space, and the ulnar branch to the index finger. In this case the intermediate and ulnar branch sufficed as vascularization for the subamputated index finger. Anatomic studies have demonstrated that the dorsal metacarpal arteries up to distal branches on the dorsum of the fingers regularly anatomose with braches from the palmar digital arteries In this patient these anastomoses were enough to secure survival of the digit thus making the FDMCA the only major vessel on which this digit survives. This case report demonstrate how patent the anastomosing network between dorsal and palmar vascular supply to the digits can be.

Steven Roulet, Bertille Charruau, Emilie Marteau, Guillaume Bacle, Jacky Laulan

Hand Surgery Unit, Department of Orthopedic Surgery 1, Trousseau University Hospital - Medical University François Rabelais of Tours, Tours, France

Introduction : Volar dislocation of the proximal interphalangeal joint associated with a dorsal fracture of the base of the second phalanx is a rare injury, with only 38 cases published. There is no consensus for their treatment.We report here four such cases: three treated surgically and one orthopaedically. Material et methods : Patients had a mean age of 19.5 years. It was a ring finger in 4 cases and a little finger. For two patients, reduction of the dislocation was secured with a transarticular K-wire and the dorsal fracture was fixed with mini anchors, and in one case a bone graft allowed the osteosynthesis by a screw ensuring cohesion of the entire P2 base and stabilized the dorsal fragment. The immobilization was 3 to 4 weeks followed by physiotherapy. The patient treated orthopedically presented no joint impaction, the joint was stable after reduction and testing under locoregional anesthesia. He was immobilized for fifteen days relayed by a dynamic extension splinting for 15 days. Results : At an average follow-up of 3 years, pulp-to-palm contact was obtained and no pain was reported with regular daily activities. All patients considered themselves cured and were very satisfied with the result. There was no boutonnière deformity. Discussion : For the orthopaedic patient, we have decided to treat his fracture as an isolated tear of the central slip given the stability of the joint during testing. Osteosynthesis is necessary in cases where more than 20% of the articular surface is concerned with a displacement greater than 1 or 2 mm. In 2 cases, the incomplete reduction of the dorsal fragment and the presence of a localized articular impaction necessitated temporary transarticular K-wire to secured the reduction. For the third case, the bone graft allowed to reduce the impaction. Conclusion : Orthopaedic treatment is of some interest in PIP dislocations associated with a dorsal fracture of the base of the second phalanx if, during testing under proper conditions including anaesthesia, the reduction is obtained and the joint is deemed stable. In this case the lesion may be treated as an isolated tear of the medial band. Surgical treatment may be reserved for patients whose compliance may be unsatisfactory, or in cases with large or highly displaced fragments of the base of the second phalanx or with an articular impaction. In all cases, early rehabilitation is necessary to fight against stiffening.

Ahmed Afifi, M Hussein Dobal, Mostafa Mahmoud, Ashraf N Moharram

Kasr Al-Ainy Faculty of Medicine, Cairo University, Egypt

Objective: To assess the rigidity of interosseous wiring as a method of fixation that permits early finger motion in management of transverse and short oblique metacarpal shaft fractures. Methods: This is a prospective study conducted at an academic Level 1 Trauma Center from February 2015 to October 2017. The study included 20 patients (16 males and 4 females). The mean age was 27.3 years (12-44 years). The dominant hand was affected in 10 cases and the non-dominant hand was affected in the other 10 cases. Regarding the fracture pattern, 17 were transverse while 3 were short oblique fractures. The mean follow-up period was 6 months (4-8 months). Patients were assessed for union (clinically and radiographically), range of motion (total active motion [TAM] and total active flexion [TAF]), hand grip strength and patient-reported outcome using the Quick-DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire. Results: ​All patients achieved union after an average of 7 weeks (6-8 weeks). The mean TAF was 246˚ (150-260̊). TAF was excellent in 18 digits and good in 2 digits. TAM was excellent in 13 digits and good in 7 digits. The mean grip strength was 90.20% (61.53%-100%) of the unaffected side. The mean quick-DASH score was 2.72 (0-20.45). Conclusion: The interosseous wiring technique is a rigid method of fixation that can be used alone for transverse and short oblique fractures of the metacarpal fractures and can permit early hand mobilization postoperatively without loss of reduction.

Yuki Fujihara, Kentaro Watanabe, Hideyuki Ota, Atsuhiko Murayama

Nagoya Ekisaikai Hospital, Nagoya, Japan

Objective Central slip tears often occur with concomitant hand injuries such as fractures, ruptured flexor tendons, or vascular injuries in the affected or adjacent fingers. However, the outcome of a central slip tear and the effect of the concomitant injuries on its outcome are rarely reported because the various patterns of damage can make evaluation in these cases difficult. The specific objectives of this study were to identify the outcomes of central slip tear injuries and clarify the effects of concomitant injuries on these tears. Methods We evaluated 67 fingers of 63 patients with central slip tears who underwent primary surgery in our hospital between April 2009 and June 2017. We performed multivariate analyses, setting the proximal interphalangeal (PIP) joint active range of motion (AROM) and existing extension lag greater than 10 degrees as dependent variables, and age, existence of concomitant fractures, skin defects, collateral ligament injuries, ruptured lateral bands, ruptured flexor tendons, or vascular injury in the injured finger as independent variables. Concomitant injuries of flexor and extensor tendons in the adjacent fingers are also included as independent variables. Because there were both continuous- and binary-type dependent variables in this study, we used linear regression analysis for PIP joint AROM evaluation and logistic regression analysis to assess PIP joint extension lag. Results The average AROM of the PIP joint was 62 degrees, and extension lag occurred in 34 fingers (51%). Patients aged older than 40 years, with phalangeal or intra-articular fractures of the injured finger, or flexor tendon injuries in an adjacent finger had lower decreases in AROM (partial regression coefficient (95% confidence interval [CI] ): -13.7 (43.5–66.0), -31.6 (29.8–57.1), -34.5 (31.7–59.8), and -33.5 (10.2–42.8), respectively) . Extensor tendon injuries in an adjacent finger caused significantly more extension lag in the PIP joint (odds ratio (95% CI): 3.2 (1.0–9.6)). Conclusions In addition to older age and a concomitant fracture in the injured finger, tendon injuries in an adjacent finger worsened the functional prognosis with respect to central slip tears. The present study indicated the negative impact of a tendon injury on the adjacent fingers, a circumstance widely known as the quadriga phenomenon. Ultimately, we can use these prognostic factors in surgical repair planning, particularly when considering central slip reconstruction versus primary arthrodesis.

Young Hak Roh 1, Seok Woo Hong 1, Hyun Sik Gong 2, Goo Hyun Baek 2

1 Department of Orthopaedic Surgery, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, South Korea; 2 Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Objective:This study evaluates the factors influencing treatment outcomes of proximal interphalangeal (PIP) joint collateral ligament injuries when treated with buddy strapping. Methods: Sixty-seven patients treated with buddy strapping for a PIP joint injury were enrolled. The finger range of motion (ROM), grip strength, and a Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score were assessed at 3 and 6 months after the initial injury. The factors that were assessed for their influence on the functional outcomes included age, sex, hand dominance, affected finger, type of injury, injury severity, time to treatment, the duration of buddy strapping, and exercise training. Results: Buddy strapping for PIP joint injuries led to satisfactory results with 77% recovery of grip strength, 84% recovery in ROM, and mean QuickDASH scores of 14 at 6 months. A decrease in grip strength was associated with an increase in age and injury severity at 6 months, and these 2 factors accounted for 22% of the variance in the grip strength. A decrease in ROM was associated with the delayed treatment, which accounted for 18% of the variance in ROM at 6 months. An increased disability was associated with delayed treatment, female gender, and radial digit injury at 3 months, and these 3 factors accounted for 37% of the variance in disability. At 6 months, only the delayed treatment remained an associated factor, which accounted for 20% variance in disability. Conclusions: PIP collateral ligament injuries had very good outcomes with buddy strapping. However, delayed treatment was significantly associated with poor functional outcomes in terms of the ROM and disability. An increase in age and injury severity were associated with lower grip strength up to 6 months, whereas a female gender and radial digit injury were associated with an increased disability up to 3 months.

Steven S. Shin 1, Carola F. van Eck 1,2, Carlos Uquillas 1

1 Kerlan Jobe Orthopaedic Clinic, Kerlan Jobe Orthopaedic Clinic, Los Angeles CA, USA; 2 University of Pittsburgh, Rooney Sports Complex, Pittsburgh PA, USA

Objective: This study aimed to evaluate and compare the biomechanical strength of repair of the thumb ulnar collateral ligament (UCL) alone and repair augmented with an InternalBraceTM. Methods: Twelve fresh frozen cadaveric specimens (six matched pairs) had the UCL divided at its attachment on the base of the proximal phalanx and repaired with or without InternalBraceTM augmentation. A material testing machine was used to provide valgus stress at a rate of 0.1 mm/sec until failure. The maximum load, load at failure and mode of failure were recorded. Results: In the specimens with UCL repair augmented with InternalBraceTM, the maximum load (46.56 SD 25.56 N) and load at failure (25.31 SD 18.34 N) were significantly higher than in the repair alone group (8.02 SD 2.24 N and 6.00 SD 2.39 N, respectively). Conclusion: In conclusion, thumb UCL repair with InternalBraceTM augmentation is biomechanically superior to non-augmented repair. InternalBraceTM augmentation of UCL repair may be valuable in the setting of acute tears, obviating the need for post-operative cast immobilization and therefore allowing for earlier thumb MCP joint motion and overall faster clinical recovery.

Susanna Pagella 1,2, Alberto Cafarelli 3

1 Ars Medica Clinica, Gravesano, Switzerland; 2 Ergoterapia Manoegomito, Mendrisio, Switzerland; 3 Croce Rossa Svizzera, Sezione del Sottoceneri , Centro ErgoterapiaChiasso, Switzerland

Objective: The aim of this article is to highlight the importance of choosing the right orthosis for the swan neck deformity correction, following, mallet finger type lesion , with conservative treatment. A literature review was performed, and an 8-bendage using KinesioTape was chosen, to combine the delicate balance of the extensor apparatus and the patient's functional needs. Mini invasive solutions are necessary to increase patient compliance and acceptance, and to minimizing the risk of complications. Methods: Literature includes Proximal Interphalangeal Joint (PIP) extension splinting, and extension block for distal Interphalangeal Joint (DIP) (0°/+15°) using a dorsal or volar splint, to be replaced with a stack orthosis during the day, to prevent the PIP stiffness. Alternatively, it can be associated the use of an oval-8 and a stack splint. In both cases, patients are forced to undergo complicated splint removal and applications that may result in a DIP flexion and compromise proper tendon healing. To facilitate day-to-day management and reduce the risk of skin maceration, an 8-bandage using KinesioTape on PIP has been used, together with DIP (+15°) custom-made stack splint. The bandage prevents PIP Iper extension allowing flexion, ensures better skin transpiration and reduces the risk of ulcers caused by prolonged use of the splint. The patient, worried that he could not manage the orthosis independently and not tolerating the other proposed solutions (dorsal-volar orthosis and oval-8), showed a remarkable appreciation for the treatment. Results: At the end of the used rehabilitation protocol, the patient shows no more PIP swan neck deformity, passing from +15 ° to 0 °, and from -25 ° to -5 ° on DIP. Conclusions: The performed treatment is an alternative to models present in literature for resolving swan neck deformities caused by chronic fingered mallet.

Anca Breahna 1, Anuj Mishra 2, Jill Arrowsmith 3, Tommy Lindau 3

1 Countess of Chester Hospital NHS Foundation Trust, UK; 2 University Hospitals of South Manchester, UK; 3 Pulvertaft Hand Centre, Derby, UK

Objective A variety of treatment options are available for the management of PIP joint fracture-dislocations. The few comparative studies available are not enough to settle the argument as to which treatment is the most appropriate. Methods A study protocol was designed in line with the PRISMA statement and registered with the PROSPERO data base. A systematic search of Medline, Embase, Cinahl, Pubmed and the Cochrane Library for studies reporting the treatment of PIP joint fracture dislocations was performed. Inclusion criteria (studies in English reporting on 10 or more adult patients/ digits with acute closed fracture dislocations of PIP joint) were applied to the studies identified. The primary outcome was active range of motion (ROM). It was postulated that success of a certain operative or non-operative technique was directly related to restoration of normal or near normal AROM at PIP joint. The key secondary outcomes were: pain, grip strength, patient reported outcome scores (DASH, Quick-DASH, PEM) and complications. Due to limited data available in the primary assessment, the hypothesis was tested in a secondary analysis of articles that marginally met the strict inclusion criteria (i.e. studies that included in their cohort patients under 18 years of age). A tertiary analysis was carried out, where all studies were divided into three groups: closed reduction techniques, ORIF and “other studies”. Results The literature search identified 502 references. Most of them are short retrospective studies, pooling together heterogeneous fracture patterns, with medium term follow-up and incomplete outcome data. Four studies fulfilled the strict inclusion criteria of the systematic review and were included in the primary analysis. The outcome measures were heterogeneously documented and a narrative synthesis was carried out. Seven studies made the subject of a secondary analysis. Only ROM at PIP joint and the complications were consistently reported. Hence, no further comparison was possible. The tertiary analysis identified a higher rate of complications and posttraumatic arthritis in the closed reduction group compared to ORIF, whilst similar ROM at PIP joint was achieved with either technique. Conclusions Notwithstanding several subsequent analyses, the systematic review found insufficient evidence to make an evidence-based recommendation for the management of acute PIP joint fracture-dislocations. There is a need for improved research with well-powered, multi-centre randomised controlled trials, as well as prospective cohort studies with a sound methodology and a standardised way of reporting the outcomes.

Daniel Gibbs, Anthony De Giacomo, Steven S Shin

Kerlan Jobe Orthopaedic Clinic, Los Angeles, USA

Objectives To date, no literature exists on the use of suture tape augmentation for repair of the thumb ulnar collateral ligament (UCL) in an elite athlete cohort. Our hypothesis is that utilizing suture tape augmentation for the thumb UCL will allow for a safe and expedient return to play in high level athletes. Methods A retrospective chart review was completed to identify all patients who underwent operative thumb UCL repair (Current Procedural Terminology codes 26540, 26541, 26542) between 2014 and 2017. All procedures were performed at a single institution by the senior author. Inclusion criteria were acute complete tears of the thumb metacarpophalangeal joint ulnar collateral ligament, treated with primary repair with suture tape augmentation in collegiate or professional athletes. Exclusion criteria included recreational athletes, patients who underwent reconstruction (rather than repair) and those patients with insufficient follow up to establish their return to play. Charts of patients identified from the retrospective review were further evaluated to determine patient-related and injury-related variables. Return to play was defined as return to game competition. Results Eight thumb surgeries in 7 elite athletes were identified. One patient had bilateral surgery at different time points over the inclusion dates. One athlete was a collegiate baseball players, 4 of the athletes were professional baseball players while 2 athletes (including the patient with bilateral surgeries) were professional basketball players. Six of the eight UCL tears were treated in-season with an average return to play of 29.5 days (for return to play at any level) and 32 days for return at the same level. Two of the eight UCL tears were treated during the off season. Both of these athletes returned to play to start the next season. All 7 collegiate and professional athletes returned to the same level of play. Conclusions The findings presented here offer evidence of a novel technique utilized in high demand and high level athletes with a difficult problem. All athletes returned to the same level of play. Those attempting to return in-season returned on average to the same level of play in just under 5 weeks. Augmenting the repair with anchored suture may prevent prolonged immobilization, expedite thumb motion and improve postoperative recovery.

Mohammed Tahir Ansari 1, Swapnil Singh 1, Prakash P Kotwal 2

1 All India Institute of Medical Sciences, New Delhi, India; 2 Pushpawati Singhania Research Institute, New Delhi, India

Introduction: The patients of palmer lip injuries of proximal inter-phalangeal (PIP) joint who presented late are difficult to treat as bone fragments have malunited, few are resorbed and in some cases, the PIP joint also becomes stiff. There has been modification in surgical technique in late cases by different surgeons, which include use of external fixator for distraction or extensor tendon tenolysis from dorsal side. We performed dorsal capsular release from proximal fragment and intend to report our results. We hypothesize that the hemi-hammate arthroplasty with modification in surgical technique should be performed in such cases. Objective: To assess the functional and radiological outcome of modified hemihammate arthroplasty in patients presenting after six weeks of injury Material and methods: This is retrospective study included 7 patients presented to us between Jan 2015 to Oct 2017 with comminuted and or displaced (unstable) palmer lip fracture. Mode of injury was sports in 3, road traffic accident in 2 and fall in 2 patients. Shotgun approach was used in all patients. Average middle phalangeal articular involvement was 62% on CT scan while volar lip involvement was 60%. In all patients we have used hemihamate autograft and fixed with 2 1.3 mm ao screw. Average timing of presentation was 12 weeks (8-15). Average time to surgery was 85 days (60- 110). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 12 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Results: All the patients had average of 90 degree of flexion at PIP and average of 60 degree of flexion at DIP. There was an average of 5 degree of extension lag. In all patients pain was not a complaint in follow up rather swelling persisted for long and took 6-8 month to resolve. All patients had bony union in follow up and grip strength was 80% of normal side. They were able to return their daily routine on average 3 month post surgery. 6 patients were very satisfied while one is satisfied. Conclusion: Hemi hamate arthroplasty with modification in surgical technique is one of the reliable and reproducible surgical option for reconstruction of the articular surface of the base of middle phalanx in patients of fracture dislocation of the PIP joint who present late.

Thomas J.M. Kootstra 1, M. van Heijl 2, J. Keizer 1, R.M. Houwert 3, Ph. Wittich 1, E.J.M.M. Verleisdonk 2, D. van der Velde 1

1 Department of Surgery, St. Antonius Hospital Nieuwegein, the Netherlands; 2 Department of Surgery, Diakonessenhuis Utrecht, the Netherlands; 3 Department of Surgery, Universitair Medisch Centrum Utrecht, the Netherlands

Abstract Background: Finger fractures are very common, but to date little is known about the functional outcome of different types of fractures and operative treatments. Purpose: We evaluated functional outcome and complications after operative treatment of proximal and middle phalanx fractures, excluding the thumb. Additionally, we registered patient satisfaction. Methods: All consecutive patients who underwent surgical treatment for proximal or mid phalangeal fractures from January 2011 to December 2015 were included. Excluded were deceased patients, patients under the age of 16 and patients that were operated on more than three weeks after the initial trauma. Indications for surgical treatment were angulation of > 15 degrees, shortening of the phalanx of > 2 millimeters or clinically observed rotation. Fractures were fixed with either K-wires (Kirschner-wires), lag screws or plate fixation. Functional outcome was assessed via phone using the Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure and the Patient Rated Wrist/Hand Evaluation (PRWHE), complications were obtained from electronic patient records. Patient satisfaction was also assessed via phone. Results: Our final cohort existed of 159 proximal phalanx fractures and 41 middle phalanx fractures. Follow-up was achieved for 143 proximal fractures (90%) and 39 middle fractures (95%). One-hundred-and-seven patients (57%) were male, the mean age was 39 years (Standard Deviation (SD) 16; range 16-72). For the proximal fractures, 2 patients (1.4%) suffered radiological nonunion and 11 patients (7.6%) suffered clinical malunion. There were 2 secondary fracture dislocations (1.4%), 6 infections (4.2%) that required antibiotic treatment and 13 fractures (9.1%) that had any unplanned surgery related to the initial surgery. For the middle fractures, there were no cases of nonunion, 3 patients (7.6%) suffered malunion, 5 patients (13%) had unplanned surgery and there were no cases of secondary fracture dislocation and infection. In total, 15% of patients suffered a complication. We reported long-term functional outcomes with mean DASH and PRWHE scores of 4.6 (SD 7.6; range 0-51) and 7.7 (SD 13; range 0-82), respectively. No significant differences in functional outcomes were found between proximal and middle phalanx fractures and methods of fixation. One-hundred-and-thirty-eight patients (76%) reported to be satisfied or very satisfied with their surgery. Additionally, we found that patients with college/university educational level had significantly lower DASH and PRWHE scores. Conclusions: The main findings of this study are excellent functional outcomes in a relatively large cohort of patients with surgically treated finger fractures. No differences were found between proximal and middle phalanx fractures or methods of fixation and in total, 15% of patients suffered a complication which compares well to previous reports. However, in spite of excellent general functional outcomes, almost a quarter of the patients (24%) reported no satisfactory outcome of their surgery. It might well be that the DASH and PRWHE are not sensitive enough as a functional outcome tool to measure fine motor disability. We additionally found that patients with a lower educational level had worse functional outcomes, which suggests these patients should receive intensified counselling in their rehabilitation.

Hidetsugu Suzuki 1, Satoshi Usami 2, Sanshiro Kawahara 2, Takuma Wakasugi 3, Ritsuro Shirasaka 1, Koji Fujita 4

1 Tsuchiura Kyodo General Hospital, Ibaraki, Japan; 2 Takatsuki Orthopaedic Hospital, Tokyo, Japan; 3 Konan Hospital, Ibaraki, Japan; 4 Tokyo Medical and Dental University, Tokyo, Japan

Objective Hemi-hamate autograft arthroplasty (HHA) is a useful surgical technique for fracture dislocation of the proximal interphalangeal (PIP) joint. However, only few reports have focused on the relationship between autograft size and postoperative PIP joint range of motion (ROM). Methods Nine patients who underwent HHA for fracture dislocation of the PIP joint were included. Eight patients were men, and 1 patient was a woman. The mean age (range) of the patients was 41.6 years (17–68 years), and the timing of surgery was 90.2 days (8–382 days) after injury. The length of the joint surface of the contralateral proximal middle phalanx, defect size, and autograft size was measured from the lateral view of the preoperative/postoperative radiographs. Defect rate was calculated as the defect size divided by the length of the joint surface of the contralateral proximal middle phalanx. Reconstruction rate was calculated as the autograft size divided by the defect size. Clinical outcome was evaluated on the basis of postoperative ranges of PIP joint flexion and extension at 6 months after surgery. The correlations between PIP joint ROM and defect rate, reconstruction rate, autograft size, and timing of surgery were analysed using the Spearman correlation coefficient. Results The mean defect size, defect rate, autograft size, and reconstruction rate were 5.0 mm (3.7–7.0 mm), 49% (42–63%), 5.3 mm (4.2–6.9 mm), and 108% (77–128%), respectively. The mean postoperative PIP joint ROM at 6 months after surgery was 87 flexion (72–100) and −20 extension (−12 to −46), respectively. None of the patients showed re-dislocation of the PIP joint after surgery. A moderate negative correlation was found between reconstruction rate and range of PIP joint flexion (coefficient = −0.67, p < 0.05). The range of PIP joint flexion was limited, especially in patients whose reconstruction rate was more than 115%. No correlation was observed between the range of PIP joint extension and reconstruction rate. Furthermore, no correlation was observed between PIP joint ROM and defect rate, autograft size, and timing of surgery. Conclusions Previous reports about HHA were mostly focused on postoperative re-dislocation of the PIP joint or PIP joint extension. This study shows the possibility that relatively bigger autograft may cause PIP joint flexion disturbance. The precise mechanism of PIP joint flexion disturbance is unclear; however, the relatively larger autograft may cause the incongruity of joint surface, impingement during PIP joint flexion and inhibition of tendon gliding. Further detailed studies are needed to clarify the acceptable size of autograft because small autograft is a risk of re-dislocation after surgery. A detailed operative plan and precise procedure are required for HHA.

Michio Okamoto, Jiro Namba, Koji Yamamoto

Toyonaka Municipal Hospital, Toyonaka, Japan

Objective: We report clinical and radiological results of palmar fracture of the proximal interphalangeal (PIP) joint treated by pinning or bone suture with suture anchor. Methods: 10 palmar fracture-dislocations of PIP joint were included in this study. There are a central slip avulsion fracture and volar subluxations of PIP joint in all cases. Associated bony injuries are 4 volar fragment of the base of the middle phalanx and 5 collateral ligament avulsion fractures (duplicate inclusion). The mean age was 50 year-old (range, 13-73). There were three men and seven women, and the injuries involved the index finger (1 case), the middle finger (1 case), the ring finger (3 cases), the small finger (5 cases). Pinning was performed in 7 cases, bone suture with suture anchor was performed in 3 cases and in 5 of 10 cases, external fixation using dynamic distraction apparatus was performed as a combined use. We examined clinical (pain, range of motion in PIP joint) and radiological outcome. And we classified the fracture type into 4 groups with or without associated injuries (volar fragment and collateral ligament avulsion fragment) and examined the relationship between the presence or absence of associated injuries and the range of motion of PIP joint using the chi-square test. Results: At final follow-up (mean follow-up was 299 days) three cases experienced motion pain, mean flexion of PIP joint was 85° (range, 66-100), mean extension was -11° (range, -30-0). There was one case of suture sepsis at suture site of dorsal fragment with suture anchor, and one case of nonunion. They were needed reoperation. There was significant association between extension angle and presence or absence of collateral ligament avulsion fragment, flexion angle and presence or absence of volar fragment. Discussion: The volar fracture dislocation of the PIP joint are rare and a challenging injury, especially in case with associated injuries. In this study, we found the correlation between associated bony injuries and range of motion of the PIP joint. It is the result of univariate analysis because of the small number of cases. The accumulation of further cases is necessary to confirm this.

J Braga Silva

Pucrs University, Porto Alegre, Brazil

Objective: analyze the treatment and prognosis in outcomes of 108 patients with fingertip and nail bed injuries. Methods: we performed 138 nail bed reconstructions between 2000 and 2014; 23 patients were excluded due to less than 12 months follow-up. In our series, 32 patients underwent suturing of the nail bed (SNB); 25 patients underwent suturing of the nail bed associated with an osteosynthesis of the distal phalanx (SNBOst); 8 patients underwent microsurgical reconstruction with transfer of the nail complex of the second toe (MRN); 18 received conventional graft reconstructions of the nail bed (CGNB); 19 received a nail bed graft in the emergency room (NBGE) and 13 others, a delayed graft (NBDG). Twenty-seven patients also underwent additional surgery - 17 Tranquilli-Leali flaps, six homodigital direct island flaps and in four cases a homodigital reversed island flap. Results: Outcomes assessed were growth (0 = no growth; 1 = partial growth and 2 = normal growth), size (0 = less than 50%; 1 = between 25 and 50% and 2 = up to 25% of the size of the contralateral nail) and shape (0 = significant deformity on the horizontal and vertical planes; 1 = vertical deformity and 2 = no deformity) of the nail compared to the contralateral finger. The results obtained by the sum of scores were classified as good (5-6), regular (3-4) and poor. Results were considered good in all patients that underwent SNB and in those with SNBOst; in 4 MRN cases; and in 14 patients treated by CGNB, as well as in 11 patients who underwent NBGE and 7 patients who received NBDG. Regular results were obtained in 4 reconstructions performed by CGNB; in 4 cases of MRN; in 8 patients who underwent NBGE and in 6 patients who underwent NBDG. We obtained poor results in 4 patients that were subjected to NBDG. Conclusions: patients without soft tissue loss of the nail bed and those who underwent reconstruction of the entire nail bed showed improved outcomes in comparison to those who underwent simple suturing.

Inga Besmens, David Jann, Olga Politikou, Maurizio Calcagni, Thomas Giesen

University Hospital of Zurich, Department of Plastic Surgery and Hand Surgery, Zurich, Switzerland

Silastic spacer replacement for the treatment of destroyed finger joints due to degenerative, post-traumatic or rheumatoid arthritis has been well established for years. The use of silastic spacers in acute severely traumatized hand is commonly performed by few hand surgeons, but it is a practice still debated and controversial. Furthermore, the literature about it is extremely scarce. We present 8 joints acutely replaced with silastic spacers in 7 traumatic patients. There was 1 woman and 6 men with an average age of 42 years (range 25-80) 1 patients had suffered a crush injury, 4 had suffered sawing or milling injuries and 2 patients had suffered traumatic amputations of at least one digit through different trauma mechanisms. We replaced 2 MCP joints 6 PIP joints and no DIP joints. The finger operated were 1 thumb 4 index, 1 ring and 1 little fingers We reviewed all our patients with a follow up of at least 1 year, with the oldest patient seen after 20 years. We report the range of motion of the operated digits, the rate of infection, the rate of revision of the implanted silastic spacer and more in general the rate of satisfaction of the patients especially regarding the stability of the treated joints. In all patients of our study, healing was uneventful, with no infections and an acceptable range of motion. No patients complained about instability, even in the thumb joints. One silastic spacer fractured. This was an incidental finding: the patients had no complaint and did not want a secondary procedure. In our opinion, with the right patient selection, joint replacement with silastic spacers is a valuable alternative to arthrodesis in acute destroyed finger joints. The silastic replacement can be definitive or just temporary before a more refined joint reconstruction is performed, maintaining the mobility of the segment.

Young Hwan Kim, Jun Yong Kim

SoonChunHyang University Bucheon Hospital, Bucheon-si, South Korea

The purpose of this study was to compare the preoperative and postoperative outcomes of repair of complete rupture of the collateral ligament of the proximal interphalangeal (PIP) joint. A complete rupture of the collateral ligament was confirmed by radiologist using ultrasound or MRI. Seventeen patients underwent operative collateral ligament repair using an anchor. All patient was followed up for at least 6 months postoperatively. We evaluated clinical outcomes preoperatively and at 6 months follow-up: 1) range of motion of the PIP, 2) joint stability, 3) VAS score, and 4) Fusiform index of the PIP joint. There was no instability in the lateral stress test at 6 months follow-up. The ranges of motion of the PIP were not statistically different between preoperative and at 6 months follow-up. Patients had less pain and better cosmetic appearance of the PIP joint. Clinical Outcomes of operative repair of collateral ligament can provide good joint stability, functional recovery.

Sellakkuddy Selvaganesh, Tan Shoun, Shanmugam Bharathi Mohan, Vaikunthan Rajaratnam

Khoo Teck Puat Hospital, Singapore

Objective – Overcoming the traditional thoughts of soft tissue cover. Methodology – Series of cases analyzed together with regard to their acute problem, initial management, comorbidity, soft tissue cover, special wound care products and future plans. The data were retrieved from the electronic data system of our hospital. It is a retrospective analysis of record of 3 cases. Results – These three patients had bad infection needing HDU management in one case. Two patients were diabetics and one had poor control at the time of presentation. All underwent initial surgery on urgent basis. One was smoker and other one was an ex-smoker. All three had exposed bare extensor tendons in their hands after initial debridement, which would have needed some sort of flap cover according to the principles. All needed intravenous antibiotics and vacuum dressing. But we bypassed the acute situation of doing a flap cover in unstable patients. The soft tissue cover was achieved over the bare extensor tendons with the help of new wound care products such as vacuum assisted dressing. Even though the results are not excellent these experiences have given us lesion to relook our traditional teaching of no graft on bare extensor tendons on the hand. No patient is keen on a reconstructive surgery at the moment. Conclusions - Newer wound care products such as vacuum assisted closure have resulted in probably less morbidity and induced us to look back our traditional way of thinking pattern of soft tissue coverage needing flaps especially in compromised patients.

Sellakkuddy Selvaganesh, Cheyenne Kate Rebosura, Hannah Ng Jia Hui, Vaikunthan Rajaratnam

Khoo Teck Puat Hospital, Singapore

Objective – Fingertip injury is the commonest hand trauma to the emergency department needing various simple to complex reconstructive procedures depending on the patient factors. It is economically high demanding due to long technically demanding reconstructive procedures and cosmetic issues. We test a simple non-invasive technique for speedy healing and regeneration of the finger tips. Uniform application of protocols for the fingertip injuries. Methods – Three dimensional semi occlusive controlled healing environment after proper debridement improves the healing giving the desirable outcome faster than other reconstructive techniques. This method gives satisfactory outcome with faster surgical time in less expensive and easy way. It is a prospective interventional study which is ongoing. The data were collected from the clinical record and operation notes. The analysis done with excel spread sheet. The patient satisfaction, pain and clinical outcome were assessed. Results – The majority were the males from employees who were injured while at workplace. The average healing time was from 2 weeks to 3 weeks. Patient satisfaction was better with regard to pain and cosmesis. Patients were happy than they expected worse outcome which was explained in the emergency department at the first contact. No new method related complications or non-compliance reported. Conclusion – Our three dimensional healing environment gives simple way of treating fingertip injuries, giving faster recovery and regeneration giving rise to good cosmetic outcome. Faster healing time enables them to start work soon. It is economically advantageous. It gives universally similar treatment protocol for all the patients who were treated.

Yukinori Hayashi 1,2, Hiroyoshi Hagiwara 1,3, Takashi Ajiki 1, Akiko Takaiwa 3, Saori Mita 3, Katsushi Takeshita 1

1 Jichi Medical University Hospital, Tochigi, Japan; 2 Shin-Oyama City Hospital, Tochigi, Japan; 3 Tochigi Medical Center Shimotsuga, Tochigi, Japan

A 16 year-old female was introduced to our institution, who was suffering from the pain and contracture of the right ring finger. She had been hit her right hand by a ball 1 month before while playing dodge ball game. Soon she visited another hospital where conservative treatment was conducted. A splint with DIP joint hyperextended had been applied. At the first present to our institution, radiograph and CT revealed not only malunited mallet fracture but also volar DIP joint subluxation. It was seemed that the articular involvement of the initial fracture had been approximately 50％. ROM of the DIP joint was 10°/10°. After 3 weeks’ treatment of rehabilitation, ROM of the DIP joint was 35°/10° and TAM of the ring finger was 0°/80°, 0°/85°, 0°/25°. Then surgical procedure was conducted. Osteotomy at the united portion using a chisel and extension block pinning procedure with direct wire fixation were applied. After splint immobilization for 2 weeks, ROM exercise was restarted. 5 weeks later all wires were removed. At 8 months after initial surgery, TAM of the right ring finger was 0°/85°, 0°/115°, 0°/45° and that of the left ring finger was 0°/85°, 0°/110°, 0°/65°. Grip strength was 27/25 Kg. Although radiograph and CT showed slight osteoarthritic change of the DIP joint, the subluxation was restored and she felt no pain. Malunited mallet fracture with subluxated DIP joint is uncommon. We conducted osteotomy and extension block pinning procedure. Favorable clinical outcome was obtained.

Ho-Jung Kang 1, Won-taek Oh 2, Sang-yun Lee 1, Jung Jun Hong 1, Il-hyun Koh 3, Kam Jinhwa 1

1 Gangnam Severance Hospital, Seoul, South Korea; 2 Severance Hospital, Seoul, South Korea; 3 Yong-in Severance Hospital, Yong-in, South Korea

Introduction: Sesamoid related trauma is rare injury. And Diseases including arthritis and tumor are even more uncommon, so publications about them are typically case reports or small series. The purpose of this study was to analyze the clinical results of 6 thumb sesamoid lesion patients treated with surgical treatment retrospectively. Materials and Methods: We retrospectively reviewed 6 patients who underwent surgical treatment from November 2009 to July 2016. Mean age at operation was 37 years (ranged from 19 to 61). Of these, four were diagnosed with sesamoid fracture, one with chronic radial sesamoiditis, and one with radial sesamoid avascular necrosis(AVN). Injury mechanism of fracture patients were composed with 1 direct compression injury and 3 hyperextension injury. Three patients had radial sesamoid fractures and one patient had ulnar sesamoid fracture. All trauma patients complained of pain in the thumb metacarpophalangeal area, and two of them complained of instability when they extended their thumb. Patient with chronic sesamoiditis complained of pain and limited range of motion. AVN Patient complained of pain and joint locking. Four cases underwent CT and five cases underwent MRI evaluation for diagnosis and detection injuries associated. Radiologic analysis, pain, range of motion and DASH score were assessed postoperatively. Results: In 4 fracture patients, open reduction and internal fixation with steel wire was performed in 1 case and the rest patients underwent sesamoidectomy. Associated injuries of surrounding structures were observed in patients with hyperextension mechanism. Radial collateral ligament injury was observed in 1 case and radial/ulnar collateral ligament with volar plate injury accompanied were observed in 1 case. Then surgical repair was performed for that associated injuries. Sesamoidectomy were performed in chronic sesamoiditis and AVN patients. Non-traumatic patients had no improvement in symptoms after conservative treatment for more than 6 months. All patients were followed up for more than 1 year after surgery. Imaging results showed that the joint congruency was maintained without subluxation in all cases. Clinical follow up showed good results regarding VAS score, ROM and DASH score. About 10 degrees flexion contracture of thumb metacarpophalangeal joint occurred in 2 cases, but all patients did not feel any discomfort at the last follow-up and returned to their daily activities. Conclusion: Sesamoid-related trauma or disease is rare. After analyzing the injury mechanism and performing appropriate physical examination, we assessed the degree of damage of the sesamoid by X-ray including 45-degree oblique view and CT scan, and performed MRI scans to identify the associated injuries. Surgical treatment of sesamoid lesion showed good prognosis when treated properly. Keyword: Sesamoid lesion, sesamoid fracture, chronic sesamoiditis, sesamoidectomy

Teodor Stamate, Camelia Tamas, Radu Budurca, Ionut Topa, Ionut Atanasoae

University of Medicine and Pharmacy "Gr.T. Popa" Iasi, Department of Plastic and Reconstructive Surgery, Iasi, Romania

Objective High-pressure injection (HPI) injuries to the digit usually present as small benign wounds, which often mask the severe underlying trauma. These injuries require early recognition and prompt review by senior surgical teams as they represent surgical emergencies. The most commonly injected materials in HPI injury to the hand include paint, automotive grease, solvents, and diesel oil. Methods Case 1. A 31 yo young suffered an injury during injection of high-pressure heated plastic (polyvinyl chloride) with a hydraulic gun. Initial evaluation at 4 hours revealed a small entry point on the volar 4th MPJ, edema in Pirogov-Parona (P-P) and on the hand dorsum and 3 mm exist point on dorsum of 4th MPJ, pain , paresthesia and positive Kanavel sign. Exploration of the 4th finger, extended towards P-P with carpal tunnel release. Collateral digital neuro-vascular bundles (CDNVB) release and fragmented excision of the foreign material. Revision at 48 and 72 h, closure of wounds on 5th day. Good evolution and early functional reeducation allowed return to work at 3 months. Case 2. A 45 yo mechanic, at 5 h from injury with 3 small wounds –on the volar side of P1 3rd finger and two palmar with 3rd digit ischemia and high tissue infiltration with engine oil. Exploration from hand up to the proximal forearm, infiltrated tissue excisions, resection of the sinovial sheet down to P-P. CDNVB of the 3rd digit revealed lesions in continuity (ribbon sign) with microthrombosis with indication of amputation at 3rd MPJ level, fasciotomies of intermetacarpal spaces. At 48h revision dorsal hand skin excision leaving a defect exposing denuded extensor tendons. At 5 days, coverage of the defect with a inguinal McGregor pedicled flap .Movement possible at 5 weeks with flexion and extension of digits 2,4,5 by progressive functional reeducation. Patient returned to work at 3 months. Results There are some important factors to be adressed in HPI injuries like the chemical properties of the substance injected. nature of the injected fluid, volume, viscosity, systemic toxicity and pressure of injection determine the extent of tissue damage. High volume, low viscosity substances produce the most severe inflamatory response with diffusion along anatomical structure and even ischemia, sometimes far from entry point. Site of injection dictates the damage of structures and latency time from accident to treatment increase risk of amputation and damage to hand function. Appropriate broad-spectrum antibiotic coverage is mandatory. Surgical treatment must be performed immediately, with decompression and debridement under plexus block anesthesia. Foreign material and necrotic tissue must be early debrided with wide microsurgical exploration. Usually the wound cannot be closed by first intention and some reconstructive procedures may be necessary. Conclusions HPI injury causes only a small lesion in the skin but with severe damage to the underlying tissue. The severity of the lesion is determined by: the entrance level and the physical-chemical properties of the injected substance (type, viscosity, volume), the pressure of injection. In cases of digital acute ischemia amputation remains an option in emergency.

Keikichi Kawasaki, Hiroki Nishikawa, Tetsuya Nemoto, Takeshi Sakai, Yutaka Kubota , Shoutarou Kamijou, Katsunori Inagaki

Department of Orthopaedics, Showa University, Japan

Purpose 】 Scaphoid nonunions are commonly treated by fixation using Headless screws (HS). Until recently we performed pedicled-vascularized bone grafts (VBG) for 76 cases of recalcitrant scaphoid nonunions, fixed by HS. In a few cases it was difficult to achieve good fixation with HS. Fixation was unsure especially when there was a large bone defect after correcting DISI deformity or in cases of failure after primary screw fixation. Recently in our country, locking plate (LP) for scaphoid by APTUS hand (MEDARTIS company) became available. We report a treatment result of VBG used with LP for recalcitrant scaphoid nonunions. Method】 In our department, we have performed vascularized bone graft fixed with LP for scaphoid nonunion in ten cases since 2015. All patients were men, the average age at the time of operation was 33.4, and the average period of postoperative follow-up was 10.6 months. The site of scaphoid nonunion was 8 cases in the waist and 2 cases in the distal part. The average period to operation from injury was 130 months. 7 cases had DISI deformity with Radio-Lunate angle of more than 15 degrees, 4 cases were long-standing untreated cases of more than ten years, and 3 cases were nonunion cases – 2 after primary fixation and one after secondary fixation for nonunion - with HS. A LP was set on the volar side of the scaphoid, and the grafted bone was harvested from dorsal radius by Zaidemberg’s procedure and was inserted to the bone defect after curettage on the radial side. We investigated union rates, radio-lunate angle, range of motion of flexion and extension, grip strength, and evaluated overall scores. Result 】 Bone union was obtained in nine cases, and the correction of Radio-Lunate angle (difference at the time of pre-operation and the last examination) was 14.9 degrees. For the range of motion, the mean dorsi-flexion was 62.2 degrees, the mean volar-flexion was 48.9 degrees, the mean grip strength (% of normal) was 86.8%, and Mayo wrist score was 83.5 points. Complication of plate removal was in 4 cases. The average of size of the grafted bones was 64.7 cm2. Discussion 】 A new locking plate system for scaphoid fracture and nonunion may increase stability and union rate for recalcitrant scaphoid nonunions, even though the surgical technique is demanding and removal of the plate is necessary. The operation of VBG fixed with LP for recalcitrant scaphoid nonunion can become a useful procedure with careful consideration of indication.

Jose M. Méndez-Lopez 1 2, Juan M. Gomez-Fernandez 1, Eva Rodriguez-Ferrer 1, Vinyet Reverter 2

1 Hand Unit, MC-Mutual, Barcelona, Spain; 2 Hand Unit, Universitary Hospital Sagrat Cor, Barcelona, Spain

INTRODUCTION For the treatment of Bennett's dislocation fracture, numerous techniques have been described. From reduction and casting to open synthesis. Berger in 1999 described the technique for performing a correct arthroscopic assessment of the CMC thumb's joint by using two portals. Culp and Johnson JW published in 2010 " arthroscopically assited percutaneaous fixation of bennet's fracture". MATERIAL AND METHODS we show three clinical cases of Bennett's fracture-luxation. Two men and one woman, all young patients. In all three cases, the surgery was performed under anesthesia with axillary block,apllying ten-pound traction on the affected thumb. We proceeded to perform the TMC arthroscopy with of 1.9mm optics through radial dorsal and ulnar dorsal portals and using a hook, joint reduction of the fracture was proven. In two cases synthesis was performed with cannulated screw under arthoscopic control and the other required two 1.6mm screws after insertion of two K wires. Immobilization was maintained with a cast splint until the removal of stitches, initiating the physiotherapy afterwards. RESULTS The three patients returned to work before the month of surgery. Restarting their sports activities after two months, with full CMC mobility. In the 9 months control they were all asymptomatic, the patient in which the noncannulated screws were used required removal of the osteosynthesis material 6 months after the surgery. DISCUSIÓN The surgical technique is simple, it allows to see the correct reduction of the joint fragment, as well as to evaluate accompanying lesions either cartilaginous or ligamentous. It allows the joint hematoma to be evacuated, as well as the removal of small free bodies and checking the synthesis of the joint. The clinical results are comparable with other treatments using less immobilization time (pomares). We believe that it is a reproducible and simple technique that can improve the reduction of the joint fragment, which would condition a better result in the long term

Moritz Fischer 1, Joachim Ganser 2

1 Department of Hand and Plastic Surgery, Kantonsspital Frauenfeld, Switzerland; 2 Department of Hand and Plastic Surgery, Kantonsspital Münsterlingen, Switzerland

Objectives: Carpometacarpal fracture-dislocations are demanding injuries. They affect the tendon-mechanics and deteriorate the hand function as a whole. In contrast to other hand fractures, it is rather the restoration of skeletal length and axis than the anatomical reconstruction of the joint surface which determines the outcome of treatment. Method: This presentation is based on a retrospective clinical study of 8 patients, at least 6 months after primary operation. All patients suffered from closed intraarticular fracture-dislocations of carpometacarpal joints, including 2 axial carpal dislocations, 2 Rolando-fractures and 1 complete Bennett-fracturedislocation. With one exception, all external fixators were administered after closed reduction, mainly by distracting the fragments and relying on ligamentotaxis. The technique used in this study rests upon two very established principles: First, the very established transfixation of fracture fragments to stable, non-fractured neighboring bones as advocated t.e. by Iselin. Second, the multidimensional, quadrangulated construction of a conventional external fixator. 4 (external fixator-) pins are inserted bicortically into the bone: 2 pins into the unstable, dislocated column, 2 pins into the neighboring stable column. These four corners are linked by 4 (external fixator-) rods. After coupling, but not yet fixing, this quadrangulated frame, the fracture-reduction is accomplished by closed means. The already inserted but not yet tightened external fixator allows for the full use of the operators both hands during this sometimes powerdemanding task. While the operator holds the reduction, the assistant tightens the 8 clamps, connecting the pins and rods, and thereby finishes the whole procedure. The external fixator is left in place for 6-7 weeks. After this period, it is extracted in local anesthesia. Results: There were no infections, no loosening of the material and no secondary dislocations. All fractures healed with irregularities of the joint surfaces. The patients returned to their original occupation within 52 to 112 days, mean 92 days. Conclusion: The advantage of the procedure relies on its simplicity: The reduction can be achieved and corrected up to the end without any repositioning of osteosynthesis material. Furthermore, the operator can focus on fracture reduction without worrying about the osteosynthesis. This method of operating sequentially instead of in parallel takes pressure off the surgeon who is treating these demanding injuries.

Alexander Zolotov

Far Eastern Federal University, Vladivostok, Russia

Objectives. Bone grafting is a common surgical procedure for the treatment of bone defects and deformities. Bone graft size and shape should be equal to size and shape of the bone defect for stability and contact with bone fragments. Very often bone defects have complex geometric shapes such as a nonsymmetrical cylinder, cone or cube. Therefore it is quite difficult to prepare the bone graft equal to the exact shape and size of the defect. To optimize this stage of the operation some surgeons offer to use an individual template as a copy of the bone defect made from silicon block or bone cement (Toh, 2007; Pulgar et al., 2017). In our practice we prepare the individual template from sterile aluminum foil. Methods. Bone grafting with the aid of an aluminum foil template was applied in the treatment of 46 patients aged from 14 to 53 years old with defects and/or deformities of the bones and joints of the upper extremity: fingers (6), metacarpal (4), wrist (23), forearm (11), distal humerus (1), glenoid (1). After exposing the place of malunion (nonunion), correction of the deformity and bone fragments fixation the surgeon measured the size and shape of the bone defect. The surgeon then prepared the template according to the size and form of the bone defect. The template was formed from sterile aluminum foil. The surgeon manipulated the piece of foil as a piece of plasticine and molded the template. The foil template was fitted to the defect to achieve close contact with the bone. The bone graft was taken equal to or little bit larger than the template. The bone graft was then compared with the template and molded with bone forceps if necessary. The prepared graft was then inserted tightly into the bone defect. Results. Using the template made preparation of the bone graft much easier in all cases. Wound healing was uneventful in 45 cases. Superficial infection was revealed in one case after bone grafting for the 4th metacarpal defect. Wound inflammation was eliminated with the aid of antibiotics. Delayed bone healing was revealed after bone grafting in two cases – 2nd metacarpal bone defect, scaphoid nonunion. Nonunion at the level of the proximal phalanx of the middle finger required reoperation – bone grafting once more with the bone chips. No specific complications connected with use of the foil were revealed. Aluminum foil is cheaper and more affordable in comparison with silicone block and bone cement. Foil sterilization is easy. The template fabrication process takes less than one minute. The template can be made smaller (with scissors) or larger (add to the piece of foil) if needed. Once prepared, the template is durable and keeps its shape. Conclusion: The method of the bone grafting with the aid of an individual foil template helps the surgeon perform the planned surgical procedure correctly.

Franco Bassetto, Regina Sonda, Andrea Monticelli, Cesare Tiengo

Plastic Surgery Department, Padova, Italy

Objective Perineural and peritendineous scar formation is responsible for loss of function, pain, loss of gliding in peripheral nerve and tendon surgery. Collagen synthesis rate is considerably increased during the 4th week. Neurolysis and tenolysis are often required to restore the range of motion (ROM) and to reduce pain, but outcomes are not always excellent. In order to prevent re-operations, anti-adhesion gels have been developed. Carboxymethylcellulose Gel has a long decomposition, compared to other anti-adhesion barrier gels, releasing Polyethilene Oxyde (PEO) and maintaining an anti-inflammatory effect. According with its properties, we reviewed our patients treated with Dynavisc, evaluating the rate of re-operation and clinical outcomes. Matherial and Methods 75 patients have been treated with Dynavisc gel from 2015 and 2016. 50 were tendon fresh injuries or tenolysis, 25 were fresh major nerve injuries, neurolysis or carpal tunnel syndrome recurrences. We evaluate at 12 months of follow-up, the rate of tenolysis or neurolysis compared to the period from 2013 to 2014 on a similar group of patient. Clinical evaluation of ROM and pain intensity has been performed. Results In the group of tendon injuries, the incidence of loss of ROM and subsequent tenolysis has been showed lower in patient treated with Dynavisc than patients treated otherwise, but with no statistically significant difference. ROM at 12 months has been shown similar in both groups after 12 months from the last surgical operation. In the group of nerve injuries, the rate of tenolysis has been reduced, with no statistically significant difference. The pain and paresthesias have been reduced in patients treated with Dynavisc. Conclusions CMC-PEO gel can reduce peritendineous and perineural scar tissue. Long term hydrolysis (> 30 days) can protect, in our opinion, the surgical site from fibroblasts migration and differentiation, during an important period of collagen synthesis (4th post-operative week), expecially compared with other faster readsorbable products. Our experience suggested a lower incidence of re-operation in peripheral nerve and tendon surgery and better clinical outcomes.

Sang Eun Park, Bong Seok Choi, Won Ha Hwang

Daejeon St. Mary's Hospital, Daejeon, South Korea

Objective : To introduce new percutaneous fixation method of the extra-articular proximal phalangeal base fracture. Methods : Surgical technique : With the proximal phalangeal joint of the involved finger fully flexed, 1or 2 0.065 or 0.045 inch K-wires were inserted through the proximal phalangeal head using drill. Once the insertion was made, further advancement across the fracture site to the articular surface of proximal phalangeal base was made using mallet to avoid iatrogenic thermal injury to articular cartilage of the proximal phalangeal head. The thickness and number of the K-wire was selected to fit the intramedullary space well to supply maximum fracture stability. During the advancement, longitudinal traction of the involved finger was made to maintain reduction. Once the intramedullary K-wire came up to the articular surface of the proximal phalangeal base, metacarpophalangeal joints were flexed up to 45 degrees and the distal end of K-wire was tapped using mallet to penetrate articular cartilage and dorsal skin of metacarpophalangeal joint. Once the proximal end of K-wire was protruded through dorsal skin, it was secured with a manual wire holder. The wire was then hammered until the image intensifier confirmed that the distal end of the wire was just within the subchondral bone of proximal phalangeal head, clear of articular cartilage. The wire was bent back distally from the point of bending. Dorsal splint was applied with the metacarpal phalangeal joint 45 degrees of flexion. K-wires were removed at postoperative 4 weeks, and physiotherapy was initiated. Results : 30 fingers in 22 patients were treated with this method. All fractures were united at the average of postoperative 5.6 weeks (range, 5-8). At the final follow up, range of motion of the proximal interphalangeal joint and metacarpophalangeal joint were reached to 100% and 98% compared to contralateral side respectively. In 2 fingers, superficial pin site infection at dorsal skin of metacarpophalangeal joint occurred but resolved with K-wire removal. Conclusions: Based on our experience, retrograde percutaneous intramedullary K-wire fixation is a simple and acceptable alternative method for the treatment of extra-articular proximal phalangeal base fractures. Especially this method is very useful for multiple digit proximal phalangeal base fractures. Key words ; Proximal phalangeal base fracture, Retrograde, Percutaneous, Intramedullary

Yoshiki Okuda 1, Masahumi Matsuki 1, Maki Asada 2, Hiroyoshi Hujiwara 2

1 Kyoto Second Red Cross Hospital Kyoto, Japan; 2 Department of Orthopaedics, Kyoto Prefectural University of Medicine Kyoto, Japan

Objective. Internal fixation of volar plate avulsion fractures caused by hyperextension injury are sometimes difficult because of the small size of the fragment. We report the short-term results of a new method of open internal fixation by the pull-out method using a polyamide suture. Methods. There were 17 patients 17 fingers who underwent surgery for volar plate avulsion fractures using this method, between January 2008 and September 2016. This included 7 men and 10 women, with an average age at time of surgery at 28.9 years (range 12 to 40). The fingers involved were 2 index, 2 middle, 3 ring and 10 little fingers. The mechanism of injury was falls in 8 and sports activity in 9. The average timing of surgery was 7 days post injury (range 1 to 12 days), and the average follow-up period was 7.8 months (range 4 to 9 months). The surgical indication was either a displacement of 2mm or more or rotated displacement. The surgical method consisted of a volar approach, where the reduced fragment was fixated by pulling out a 2-0 polyamide suture to the dorsal side, then tied over a button. A dorsal splint was applied for 2 weeks, then rage of motion exercises were initiated. The suture button was removed 1 month after surgery. Results. Bone union was achieved in all cases. The average range of motion of the proximal interphalangeal joint was -5 degrees extension and 94 degrees flexion at the final follow-up, with a 95% total arc of motion compared to the unaffected side. Discussion. Conservative therapy for volar plate avulsion fractures of the proximal interphalangeal joint is advised in stable fractures or where the fragment is very small. However, in cases of larger or displaced fragments, restricted range of motion or osteoarthritis may occur if proper treatment is not administered. Surgery can sometimes be challenging because there is no ideal material that can achieve good internal fixation without causing further fracture of the fragment. The polyamide suture does not twist like the pull-out wire, but has enough tensile strength to fixate the bone fragment with minimal invasion, not to mention easy removal. In conclusion, the pull out method using a polyamide suture is an effective option for the treatment of volar plate avulsion fractures.

Alexandru Georgescu 1,2, Ileana Matei 1,2, Octavian Olariu 2

1 University of Medicine Iuliu Hatieganu Cluj Napoca, Romania; 2 Rehabilitation Hospital Cluj Napoca, Romania

Objective “Spaghetti wrist” defines complex volar wounds involving more than three major structures; it is a very severe lesion and with a significant morbidity. The lesion becomes more severe in association with skin defects. This paper will present the results in 49 patients operated in a 10 years period, in terms of functional recovery and socio-professional reintegration. Materials and Methods We analyze the patients operated in a ten years period for pure “spaghetti wrist” lesion, or associating a skin alone or a complex soft tissue defect. The patients were analyzed with regard to the mechanism of injury, type of surgery, functional recovery and socio-professional reinsertion. Results In a ten years period, 49 patients (35 men and 14 women), with an average age of 34 were operated for a “spaghetti wrist” lesion. From those, 37 presented a pure “spaghetti wrist” lesion and 12 associated also a soft tissue defect, of more anatomical elements in 7 cases and of skin alone in 5 cases. The mechanism of injury was work related in 35 cases, traffic accidents in 2 cases, home accidents in 10 cases, and suicidal attempt in 2 cases. At least 3 tendons were injured in all the cases. The median nerve was injured in 19 cases, the ulnar nerve in 13 cases, and both of them in 17 cases. The radial artery was lacerated in 11 cases, the ulnar artery in 19 cases, and both of them in 7 cases. A complex soft tissue defect, including skin and tendons/arteries/nerves was registered in 7 cases, and a skin defect alone in 5 cases. All the cases were solved in emergency as an all-in-one procedure. A free flow through simple or composite flap was used in 7 cases, and a propeller perforator flap in 5 cases. The range of motion was very good in 31 patients (8 from those associating defects), good in 12 patients (4 from those associating defects), and fair in 6 patients. The sensory recovery was very good in only 21 patients, good in 19 patients, and only protective in 9 patients (two-point discrimination of 2-5mm in 21 patients, and of more than 6mm for the others). Conclusions The outcomes after repair of both simple spaghetti wrist or associated with soft tissue defects are similar if a careful emergency all-in-one procedure is done. The overall functional outcomes after repair are generally good, allowing the socio-professional reintegration of the patients.

Silvia Bernuth, Michael G Jakubietz, Fabian Gilbert, Rainer H Meffert, Raphael G Jakubietz

Department of Trauma-, Hand-, Plastic and, Reconstructive Surgery, University of Wuerzburg, Wuerzburg, Germany

Objective: Although the injury of the radial collateral ligament accounts for only a low percentage of the ligamenteous injuries of the thumb metacarpophalageal joint, lack of treatment may result in chronic instability, pain and degenerative arthritis. Primary repair is rarely done, more often patients present with a chronic instability. A radial equivalent to the Stener-lesion might be the reason that conservative treatment is unsuccessful. The radial Stener-like lesion has been described in very few cases. We report on an acute case of radial ligament rupture and a cadaver study to delineate specific anatomic findings. Methods: A 26 year old man presented after luxation of the MCP joint of the thumb, which was reduced. An instability of the radial collateral ligament and palmar subluxation on plain radiographs was present. In surgery the distally avulsed end of the RCL was proximally retracted lying superficial to the aponeurosis. A cadaver study was conducted to investigate the exact anatomic relation of the RCL and abductor aponeurosis Results: After transosseus suturing the patient was splinted for 6 weeks. No instability developed after 6 months. In a cadaver study we found that the abductor aponeurosis on the radial side forms a proximally more acute hood over the MCP joint. Regarding the extension of dislocation required to induce a Stener lesion no definitive comparison to the ulnar collateral ligament can be made. Conclusion: Acute ruptures of the RCL of the thumb rarely receive operative treatment in comparison to the UCL rupture. However chronic instabilities often present a surgical challenge. One of the reasons might be that these injuries are overlooked. In the current case an operative exploration revealed a Stener like lesion. If treated conservatively, this will lead to a chronic instability and subsequent osteoarthritis. We believe that in cases of acute rupture of the RCL physicians need to have a high index of suspicion and apply the same diagnostic tools to rule out a Stener type lesion.

Saskia Kamphuis 1, Liane Kecker 1, Cornelia Merki-Künzli 1, Julia Sproedt 1, Abdul Rahman Jandali 1, Dirk Schaefer 2

1 Department of Hand- and Plastic Surgery, Cantonal Hospital Winterthur, Winterthur, Zurich, Switzerland; 2 Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland

Objective Base of finger metacarpal fractures or fracture-dislocations concern mostly young and physically active males. It is a relatively rare injury. However, when treated inadequately, it will cause substantial long-term complaints. The aim of this study was to assess operatively treated patients by closed reduction and percutaneous Kirschner wire fixation with a minimal follow-up of two years, regarding functionality and residual pain complaints. Methods We invited all patients who sustained a base of finger metacarpal fracture and who were treated operatively in our outpatient clinic with a follow up of at least two years. After a retrospective patient file investigation concerning trauma- and postoperative data, we completed a subjective outcome assessment and a quick DASH questionnaire. We also performed a physical examination with range of motion assessment and measured grip- and pinch strength. Results Thirty base of finger metacarpal fractures in 23 patients were included in the study, twenty male and 3 females. Mean follow up was 5.7 +/- 2.3 years, the mean age was 34.8 +/- 16.3 years. The fifth metacarpal was injured in 22 cases, the fourth metacarpal in 5 cases, the third metacarpal two times and the second metacarpal was involved once. Five patients suffered a combination of at least two injured metacarpals. Of the 23 patients, 18 injured their dominant hand. Cause of the fracture was a fall in 16 cases, a motor-vehicle accident in 6 cases and another mechanism in 8 cases, were most patients punched or crushed their hand. Median number interquartile range of days until diagnosis was 0.5 (0-2.0), median number of days until operation was 7.0 (5-10). All patients were treated by closed reduction and percutaneous Kirschner wire fixation followed by brace or cast immobilization. In all cases, the percutaneous wires were removed in the outpatient clinic after 6 weeks. In two cases, a slight redness and swelling around the pin tract was seen without a deeper infection and in one case, a CRPS I was treated. At follow-up, two patients described a persisting dullness in the operation area. Subjectively, the pain score patient experienced in daily life has a median of 0 (0-0). The maximum pain score the patients experienced was 0 (0-5). Subjectively, the regained strength is 10 (9-10) out of a maximum of 10. The median quick DASH score was 0.0 (0.0-2.3), for the work 0.0 (0.0-0.0) (n= 21) and the hobby module 0.0 (0.0-0.0) (n= 17). Range of motion in the wrist, MCP, PIP and DIP joints did not differ significantly between injured and non-injured extremities. All patients could reach full fist formation. Grip- and pinch strength showed no significant difference between affected and non-affected hands. Conclusion In our patient population, long term follow-up shows good results with very few complications. Although our study is of a descriptive nature, it is relevant because of the high impact the functional outcome and residual pain complaints may have on the ability to work and the quality of life of young and active patients and supports the chosen operative method.

Gero Meyer zu Reckendorf, Jean-Claude Rouzaud, Amirouche Dahmam

Institut Montpelliérain de la main, Montpellier, France

This study concerns pulley ruptures in high level climbers, all operated on by one surgeon with the same reconstruction technique, and postoperatively managed with the same rehabilitation protocol supervised by one physiotherapist. Ten patients underwent surgery for A2 pulley reconstruction with the Bunnel technique with three loops (Palmaris longus graft). The same technique was used in all patients by one surgeon followed by physiotherapy and an orthosis from the first postoperative day with passive mobilization, active from the third week with permanent protection by a ring. The follow-up include total active motion, recording strength (Jamar) and the Buck-Gramcko score to evaluate the climbers. The TAM score was about 248°. Mean grip strength was 38 kg for the injured hand in comparison to 42 kg for the opposite side. The Buck-Gramcko score showed a 100% result, qualified as “excellent”. X-ray evaluation of the first phalanx showed some bone resorption in 3 cases and cortical thickening in 1 case. The ultrasound checkuo on the operated finger found good resistance of the neo-pulley without any bowstringing of the tendon, even after 10 years of follow-up or more. The mean strength of the injured finger was 20% better than the opposite side. We noted a slight extension deficit, especially on the distal interphalangeal joint. When using the Buck-Gramcko score, the result was qualified as “excellent” in 7 out of all 10 patients. 43% of the climbers had improuved their level of climbing postoperatively. The DASH-score was 0 for 72% of climbers. The Bunnel technique showed no significant changes in the periosteum of the first phalanx. Pressure resistance of the neo-pulley was of good quality and did not decrease with time. Contrary to other studies with the finger in flexion position, the extension position of the operated finger in the postoperative phase allowed effective protection of the reconstructed pulley. Early mobilization avoided adhesions of the flexor tendons and extensor apparatus dorsally. The surgical technique accompanied by our specific rehabilitation protocol allowed the climbers to resume, at least, the same level of climbing and, in several cases, a higher level than before the accident. No complications were noted in this series.

Marcello Cunha, Jose Pistelli

Einstein Hospital, Sao Paulo, Brazil

40 cases of fracture of the metacarpal treated with rods intramedular all cases have evolved into consolidation

Francisco Cuadrado Abajo, Olga María Vélez García, María de los Ángeles de la Red Gallego, Manuel Rubén Sánchez Crespo, Higinio Ayala Gutiérrez, José Couceiro Otero, Fernando Javier del Canto Álvarez

Marqués de Valdecilla Universitary Hospital

Background and objectives Metacarpal-phalangeal instability (MCP) of the second finger in an infrequent pathology associated with rheumatic diseases. The surgical treatment of this condition is not well defined yet. Our objective was to evaluate the clinical result of the ligamentoplasty with flexor carpi radialis hemitendon (FCR). Matherial and methods We present a clinical case of a 34-year-old woman who was referred to our consult for instability, which conditioned her work activity, at the level of the MCP joint of the 2nd finger due to incompetence of the radial collateral ligament. The patient did not report a history of rheumatic diseases or trauma at that level. Clinical examination revealed a positive ulnar stress test at the level of the MCP joint of the 2nd finger at 90º of flexion and in full extension. On plain radiographs, subluxation of the joint is observed. An MRI is requested, which aims for a complete rupture of the radial collateral ligament. The patient is offered a surgical intervention consisting of a FCR hemitendon ligamentoplasty. The objective of this technique is to reproduce the anatomy of the ligamentous complex (collateral radial and accessory ligaments). It is important to be able to control with precision the tension that we will give to the plasty both in flexion and in extension, that is why we will use interferential screws instead of anchors. A dorsal-radial approach of the MCP joint was performed, opening the joint capsule and identifying the palmar plate. Two transosseous tunnels parallel to the joint were made in the 2nd metacarpal (MTC) and the proximal phalanx (PF). After this, the V-shaped ligamentoplasty was slipped through the transosseous tunnel of the 2nd MTC so that we obtained two bundles, which are responsible for reproducing both radial collateral and accessory ligaments, then this tunnel was blocked with an interferential screw (screw type Swive lock). The first one would be in charge of replacing the radial collateral ligament and it was slipped through the transosseous tunnel carved into the PF and blocked with another interferential screw. The second of the bundles replaced the accessory ligament and was sutured to the palmar plate. The stability of the ligamentoplasty in flexion and extension was checked. Afterwards, the joint capsule was closed Results The clinical result has been satisfactory. On examination, the MTCF joint is stable and with full range-of-movement. The patient has resumed her work activity. The patient was referred to the rheumatologist, who indicated an inmonological study that diagnosed a psoriatic arthritis. Conclusions The ligamentoplasty for the chronic rupture of the radial collateral ligament of the MCP joint of the second finger is an original technique whose design is based on reestablishing the anatomy of this ligamentous complex. The clinical results after 6 months of the intervention are satisfactory, although long-term controls will be necessary.

Laura Velasco-González, Laura Noguera-Alonso, Luis Trigo-Lahoz, Julio de Caso-Rodriguez, Ariadna Da Ponte-Prieto, Claudia Lamas-Gómez.

Hand Unit and Upper Extremity, Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain

Objectives: This study analysed the systemic conditions and local factors associated with the failure of bone fracture healing. The aim of our study was to identify the anatomical and epidemiological risk factors for ulnar nonunion. Methods: We retrospectively reviewed a cohort of ulnar fractures treated surgically with open reduction and internal fixation (ORIF), during a period of 10 years (2007-2016). We identified 211 ulnar fractures, 16 distal, 52 diaphyseal, 143 proximal. All patients had a minimum follow-up of 1 year. We defined non-union if there was no radiological consolidation of the fracture after this period, and we classified them ac- cording to Weber classification. We assessed risk factors like: fracture site vascularity, surgical treatment technique, biological factors of the patient, and the fracture’s mechanism. Data were analysed using SPSS software system version 21. Multivariate re- gression analysis was performed to assess independent risk factors of ulnar non-union. Chi square test or Fisher exact test was used to compare categorical measurements. Statistical significance was considered as p < 0.05. Results: We found 17 ulnar non-union (8,1%), 13 diaphyseal and proximal ulna (6,2%). The 94% were hypertrophic non-union and 6% of atrophic non-union. There were 116 male and 95 female. The mechanism of the fractures was high-energy traumatism in 30%. The 30% of patients smoked, 10,4% have diabetes mellitus, the 40,7% have vascular pathology. The fractures were open in 15,2%, the 72,5% were isolated ulnar fracture, the 25,6% were comminuted. We analyzed the ORIF and the 93,8% were well done (according to AO principles). We obtained statistically significant results in the relationship of high-energy injuries (p=0,0001), comminution (p=0,0001) and subopti- mal fixation of the fracture (p=0,013), with the risk of developing nonunion. We didn’t find statistically significant results in relation to the others clinical data analyzed. Conclusions: Our results showed that a hipovascular areas, high-energy injury, comminuted fracture, and suboptimal fixation of the fractures are risk factors of an ulnar nonunion.

Barbara Igielska-Bela 1,3, Agnieszka Jackiewicz 2, Marek Krzemiński 1

1 Szpital Specjalistyczny w Kościerzynie, Poland; 2 Swissmed Hospital, Gdansk, Poland; 3 Medical University of Gdansk, Poland

Objective: Traumatic loss of hand fingers are common cases in Emergency Department. Not in every case is possible to rescue or replantate the finger. Sometimes is necessary to make an amputation. It is hard decision to make, especially in the thumb. We can reconstruct the thumb using toe, but there is also described method to lengthen metacarpal. In this study we present 2 cases of using such method. Methods: 2 patients with traumatic thumb loss after working with circular saw were admitted to Orthopaedic Department in Koscierzyna. First they underwent operations of saving the thumb, but owing to the lack of neurovascular bundles they had to have an amputation. Because of good range of motion in CMC joint we decided to make two-step metacarpal lengthening. In first step they have deepened the thumb web space. The second phase was osteotomy of the metacarpal bone and implantation of external fixator. Lengthening rate was 0,5mm twice a day. Results: After 7 months of lengthening, this procedure adds approximately 2 cm functional length to the thumb, giving patients possibility to grab things in their hands. Conclusion: Distraction osteogenesis of I metacarpal bone, in cases of the thumb amputations, can add some functional legth to the thumb.

David García-Romero, Angeles García-Frasquet, Isabel Nieto

Hospital Universitario Virgen Macarena, Sevilla, Spain

Purpose: To evaluate the use of conical burs rather than oscillating saw to make an extraarticular osteotomy in the treatment of malunited unicondylar fractures of the phalanges. Methods: An extra-articular osteotomy was done with conical burs to correct the deformity resulting from malunion of a unicondylar fracture of the phalanges. A closing wedge osteotomy that was stabilized with Kirschner wires accomplished realignment of the joint. We retrospectively reviewed the results of our technique in 4 patients, in each one we evaluated radiographic healing, correction of angulation, digital motion, postoperative complications, current level of pain, and overall satisfaction with the procedure. Results: All of the osteotomies healed without malunion, with an average angular correction of 20º. We found an improvement of proximal interphalangeal joint motion and total digital motion. We didn’t found postoperative complications. The DASH score improved and at final follow-up all our patients had returned to pre-injury work and sports activities. Conclusions: This method of extra-articular osteotomy with conical burs is highly reproducible, avoids the risk of soft tissues lesions, and leads to a correction and improvement of realignment of the joint.

A Carmel, C Piccard

Laniado Hospital, Netania, Israel

objective: To show that closed proximal-distal "free hand" imn of border metacarpal shaft and neck fractures by a single or double bent k wires (modified" Fouche technique" or "internal splinting") is a safe and reliable technique Method: in 23 patients over 6 years period, we operated neck and shaft MC fractures by intramedulary bent 1.6-1.8 m"m k- wire inserted freehand with a T handle from the MC base. 1-2 k wires are used. Reported are clinical and radiological results and complications in 23 Pts. Results: All 23 fractures united within 1.5-3 months, there were no rotational deformities or significant residual angulation or shortening. There were few minor complications: 2 pin tract infections,, I pt. had partial loss of PIPJ extension, 1 had re-fracture over a retained k wire. Conclusion: the method is reliable for deformity correction up to 2 weeks from injury. It is readily available, low cost and relatively safe. A single k wire usually suffices. It is easier to perform in border metacarpals.

David Izadi, Alasdair Barrie, Kevin Williams, Vikram Devaraj, Andrew Watts, Christopher G. Wallace

The Royal Devon and Exeter Hospital, Exeter, UK

Objectives: In 2007, the British Society of Surgery of the Hand (BSSH) established minimum standards for hand units treating patients with hand trauma in the UK. A comprehensive audit of the hand trauma service at the Royal Devon and Exeter Hospital in 2016 demonstrated a gross failure to comply with these standards. We thus sought to introduce new measures to improve the service delivered to our hand trauma patients. Methods: In 2016 following the first hand trauma service audit at the Royal Devon and Exeter Hospital, a series of new measures were introduced with the aim of improving the service received by hand trauma patients. The emergency department’s direct access to the hand trauma clinics was removed and replaced by a consultant led virtual triage clinic run by the on-call consultant every morning. The hand trauma clinic was relocated next to the hand therapy clinic; all new hand trauma patients needing hand therapy were seen on the same day as their hand trauma clinic appointment; new patients slots were made available via triage, directly with hand therapists; dedicated hand trauma day case operating lists were established on three days per week; all new SHOs covering plastic surgery on-calls were taught the BSSH hand trauma standards at induction. One year after the first hand trauma clinic audit, the same audit was repeated for the same period in 2017, assessing our performance against 2007 BSSH hand trauma standards. Results: Following implementation of the above changes, 15 additional new, and 15 additional follow-up patients were seen in the hand trauma clinic each month, and 13 additional hand trauma patients were operated on each month. This resulted in an increased hand trauma generated income of approximately £29,000 per month. There was a 50% improvement in the number of patients seen in the hand trauma clinic within 5 days of their referral, a 35% improvement in the number of patients waiting less than 5 days for their surgery and 25 extra new cases per month referred directly to hand physiotherapy clinics. Open hand injuries were still being seen in the hand trauma clinic. Overall complaints due to repeat hospital visits and cancelled operations were down by 80%. Conclusions: This audit loop demonstrates how the introduction of a series of simple interventions can significantly improve the service delivered to hand trauma patients. There are still improvements to be made, especially in the management of open hand trauma, to comply with the standards set out by the 2007 BSSH hand trauma report. There was an increase in the revenue generated from the management of hand trauma patients, which can be used to further improve the infrastructure and the service delivered to our hand trauma patients.

Alberto Sgarbossa

Ist Clinico S. Anna, Brescia, Italy

Objective Reconstruction and stabilization of bony mallet finger with hook plate and shortening of post op immobilization. Methods 25 mallet fractures type Doyle IV b and IV c with dislocation of the fragment by more than 2 mm was treated in 3 years. Dorsal approach to the distal interphalangeal joint (H-shaped). Repositioning of the fragment stabilization with plate and screw. 15 days of post op immobilization , active and passive mobilization after 15 days. Results The 25 patients were followed up at a mean interval of 22 (12-42) months after surgery. Wound healing problems were not observed, transitory inflammation of skin were observed in 5 cases. Visible disturbances of nail growth were macroscopically seen in 2 patients and were resolved after plate removing. With Crawford clinical classification the results were excellent in 20 (80%), good in 3 (12%), poor in 2 patients (8 %). Conclusion Hook plate could be consider a valid alternative of other technique (Ishiguro), is simple to realize with very low x-ray exposition (final fluoroscopy control) and with simple control in reduction and stabilization of fragment, there no more local complications in relationship with other techniques, there’s no necessity to routinely medications like percutaneous pinning, the bone stability allow an early mobilization after 15 days. The limit was represented to necessity to remove the implant and were not advise to use in fifth finger. Frequently there’s a discomfort of the skin but this was resolved after removing.

Soo Min Cha, Hyun Dae Shin

Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea

Purpose: The purpose of this study was to evaluate the efficacy of antegrade intramedullary pinning performed for neck fractures with angulations of over 30° after failed conservative treatment during the subacute phase, and to compare the radiologic and clinical results with those of acute fractures with angulations of over 30° treated via the same procedure. Methods: Seventy-three patients with a fifth metacarpal neck fracture, were admitted to our institute between January 2010 and April 2015. Among them, 26 patients with an acute fracture (Group 1) and 27 patients with a subacute fracture after failed conservative treatment who met the inclusion/exclusion criteria were investigated. After surgery, improvements in angulation and shortening, visual analog scale (VAS) score for postoperative pain, Disabilities of the Arm, Shoulder, and Hand (DASH) score, active range of motion (ROM), and grip strength were evaluated and compared. Results: The mean durations of surgery from injury were 4.92 and 32.74 days in Groups 1 and 2, respectively, with a significant difference (p < 0.001). The preoperative amounts of angulation were 44.91° and 45.89° and the amounts of preoperative shortening were 3.31 and 3.44 mm, respectively, with no significant difference (p > 0.05). At the final follow-up, the angulation had definitively improved compared with before surgery in both groups (p < 0.001, both). However, there was a slight significant difference in terms of the residual angulation of 3.35° and 5.56° in Groups 1 and 2, respectively (p = 0.02). Preoperative shortening was restored in both groups (p < 0.001, both) and the final state of residual shortening were similar (p = 0.06). The final VAS scores, DASH scores, ROM, and grip strength were all satisfactory in both groups without any significant difference. Conclusions: The failed treatment group, which had been predicted to obtain proper union through the initial use of conservative treatment, provided an adequate indication for non-invasive antegrade pinning. Additionally, the current study suggested that closed reduction/immobilization remains a primary recommendation for angulated metacarpal neck fracture as long as careful observation is conducted if progression of the reduced fracture towards dorsal angulation is suspected.

Ciara Deall, Parkash Lohana, Khalid Qureishi, Garth Titley, Rajive Jose

Queen Elizabeth Hospital, Birmingham, UK

OBJECTIVE: Reconstruction of metacarpal defects following resection of tumours or trauma can be a challenging problem. In the presence of a healthy soft tissue bed, non-vascularised bone grafts such as from the iliac crest can be used with success. However when the soft tissues are not optimal, vascularised bone grafts are recommended. METHODS: We conducted retrospective analysis of seven cases, who underwent metacarpal reconstruction after trauma and tumour resection. The clinical details of the patients, operation detail, post-operative recovery and outcome were reviewed. RESULTS: Seven (n= 3 tumour resection and n= 4 trauma) cases were identified. All of the tumour cases and one case of trauma had reconstruction using non-vascularized bone grafts, predominantly from the iliac crest. The remaining three trauma patients had reconstruction using vascularised bone grafts. In all the seven cases the bone grafts healed with no resorption. One patient had a temporary paraesthesia along the lateral cutaneous nerve of the thigh following iliac crest bone graft. There was loss of one vascularised reconstruction due to subsequent invasive fungal infection. CONCLUSION: Vascularised bone graft can be a versatile option for composite reconstruction. The technique of harvesting, fixing bone graft and an algorithm for managing bone defects in the hand will be discussed.

Hazem Alfeky, Susie Yao, Jamie Barnes, Ahmed Abd El Gawad, Irfan Khan, Chris West, David Bell

Whiston Hospital, Liverpool, UK

Introduction: The mangled hand is one of the challenges hand surgeons face on a routine basis. Hand surgeons should have their options open when faced with such devastating injuries. Restoration of not only the look but mainly the function is crucial for post injury functional and psychological integration with society. Patients and methods: We present our experience with mangling hand injuries including sever soft tissue and bone loss that necessitates bone and soft tissue transfer through pedicled and microvascular techniques as the wound dictates. In our regional Plastic surgery service, we provide a great variety of post traumatic reconstruction for complex hand trauma cases with good functional outcomes. Results: Reconstruction through analysis of the defect and adopting staged approach when needed. Planning in reverse and respecting the early mobilisation principles usually dictates the sequence of the layered repair of mangled hand. Conclusion: Early tumour like surgical debridement combined with soft tissue coverage and anatomical layered repair through replacing like by like can improve the functional and aesthetic outcomes.

Jung Eun Lee 1, Young Ho Lee 2, Jihyeung Kim 2, Hyun Sik Gong 3, Goo Hyun Baek 2

1 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 2 Seoul National University Hospital, Seoul, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea

We treated 95 displaced mallet finger fractures using a modified two extension block Kirschner-wire (K-wire) technique. Of these, 18 (18.95%) were found to have an irreducible dorsal fragment and distal interphalangeal joint (DIJ) incongruence, due to rotation of the dorsal fragment in the sagittal plane. In these cases, we additionally employed a novel dorsal counterforce technique. An additional K-wire was used to apply counterforce against the distal part of the dorsal fragment and control rotation in sagittal plane. All 18 fractures united with a mean time to union of 6.1 weeks. Congruent joint surfaces and anatomical reduction were seen in all cases. The mean active flexion of the DIJs was 83.8° (range: 79–88°) and the mean extension loss was 0.4° (range: 0–4°). We believe that the dorsal counterforce technique effectively supplements the two extension block K-wire technique and aids control of dorsal fragment rotation in the sagittal plane.

Amir Reza Farhoud, Ehsan Vahedi, Keivan Rahbari, Atieh Sami

Tehran University of Medical Sciences; Joint Reconstruction Research Center (JRRC), Iran

Background: The principles for treatment of intra-articular fractures include anatomic reduction, rigid internal fixation and mobilization of the joint as soon as possible. A paradox for these principles occurs when a displaced intra-articular fracture of finger joints is encountered after its acute phase. Delayed surgical intervention is notorious for resulting in a stiff finger. The purpose of this study is to assess the results of delayed surgical treatment of this type of finger fracture. Method: Twelve intra-articular fractures of 12 patients were treated by mean delay of 26 days (range: 12 - 57). For 8 patients, open reduction by removing callus and fibrous tissue between osteo-cartilage fragments were cut by a number 11 blade knife and after reduction and fixation was achieved by screw, plate and screw, anchor suture and/or pins. For displaced and unstable fractures of one dorsal base P2 and 3 mallet fractures closed extension block pinning was done. Hemi-hammate arthroplasty was done for 4 patients by P2 volar base fracture. Results: Ten males and two female by mean age of 26.4 (range: 8-49) were treated and followed averagely for 9 months (range:4-34). The mean of total ROM was 178 (range: 105 -310) preoperatively and 220° (range: 95- 280) post operatively (p>0.01). Two fingers lost their fixation and had the stiff joint finally. One patient treated by hemi-hammate arthroplasty failed its fixation after 2 weeks and tolerated the revision surgery. This patient had clinically painless moving PIP (ROM: 5-65°) but radiologically subluxated join. Conclusion: The paradigm of / of fingers may be needed to be revised. More studies by large number of cases and comparison of different treatments are recommended.

Fernanda Bellei Rocha 1,2,3, Luiz Carlos Angelini 1,4, Marcelo Tavares Oliveira 4, Marcos Yoshio Yano 4

1 UNIFESP University of São Paulo SP, Brazil; 2 Hospital University of Taubaté- SP, Brazil; 3 Orthoservice Hospital - São José dos Campos SP, Brazil; 4 Hospital Germany Osvaldo Cruz - São Paulo SP, Brazil

The aim of our study was to evaluate the outcome of nonsurgical treatment of acute lesions of the terminal extensor tendon, Type I Doyle of patients seen in the emergency department of the municipal public hospital in São Paulo, in the period January-September 2014 . Twenty-five patients with mallet finger acute injury were attended, of which, 14 women and 11 men, aged 50 years old (age range: 29-71 yo). All lesions were closed, with the middle finger showing higher incidence (36%) followed by the ring finger; 91.6% occurred in the dominant hand. The treatment consisted of immobilization of the affected finger in a metal volar splint with light extension (10), for a period of 42 days, complemented by two more weeks with nightly use orthosis. Radiographically, the consolidation was achieved in all patients. There were no mal-union or subluxations in any case, neither complications with use of splint, such as skin lesions, among others. In our sample, the average angle found after nonsurgical treatment was 8,1º (zero to 18) and no cases of complications related to the use of immobilization. We conclude that the nonsurgical treatment of mallet finger presents satisfactory results, secure, with a good movement arch of the distal interphalangeal joint and minimal complications

Dong Geun Lee

Chungbuk National University Hospital, Cheongju, South Korea

Fracture dislocation of the proximal interphalangeal joint is common developed during severe exercise. Several treatment modalities are adjusted according to the type of injury. Until now closed reduction, extension block splint, K-wire fixation and miniscrew or dirclage wire fixation are commonly used. But we performed an internal fixation using lag screw. A 24 year old man visited the our emergency center with posterior fracture dislocation of PIP joint of right index finger. He is a jazz guitarlist. And he wanted a compete recovery of his finger function. We performed an internal fixation using lag-screw through the dorsal incision. Physiotherapy was started from on postoperative 3 days. On radiological finding the fracture fragment was well reduced and fixated. On long-term follow-up functional recovery was complete. No joint stiffness and arthritis were observes. And he took a second place on the international jazz guitar concours one year later after operation. There is not a definite treatment modality for the posterior fracture dislocation of the PIP joint. We can select an appropriate treatment modality according to the type of injury. But any method is not free from the complications such as joint stiffness, pain, arthritis, re-dislocation, and motion restriction. Recently the method using lag screw is not popular method for this situation. But I recommend a this modality in the aspects of a less joint stiffness, less pain, and early joint motion.

T Jegathesan,Chong Xue Ling, Vaikunthan Rajaratnam

Khoo Teck Puat Hospital, Singapore

Objective: The aim of this study was to determine if there was a difference in outcomes of patients who sustained hand metacarpal or phalanx fractures and were treated conservatively, versus those who underwent surgical fixation of their fractures. Materials & Methods: This is a retrospective study where data was collected on patients who had sustained hand metacarpal or phalangeal fractures from 2013 to 2016 in our single institution in Singapore. The hospital radiology database was trawled to identify patients who had sustained fractures of the metacarpal or phalanges of the hand during the above time period. A series of cases were identified where pairs of patients were matched for age, gender, premorbid function as well as type and location of fracture. One of the pair of patients would subsequently undergo surgical fixation of the involved fracture. Demographic data were collected from all patients, and surgical data for the respective ones who underwent surgery which included type of fixation, duration of surgery as well as complications were recorded. Subsequent range of motion of the hand & fingers of all patients were measured during follow up with the hand occupational therapist and was analysed to evaluate the functional outcome using the total active motion. The data was analysed using SPSS version 24. Results & Conclusion: Outcomes for a total of ten matched pairs of patients with differing fracture patterns were analysed. Analysis, results and conclusion for this study are still undergoing further refining, and will be ready for presentation by the time of the conference.

Trauma (in general) / Contractures (1 abstracts)

Marta de Prado Tovar, María de los Ángeles de la Red, Carlos Garcés, Gonzalo García, José Couceiro, Higinio Ayala, Olga María Vélez, Manuel Sánchez

Hospital Universitario Marqués de Valdecilla; Santander; Spain

OBJETIVE: To report a case of arrest of distal ulnar physeal growth after a displaced fracture of the distal radius and ulna, corrected using a CT-guided technique. METHODS: A 16 year old girl with history of distal radio-ulnar fracture when she was 5 years old, treated surgically in another center. Clinically supination was limited to 40º. She had pain over the dorsum of the ulna; this pain increased when she grasped objects and in pronation. Physical examination revealed a stable distal radio-ulnar joint. She also referred pain over the radial head at the elbow joint. Forearm deformity was clinically evident and she also presented a cubitusvarus of 15º. Radiographs showed distal ulna shortening and radius bowing. The ulna has a dorsal angulation at its distal third of 20º. CT showed a dorsal incurvation of the radius and volar incurvation of the ulnar bone. Left ulnar length was 21,5 cm while the right ulnar length was 24,8 cm. The left radius length was 22,6 cm and the right radius length was 23,4 cm. The left radial head was slightly dysplastic but it was not dislocated. The radial torsional angle was of 6,5º on the left side and 10,8º on the right forearm. A corrective radio-ulnar osteotomy was proposed as treatment. We planned the osteotomy in a 3D bone model. A mirror image of the contralateral normal radius was obtained to quantify the degree of the deformity. 3D surface generation models were constructed and corrective osteotomy was simulated. Real size plastic bones were utilized during surgery to aid in orientation. The radius was approached thought a volar approach. Using the real size bones the position of the radius template was estimated. For the radius a closing wedge osteotomy of 15º correcting the bone in the 3 planes was performed. Plate was then inserted thought the Kirschner wires and definitively stabilized with screws. For the ulna, we used the dorsoulnar approach. The preoperative planning consisted in a closing wedge osteotomy of 20º and resection of a dorsal spur. To avoid excessive ulna shortening the triangular osteotomy graft was interposed in a reversed way. An ulnar plate was inserted and filled with screws. A sugar tongue cast was maintained 3 weeks after the surgery, then, it was changed to an antebraquial forearm cast 3 additional weeks. RESULTS: Union was considered complete when the osteotomy line has disappeared and osseous trabecular continuity was confirmed. It was achieved at 8 weeks. Forearm pronation and supination at 6 months were 60º and 50º respectively. However she was out of pain at the DRUJ and in the elbow joint, but restricted forearm supination persisted. CONCLUSION: Symptoms after malunion of a diaphyseal forearm bone include restriction of forearm rotation, pain and instability of the radioulnar joint during pronation and supination. In this complex forearm deformities quantification of correction of a multiplane malunión remains challenging. Technology advances with three dimensional planning and printing technique aids the surgeon to achieve an accurate preoperative plannification and is a promising technique.

Tumours (16 abstracts)

L Madero de la Fuente, JJ Correa Gámiz, M D Izquierdo Santos, E Peñalver Romero

Hospital Virgen de la Luz, Cuenca, Spain

OBJECTIVE The carpal tunnel syndrome is a group of symptoms associated to the compression of the median nerve where it passes through the carpal annular ligament. These symptoms include paraesthesia, numbness, pain and weakness on the innervation area of the median nerve. This situation is usually the result of the combination of several factors that provoke an increase in pressure on the median nerve: genetic predisposition, traumas and wrist fractures, obesity, hypothyroidism, rheumatoid arthritis, working activity, pregnancy or development of cysts or tumours inside the channel (infrequent). Some of the tumors that can cause carpal tunnel syndrome would be: nerve sheath ganglion cysts, neural fibrolipoma, schwannoma or neurofibroma. Here, we are introduced to an example of a patient operated on of a carpal tunnel syndrome, with the casual find of a fibrolipoma of the median nerve. METHODS It consists of a male patient of 49 years of age who comes for outpatient consultation due to paraesthesia and equal pain in both hands. By physically exploring him, we find out the patient presents Tinnel + and Phalen + in both median nerves. Furthermore, stenosing tenosynovitis of 3rd and 4rd fingers of the left hand is diagnosed. On clinical suspicion of bilateral carpal tunnel syndrome, an electromyography is needed to confirm the diagnostic. Once this test has been made, the patient is diagnosed with bilateral carpal tunnel syndrome of mild intensity on the right hand and moderate on the left hand, so surgical release of the median nerve of the left hand and A1 polectomy of the 3rd and 4 rd fingers was scheduled. Intraoperatively, once the carpal transverse ligament was opened, a rice grain size perineural, yelowish colouring and soft consistency tumour was detected. The tumour was resected and the sample is sent on for testing. RESULTS The pathological study of the tumour was reported as “Fibrofatty tissue with no other relevant alterations”. The patient evolved positively, with a significant improvement of his symptoms. CONCLUSIONS The neural fibrolipoma, also known as perineural lipoma or fibrolipomatous hamartoma, is a benign and infrequent neoplasia that usually affects to the median nerve. It is frequently associated with the macrodactyly, and when this happens it is present since birth, and is known as lipomatous macrodistrophy. Its cause is unknown. Clínicaly, in most cases is manifested as a slow growth mass of soft tissues (accompanied or not of macrodactyly), associated to distal compressive nervous symptomatology. Its treatment is controversial, and can be made a conservative treatment, external or internal neurolysis for the tumor resection, or radical excision associated or not to a graft. Moreover, median nerve decompression inside the carpal tunnel is recommended if the nerve is compressed.

Konstantinos Tolis, Emmanouil Fandridis, Filippos Giannoulis, Meletios Rozis, Isidoros Dontas, Sarantis Spyridonos

Hand Surgery, Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece

Objectives: Epidemiological studies considering upper limb neoplasms are few in the current literature. The aim of this study is to report the frequency of upper limb tumors in the Greek population and create a data base for future analysis. Methods: We retrospectively reviewed the medical archives of Microsurgery, Hand and Upper extremity Department (General Hospital KAT,Athens,Greece), considering patients who were operated for tumor and tumor like lesions between 1995 and 2015. Patients were reviewed for demographic data, type of tumor, affected area and recurrence. Results: 1102 patients were operated during a period of 20 years, of whom 605 (54,9 %) were females and 497 (45,1%) were male. Mean age was 46,9. The right side was mostly affected (595 patients, 54%) on both sexes (259 males, 336 females). Lesions were mostly presented during the 6th decade of life (240 patients, 21,8%), followed by the 5th (218 patients, 19,8% ) and 4th (192 patients, 17,4%). Considering the anatomical area, the index finder (224 patients, 20,3%)was most affected, followed by the palm area (177 patients, 16,1%), the middle finger (148 patients, 13,4%), the thumb (107 patients, 9,7%) and the ring finger (100 patients, 9,1%). The clavicle (2 patients, 0,1% ) and the scapula (6 patients, 0,55%) are rarely involved. Bone tumors were detected in 136 patients (12,3%), while soft tissue tumors involved the majority of cases (966 patients, 87,7%). There is predominance for benign tumors (1046 patients, 94,9%) to malignant (56 patients, 5,1%) in the Greek population. Giant cell tumor (GCT) of sheath is the most common neoplasm in Greek patients (316 patients, 28,7%) followed by lipoma (103 patients, 9,3%), hemangioma (70 patients, 6,4%), epidermoid cyst (67 patients, 6,1%), gagglion (64 patients, 5,8%) and enchondroma (61 patients, 5,5%). Conclusions: Tumor and tumor like lesions are generally rare in the upper limb. They involve usually women rather than men, when considering the Greek population. Right upper extremity is more involved and in most cases is considered of benign origin. Hand area is mostly involved, while the shoulder girdle is rarely affected. Soft tissue tumors, such as giant cell tumor of the sheath and lipoma, are covering the majority of cases.

Ji Hun Park,Tae Wook Kang, Young Woo Kwon, In Cheol Choi, Jong Woong Park

College of Medicine, Korea University Anam Hospital, Seoul, South Korea

The trapezium is rare site of osteoid osteoma development. The diagnostic challenge lies in its rare occurrence, and requires differentiation from various disease entities causing thumb basal joint pain. We report the case of a 29-year-old male who presented with severe thumb basal joint pain. He was initially treated for calcific periarthritis because of concomitant calcifications around the thumb basal joint, but had undiscovered osteoid osteoma. In this case, the patient was initially treated for calcific periarthritis, but had undiscovered osteoid osteoma. A high index of suspicion and careful attention to a patient withrnwrist pain unresponsive to prior treatment is necessary for diagnosis of osteoid osteoma. If radiographs are inconclusive,rnadditional views, CT, or MRI should be considered to better visualize the nidus of osteoid osteoma in the small bones of the hand.

Jose A. Oteo, Patricia Merino, Cristina Salvador

Hospital Universitario de Fuenlabrada, Madrid, Spain

Introduction. Gigant cell tumor (GCT) of bone is a benign but locally aggressive tumor and treatment consists of either curettage or en bloc resection of the lesion with subsequent reconstructions. Aggressive GCTs poses question to the surgeon about the surgical planning for complete removal of the tumor with reconstruction modality for better preservation of the forearm and hand function. Methods. A 63-year-old, right-hand-dominant woman, with an aggressive GCT of distal left radius Campanacci grade 2. She was first treated with curettage combined with bone grafting and cement filling, but after this surgery she started with intensive pain and limited mobility in left wrist. X-ray showed distal radius deformity, especially distal radioulnar joint. Distal radius was resected and reconstructed using ulnar translocation and wrist arthrodesis. The ulna-carpal radius fixation was performed with LC-DCP plate and screws. Result. Bone union time was 5 months. No recurrence. One year after surgery she had a total reduction in pain (presurgical VAS 8, postsurgical VAS 0) and improvement in daily function (presurgical DASH 84, postsurgical DASH 20). Full supination, loss of pronation of 70º. Grip strength 12kg (contralateral hand 21kg). Conclusions. Reconstruction of the distal radius by ulnar translocation without complete detachment from surrounding soft tissues functions like vascularized graft without use of microvascular techniques, and provides excellent functional outcomes.

J Rodriguez-Miralles, A Escola Benet, G Bucci, G Fallone Lepi

Hospital Universitari General de Catalunya, Sant Cugat del Valles, Barcelona, Spain

MASSON’S TUMOR OF DE HAND Objective The intravascular papillary endothelial hyperplasia (IPEH), also known as hémangioendothéliome végétant intra-vasculaire or Masson´s pseudoangiosarcoma, is an unusual benign, non-neoplastic, vascular lesion, with rare non-neoplasic reactive endothelial proliferation most commonly located in the skin or subcutaneous tissues. It is important to remark the features that can distinguish this entity from other neoplasms to avoid inappropriate treatment. Pathological characteristics that distinguish IPEH from angiosarcoma could be reduced to circumscription of the lesion, location in a vessel or association with thrombus and papillary architecture without significant cytologic atypia or areas of solid growth. Methods We present two cases.: 1.A 60 year old Caucasian male . The patient presented a small tumor in the hypothenar eminence wirth neuropathy of the ulnar nerve at the level of the Guyon Canal of the right hand. The RNM showed small tumor in the Canal suggestive of angioma. Excision of the tumor was performed. The histological study showed an intravascular proliferation of small papillae (Masson's Tumor) 2.A 28 year old Caucasian male He had a subcutaneous mass in the palm of the hand distal to the carpal tunnel. Blood tests were normal. Ultrasound showed an 17x12 mm mass The RNM showed a cystic image suggestive of hemangioma. A wide surgical excision was performed. Histological examination again diagnosed Masson's tumor Clinical follow-up at 7 years average (4/10) showed no evident complications or recurrences. Results Intravascular Papillary Endothelial Hyperplasia ( IPEH), most commonly referred to as Masson’s tumor, is a rare, benign endothelial proliferation representing about 2% of vascular tumors of the skin and subcutaneous tissues. Initially described by Masson in 1923 “hémangio-endothéliome végétant intravasculaire” is considered to represent a histopathologic reaction and eventual proliferation of endothelial cells of normal blood vessels in response to a variety of chemical and physical inputs. Although the true pathogenesis of IPEH remains unknown,cellular proliferation may be under hormonal or growth factor (bFGF) control. Its presentation withother vascular anomalies, such as hemangiomas, suggest a pattern of reactive growth rather than a true neoplasm. Lesions may arise de novo, however, and therefore its pathogenesis has remained elusive. There is question as to whether proliferation is primary and thrombosis secondary or whether proliferation is due to an exuberant growth phase of an organized thrombus. Differencial diagnosis should be carried out against pyogenic granuloma, Kaposi sarcoma, hemangioma, angioendothelioma, Kimura disease and intravenous atypical vascular proliferation. Masson’s tumor can be mistaken for angiosarcoma. Conclusions The importance of Massons’s hemangioma lies in the fact that it hitologically simulates angiosarcoma. Moreover, it tends to recur if incompletely resected. Correct diagnosis of the entity is essential to prevent aggressive treatment.. Treatment consists of complete resection of the tumor, including wide enough margins to avoid recurrence.

Michihito Miyagi 1, Takao Omura 1, Yoji Shido 1, Hiroaki Ogihara 2, Yukihiro Matsuyama 1

1 Department of Orthopedics Surgery, Hamamatsu University School of Medicine, Japan; 2 Hamamatsu Redcross Hospital, Japan

Purpose Enchondroma is the most common bone tumor arising in the hand. The tumors are often recognised with the incidence of pathological fractures. Once these fractures are healed, the patients are usually treated by curettage and bone graft. However, we sometimes enoconter cases with limitation of finger range of motion (ROM) postoperative to the treatment of pathological fractures. The aim of this study is to clarify the risk factor of ROM limitation in enchondroma patients with pathologic fractures. Material and method Twenty four patients with enchondroma of the hand who underwent curettage and bone graft during 2002 and 2017 were studied. These patients sustained pathological fracture and intially recieved concervative treatment prior to surgery. There were eight males and sixteen females with a mean age of 43 years (range, 10-78). The average follow-up period was 18 months (range, 5-60). We retrospectively analyzed the clinical data for each patient, including the affected digit and the bone, the periods from injury to operation, the length of the fracture displacement and the finger ROM at the last follow up. The Strickland test and Total Active Motion (TAM) was used for evaluation. Result The tumor was located in 7 metacarpal bones( 4 ring and 3 littlle fingers), 8 proximal phalanges (1 index, 5 ring and 3 little fingers), 5 middle phalanges (1 middle and 4 ring fingers) and 3 distal phalanges (2 middle and 1 ring finger). The periods from injury to operation was 74 days (range, 32-132). 6 cases (25%) had a fracture dislocation of more than 2 mm. With TAM evaluation, 16 cases (66.7%) were excellent , 5 cases (20.8%) were good and 3 cases(12.5%) were fair. In cases with dislocation of more than 2 mm, only 2 out of 6 cases (33%) had excellent result. In comparrison, the cases with dislocation of less than 2 mm had 14 out of 18 (78%) excellent results, which was significantly different between the two groups (p=0.01). Using Strickland test, 18 excellent cases (75%) were excellent, 2 cases (8.3%) were good and 4 cases(16.7%) were fair. In cases with the age of 40 years and more, only 10 out of 14 cases (71%) were good or excellent, whether as the 10 cases with the age of below showed 100% good or excellent result. This was also statistically different between the two groups (p=0.01) .None of the cases had recurrence tumor or additional fracture. Conclusion We found the risk factor of ROM limitation for the enchondroma patients of with pathologic fractures were displacement of the fracture of more than 2 mm, and patients with age of 40 years and more.

Won-woo Kang, Ki-tae Na, Jong-hoon Lee, Sang-uk Lee

Saint Mary Hospital Incheon, South Korea

Leiomyoma of the hand: case report OBJECTIVE Leiomyoma is a benign, slowly growing tumor that originate from smooth muscle. It is commonly found in the uterus of mid-aged women. Leiomyoma of extremity is relatively uncommon, and most of cases are occurred in the lower extremities. Since, Butler et al. reported leiomyoma of the hand in 1960, several papers reported that. We present leiomyoma of the hand that occurred in hypothenar area. MOTHODS CASE A 24 year-old, right hand dominant woman presented with a 1 year history of a slowing growing, painful mass on the volar aspect of hypothenar area. She also complained numbness at the radial aspect of little finger. On physical examination, a 3cm sized, tender, and rubber mass was present on the volar surface of the fifth metacarpal bone. . Plan radiographs revealed increased soft tissue density at hypothenar volar aspect and no bony abnormality. MRI demonstrated 2.4 * 1.8 * 2.9 cm sized lobulated mass at plamar aspect of 5th metacarpal shaft level. This soft tissue tumor had a high signal intensity on the T2 weighted image and showed a similar signal intensity to the surrounding muscle on the T1 weighted image. Also it was strongly enhanced by contrast media. Under general anesthesia, a longitudinal incision was made over the mass. The mass was well capsulated, but involved the tendinous portion of interosseous muscle. Otherwise, it is easily dissected from the surrounding tissue. After surgery, splint was applied for 2 weeks for wound healing and pain relief. RESULTS Macroscopically, the mass was firm, encapsulated, and the length of longitudinal axis was 2.2 cm. Microscopic examination revealed intertwining bundles of the smooth-muscle cells without mitotic activity. Immunohistochemical staining was positive for actin and negative for S-100. Histopathological examination confirmed the clinical diagnosis of leiomyoma. From 2 weeks after the operation, the patient was able to do all the daily activity, and there was no pain from POD 2 months. Conclusion Leiomyomas are rare benign soft tissue tumors presenting with non-spedific symptoms. Preoperative MR imaging is crucial to demonstrate the extent of the mass and the relationship between the neurovascular structures as well as the bones. Immunohistochemical staining with demin and actin provide definite diagnosis.

Atsushi Yokota 1, Katsunori Ohno 1, Naoki Ueda 4, Ichiro Baba 1, Kazuhiro Yamamoto 2, Yoshinobu Hirose 3, Masashi Neo 1

1 Department of Orthopedic Surgery, Osaka Medical College, Japan; 2 Department of Radiology, Osaka Medical College, Japan; 3 Department of pathology, Osaka Medical College, Japan; 4 Department of Orthopaedic Surgery, Hokusetsu General Hospital, Japan

Objective: Schwannoma (SN) and vascular leiomyoma (VL) in the hand are rare but preoperative differential diagnosis of these soft tissue tumors is difficult due to the anatomical feature of the hand where peripheral nerve and vascular system are located closed each other. The objective of this study was to clarify the characteristic findings of magnetic resonance imaging (MRI) of both tumors in the hand and finger. Methods: This retrospective study was approved by ethical committee of our institute. The study group comprised thirteen patients (seven SN and six VL) that preoperative MRI was performed and underwent the surgery in our department and diagnosed by means of histopathology between 2003 and 2017. MRI were obtained with either a 1.5T or a 3.0T apparatus. T1-weighted spin echo, T2-weighted fast spin echo and short tau inversion recovery (STIR) were acquired but the planes included various combinations. T1-weighted spin echo sequences after intravenous gadolinium-DTPA were available in four of SN patients and all of VL patients. The paraffin-embedded specimens of excised tumors were thin-sectioned and stained with Hematoxylin and Eosin (HE), Masson’s Trichrome (MT) and Alcian blue (AB), and then observed with light microscopy. The MRI findings of SN and VL were compared and the correlation between the MRI findings and histological features of each tumor were evaluated. Results: All lesions were appeared as well-defined masses and the average size was 21mm in both tumors (SN: 11-44 mm, VL: 14-26 mm). In T1-weighted images all except one of SN cases showed homogenous and isointense to skeletal muscle. Whereas, multiple signal void were observed in all of VL cases. T2-weighted images revealed the characteristic features in both tumors; five of SN showed heterogeneous with isointense nodular regions surrounded by high-intensity. Remaining two SN showed homogeneous high intensity. Whereas, five of VL showed heterogeneous with linear isointense region surrounded by high-intensity. Remaining one VL showed homogenous isointensity. All of SN cases that received intravenous contrast medium showed marked but heterogeneous enhancement and two of four SN cases showed ring enhancement. On the other hand, in VL cases received intravenous contrast medium, four showed marked but heterogeneous enhancement and remaining two showed marked homogenous enhancement. In addition, in five of VL cases, serpentine vessels adjacent to the tumor were observed. Histological feature of SN cases was interminglement of hypercellular Antoni A and Antoni B showing scattered cells and myxoid matrices (stained by AB). In five of SN cases showing heterogeneous with isointense nodular regions surrounded by high-intensity in T2-weighted images, histological feature is well correlated with the “texture” shown in T2-weighted images. Histological feature of VL was many cavernous vessels and linear fibrous bundles with or without hyaline degeneration (stained by MT). In four of VL cases showing heterogeneous with linear isointense region surrounded by high-intensity n T2-weighted images, histological findings also reflected this “texture” shown in T2-weighted images. Conclusions: The characteristic findings of both tumors in MRI well reflected the histological features of both tumors and were useful for differential diagnosis.

Mihaela Perţea 1,2, Sorinel Luncă 1,3, Oxana-Mădălina Grosu 2

1 University of Medicine and Pharmacy “Gr. T. Popa” Iași, Romania; 2 Clinic of Plastic and Reconstructive Microsurgery, “Sf. Spiridon” Emergency Hospital Iași, Romania; 3 Surgery II Department, Regional Institute of Oncology Iași, Romania

Objectives This presentation aims to highlight the possible existence of rare tumors in hand and fingers. Sometimes, only imagistic examinations, such as MRI and histopathology, can orient and establish the diagnosis. Therefore, these rare tumors must be considered, even when they are present in hands or fingers. Methods Our study is based on a group of 10 patients, aged between 30 and 65 years old, diagnosed and treated over a period of 9 years. In 7 cases, the tumor was a lipoma, in two cases was a cystic formations in the palm and in one case was a neil bed neurofibroma. The lipomas localization was the thenar eminence in 6 cases and mid-palm region in 1 case. All tumors were over 5 cm (giant), the bigger size was sizes in the mid-palm, being 9.5/5/3.5 cm, with a weight of 137 grams. In other two cases of lipoma, the fact that the tumor was overlying the median nerve. The differential diagnosis included a variety of other tumors (lipoma, hamartoma). In two cases the MRI exam oriented us to the diagnosis of cystic formation, but it did not give other details. Surgery and the pathological examination established the diagnosis of epidermal inclusion cyst, tumor that is rare in the palm. In one case, it was a nail bed tumor with bone deformities, in which the pathological examination and immunochemistry (the presence of protein S100) confirmed the diagnosis of nail bed neurofibroma tumor. This tumor is reported in approximately 10 cases in the literature. In all our cases, the treatment consisted in surgery with complete excision of the lesions. Results In all cases, the ablation of tumors was performed with good results, without relapse at distance in the case of nail bed neurofibroma and lipomas. Socio-professional reintegration was complete and fast, functional and aesthetic results were very good. The patients rated the results with “good” and “very good” in all cases. Conclusions In the presence of a tumor in the hand we have to think about the possibilty of a lipoma or an epidermal inclusion cyst, even though their localisation at this level is rare and very rare. In front of a nail bed tumor, we should not forget the possible diagnosis of a neurofibroma. Keywords: lipoma, epidermal inclusion cyst, neurofibroma

Moritz Scholtes 1, Antonio Rodríguez 2, Joachim Ganser 1

1 Department for Hand- and Plastic Surgery, Kantonsspital Münsterlingen, Switzerland; 2 Institute of Pathology, Kantonsspital Münsterlingen, Switzerland

Objective: Bizarre parosteal osteochondromatous proliferation (BPOP, Nora’s lesion) is a rare yet increasingly recognized benign bone tumor mainly of the hands and feet, although there have been reports on numerous other locations. Various conditions were discussed as contributing factors of formation including posttraumatic and genetic ones. Radiologic examination shows an irregularly shaped mass of bone adjacent to usually intact cortical bone. MRI typically shows no communication between the tumor and the medullary canal. Histologic examination reveals bone and cartilage tissue with bizarre appearing chondrocytes and hypercellularity with a cartilage cap and adjacent zone of enchondral ossification (blue bone). Surgical excision is the treatment of choice while recurrence rates are described up to over 50%. Methods: A retrospective analysis was performed and four patients were included, who were operated on by or in the presence of the same level IV (highly experienced) hand surgeon with local resection of BPOP. Patient demographics, medical history, history of trauma and postoperative complications as well as clinical signs of recurrence were noted. Operative technique was total resection of the tumor with the underlying periosteum in regional or general anesthesia. Specimens underwent histological examination for confirmation of the diagnosis. Follow-up was performed by outpatient clinical examination. The latest follow-up was by telephone interview. Results: Four patients (1 male, 3 female) with BPOP in different bones of the hand were treated by excision; one in a thumb distal phalanx, one in an index finger proximal phalanx, one in a third metacarpal and one in a long finger middle phalanx. One patient reported on antecedent trauma. No relevant medical history was discovered. The patient with resection of BPOP in the third metacarpal developed signs of CRPS that resolved after 3 months. Follow-up was 9 years, 6 years, 6 months and 2 weeks respectively without clinical signs of recurrence reported. Conclusions: Fewer than 200 cases or BPOP are described in the literature since the original publication in 1983. According to current publications and our own findings, first line therapy for BPOP should be surgical resection, preferably with the underlying periosteum. In our small study cohort there was no clinical sign of recurrence after up to 9 years.

João Paulo Mussi, Christophe Camps, Alexandre Durand, Christophe Duysens, Rainer Andrea Falcone, Thomas Jager

Institut Européen de la Main, France

Objective: In front a case of either aggressive or malignant tumor of the distal ulna, wide resection with free margin is the procedure of choice, however when performed alone, this procedure can produce loss of motion, impingement and pain, being necessaire to perform stabilization procedures. We presented a case-report of a patient treated with wide ulna excision and stabilization by a fascia lata tendon strip. Methods: A 35-year-old male patient suffered a pathologic fracture of the distal ulna being diagnosed, after open biopsy, clear-cell chondrosarcoma. To ensure free margin excision, we resected 11 cm of the distal ulna, as well as the distal radioulnar joint, extensor carpi ulnaris and the TFCC. After, we harvested a 2.5x15cm fascia lata tendon strip and performed and suspensoplasty of the proximal stump with the fascia lata strip and the flexor carpi ulnaris. Results: At the 18-month follow-up, the patient presents extremely satisfied with the procedure, he presents and excellent result in the Ferracini Score (16/18), his PRWE was of 22/100, his QuickDash was of 15.9. In terms of motion he has normal flexion-extension and prono-supination motion compared to the contralateral side and a decrease of 10 degrees in the radioulnar deviation compared to the contralateral side. His grip strength is of 24kg (81% compared to the contralateral side). He has no pain on neither the wrist nor the tight and no signs of recidive at this point Conclusions: The management of tumors of the distal ulna is always individualized being the wide resection with or without stabilization the choice more usually performed. We showed that despite the big resection, the suspensoplasty with the fascia lata tendon is capable of providing and stable proximal stump and also maintaining a good grip strenght

Chris Mills 1, Woan-Yi Chan 1, Gabriel Fieraru 2

1 Royal Devon and Exeter Hospital, UK; 2 Plymouth Hospital Trust, UK

Objective Lipomas are slow growing benign fatty tumors which occur anywhere in the body. Common sites are neck, shoulders, back, abdomen, arms and thighs. However, lipoma is an unusual cause of a mass in the hand which can present initial diagnostic challenges. We reviewed our experience of cases of lipomas in the hand and discuss their diagnostics, management and pitfalls. Methods Our sarcoma service provides a rapid access single referral point for the initial assessment and investigation of all soft tissue tumors from any body site. Having being referred several hand lipomata, we carried our a review of our practice. Clinical databases were searched to identify cases of interest. Individual case files were reviewed with particular focus on presentation, diagnostics and surgical management. We also performed a literature review using search terms hand lipoma and lipomatous tumors. Online medical databases were used alongside textbooks on hand surgery. Results Database search identified several cases. We focused on our most recent cases as being of Interest. Ages ranged from 30 to 57 years and presented with symptoms of a lump in the hand for between two to five years. One patient had a relatively small lipoma but noticed some paraesthesia to two fingers. She was however functionally not compromised. Another patient had a very large multi-lobulated lipoma increasingly interfering with his job due to size. A third patient was clinically diagnosed by the general practitioner and initial hand surgeon as a lipoma but further investigations revealed an extra skeletal myxoid chondrosarcoma. After completion of relevant imaging, biopsy and multidisciplinary discussion in the sarcoma team, the two patients with lipomas underwent surgical excision and the sarcoma patient referred to a further specialist center. Careful planning of incision lines for skin flap survival was carried out and intra-operative anatomical distortions were taken into account. Our literature search identified a large number of papers regarding lipoma in the hand. Most reported cases are asymptomatic and many reports relate to median nerve symptoms and/or incidental finding during carpal tunnel surgery. Overall, the advances of medical imaging technology have improved diagnostics and become more important in the management pathway. Conclusion Lipomas in the hand palm are uncommon and may present with minimal symptoms. Early referral to a specialist center is important to exclude sarcoma as well as choosing the correct imaging for diagnosis, followed by biopsy as appropriate. Technical challenge may be encountered during surgery due to the distorted/displaced anatomy of neurovascular bundles and tendons. Skin integrity need to be taken account of if the tumor is large and multiloculated.

May Tove Hestmo 1, Magne Røkkum 1,2

1 Department of Hand and Microsurgery, Ortopaedic Clinic, Oslo University Hospital, Norway; 2 The Faculty of Medicine, University of Oslo, Norway

Giant Cell Tumor (GCT) of bone is rarely located in the carpus. Due to easy extension to the adjacent joint spaces, bones and soft tissue, the GCT in carpus has a high recurrence rate. Hamatum is the most affected bone, followed by the capitate, schapoid and the lunate. We describe a case of GCT located in the hamatum, capitate and in the base of 3. and 4. metacarpal bone and discuss its treatment. A 59-year old woman visited her GP because of swelling on the dorsum of the left hand and wrist. The swelling had been present for the last 2 years, the last 6 months combined with pain and a more rapid growth. The patient was referred to Radiumhospitalet, Oslo University Hospital for further evaluation. In evaluating the extent of the lesion, plain radiographs, computed tomography and magnetic resonance imaging revealed a distinct lucency in the hamatum, capitate and in the base of the 3. and 4. metacarpal bone limited by a thin sclerotic rim and cortical effractions. A soft tissue swelling was located dorsal to the hamatum. The investigation resulted in suspected grade III GCT according to the Campanacci`s classification. An ultrasonography-guided needle biopsy concluded with GCT of bone. The patient was referred to our unit. She underwent surgery with a dorsal wrist approach and wide resection of the tumor and adjacent pathological soft tissue. The bone defect was reconstructed with a corticocancellous bone graft from the iliac crest with a carpometacarpal arthrodesis fixed with K-wires. The wrist was immobilized for 12 weeks, when radiographs revealed bone union. The K-wires were removed and rehabilitation with handtherapy started. At 6 months after surgery, the patient had no pain and a functional range of motion (30 degrees of extension, 35 degrees of flexion). The grip strength was 50% of that of the unaffected side. The tumor had not recurred. Giant Cell Tumor of bone located in the carpus are often locally advanced at the time of diagnosis. Surgical intervention with wide resection and partial wrist arthrodesis is recommended.

Ahmet Savran 1, Ozgun Gunturk 2, Omur Balli 1

1 Izmir Katip Celebi University Ataturk Education and Research Hospital, Izmir, Turkey; 2 Gaziantep Dr. Ersin Arslan Education and Research Hospital, Gaziantep, Turkey

38 years old male patient is administered our hospital with vascular thenar mass with hemorrhage after biopsy for diagnosis attempt. Emergent bleeding control can not be achieved and embolisation is performed at Interventional radiology department. Due to recurrent hemorrhage within a few days, mass is excised and detailed coagulation is performed. But at the postoperative second day hemorrhage started again. With conventional bleeding control efforts it can not be controlled. And pathology is reported as angiosarcoma. Multiple metastasis is detected at PET-CT and transradial forearm amputation is done for palliative treatment with the decision of musculoskeletal tumor council. Soft tissue mass is a common diagnosis at upper extremity which are they usually benign conditions. If a vascular mass can not be controlled easily rare malign etiology must be kept in mind. And for any mass biopsy must be done after imagination. Our diagnosis and treatment experience with one patient is presented in our case report.

Judit Réka Hetthéssy 1, Noémi Szakács 1, Péter Vancsó 1, Andrea Újszászi 2, Tünde Szilas 3

1 Semmelweis University, Department of Orthopedics, Budapest, Hungary; 2 Heim Pál Children\'s Hospital, Budapest, Hungary; 3 Semmelweis University, Faculty of Medicine, Budapest, Hungary

Objective: Enchondroma is the most common primary bone tumor of the hand, often found incidentally at presentation. Even though they are benign lesions, they may weaken the cortex resulting in pathological fractures to banal trauma. Although curettage and bone grafting is considered the gold standard in the literature for primary treatment of enchondromas uncomplicated by a pathological fracture, guidelines on timing of the surgery, and thresholds for conservative treatment involving observation and regular radiographic follow-up are unclear. The purpose of this study is to identify objective reproducible clinical criteria that are associated with pathological fractures involving enchondromas on the hand that may be used to guide clinical decision making. Methods: A total of 79 enchondroma cases involving the hand were retrospectively reviewed to determine whether clinical and radiographic criteria could be used to delineate at risk patients and/or lesions. The analyzed criteria included gender, age, the hand involved (left vs right), the bone involved (distal, middle and proximal phalanx, or metacarpal), the digit involved (little, ring, middle, index, or thumb), the longitudinal percentage of the bone occupied by the lesion on anteroposterior (AP) radiographs and Takigawa classification. Syndromic cases of enchondromatosis, and pediatric patients under the age of 16 were excluded. Odds ratios were calculated for each clinical criterion; statistical significance was evaluated using chi-square test. Results: Enchondromas of the hand treated at the Orthopedic Department of Semmelweis University in the last five years (2011 – 2016) were reviewed. A pathological fracture occurred in 1/3 of all cases (n=26, 34%). 2/3 of the patients were male (n=53, 67%), but only 22% (n=12) of the male patients had pathological fracture. Meanwhile 53 % (n= 14) of the female patients with enchondromas on the hand (n=26, 32%) suffered a pathologic fracture. 53% (n=41) of the patients were from the age group of 26 years to 50 years, 34 % (n=14) of them had a pathologic fracture. Even though enchondromas occurred evenly on the left and right hand in our series evenly (47 % and 53%), the ones on the left side were more prone to a fracture (40%, n= 15). The little and the ring finger were the most commonly affected fingers regarding enchondorma, the little finger was fractured in 51% (n=14) of the cases. Most enchondromas were located on the proximal phalanx (52%, n=42), but the metacarpal ones fractured most frequently (47%, n=8). There was a statistically significant difference between the fracture and non-fracture group in regard to the digit involved, the percentage of bone occupied by the lesion on AP radiographs, but there was no statistically significant difference in regard to sex, age or bone involved. Conclusions: There were several criteria in the study that were statistically different between the fracture and the non-fracture group; affected finger and the percentage of the bone occupied by the pathologic lesion on AP radiographs can be used as a clinical guide to identify enchondormas on the hand at risk for a pathological fracture.

Slimane Ouali, Laurent Bourcheix, Patrick Houvet

Institut Francais de Chirurgie de la Main, Paris, France

ObjectivernrnElastofibroma was first describe by Jarvi and Saxen in 1961. It is a benign soft tissues tumor, slow growing of the caracterized by an unclear aetiology and is a source of ongoing debate. It is mainly located on the posterior wall of the thorax in a sub-scapular region, hence its name of elastofibroma dorsi. Relatively rare tumor with a prevalence of 2%, predominant in women over the age of 55. The diagnosis is more often evoked by the clinical symptoms as: pain, scapular snapping and discovered of a ill-mass. MRI is the more effective radiological examination and finally, the confirmed diagnosis belong to the pathological findings.rnrnMethodsrnWe report the case of a 71-year-old right-handed man without past surgical history who has a periscapular ill-mass on the left periscapular side for 3 years, initially considered as a lipoma. On MRI, the diagnosis finally retained is a bilateral elastofifroma dorsi. The evolution is reflected in the appearance of pain with limitation of the mobility of the left shoulder. The physical examination finds a firm tumefaction, adherent to the chest wall that interferes with the movements of the scapula. MRI shows a fibrilar tumor mass with a T1 and T2 hypersignal with the lenght of 89 x 24 mm on the costal surface of the scapula, without modification for 3 years. Surgical indication was based on the symptomatology and the size of the tumor.rnrnResultsrnThe surgical procedure was performed under general anesthesia in prone, longitudinal approach, along the left spinal margin of the scapula. Marginal tumor excision. The tumor very adherent to the latissimus dorsi as well as to the periosteum of the opposite ribs without bone lysis. The postoperative outcome was simple. The diagnosis was confirmed by pathological examination.rnrnConclusionsrnElastofibroma is a benign, rare, slow-growing tumor. The location is more often in the sub and periscapular region, and almost exclusively adjacent to the lower angle of the scapula. Bilateral asynchronous localization is present in 37% of cases. The treatment of symptomatic forms is marginal surgical excision. For some authors, even in the absence of clinical findings when the diameter is greater than 5 cm, surgical resection should be performed. For others, because of the absence of malignant transformation, only biopsy confirming the diagnosis is required in the absence of symptomatology.rnrnKey words: elastofibroma dorsi, tumor, soft tissues, treatment

Ulnar Wrist Pain (7 abstracts)

Takaaki Shinohara 1, Masahiro Tatebe 2, Etsuhiro Nakao 1, Ryogo Nakamura 1, Hitoshi Hirata 2

1 Nagoya Hand Surgery Center, Chunichi Hospital, Nagoya, Japan; 2 Department of Hand Surgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan

Objective We investigated factors influencing the radiological development of osteoarthritic changes in the distal radioulnar joint (DRUJ) and the clinical outcomes after ulnar shortening osteotomy (USO) in patients with idiopathic ulnar impaction syndrome. Methods We retrospectively reviewed 51 patients (55 wrists) who had undergone USO for idiopathic ulnar impaction syndrome for a mean follow-up of 52.7 months (range, 24 to 165). Twenty-one wrists (38%) showed new osteoarthritic changes in the DRUJ and the wrists were classified into two groups (with or without new osteoarthritic changes). The following factors were analysed to determine the factors associated with new osteoarthritic changes: 1) demographic factors; 2) radiologic aspects, including ulnar variance, radioulnar distance, cystic changes in the lunate, morphology of the ulnar head, morphological DRUJ type in the coronal plane, and the shapes of the sigmoid notch in the transverse plane (classified according to Tolat et al.). Patients were evaluated for wrist pain, grip strength, range of wrist motion, and the Mayo Modified Wrist Score at the final follow-up. Results Logistic regression analysis revealed that amount of shortening, and the shapes of the sigmoid notch in the transverse plane were significantly associated with the development of osteoarthritic changes in the DRUJ after USO. There was no difference in all clinical outcomes between the two groups. Conclusions Radiological development of osteoarthritic changes after USO, were associated with amount of shortening, and the shapes of the sigmoid notch in the transverse plane. Osteoarthritic changes of the DRUJ did not affect the clinical outcomes after USO.

Yukio Abe, Kenzo Fujii

Saiseikai Shimonoseki General Hospital, Shimonoseki, Japan

The TFCC tear is recognized as a major cause of ulnar-side wrist pain. We have sometimes encountered two different tears coexistent in one wrist, an injury we define as the “double lesion” and described before (Abe Y et al. J Hand Surg [Eur] 38: 807-808, 2013). Records of 532 traumatic TFCC tears were examined retrospectively, and the double lesion was identified in 92 wrists. The most frequent pattern (n = 51) was the combinations of a slit tear at the disk and an ulnar styloid tear (Atzei Class 1 tear). We call this pattern of combination the “skip tear”. If we recognized skip tear with arthroscopy in the patient who complained chronic ulnar-side wrist pain, it is very tricky which tear is the main cause of pain. The surgical choice for this pattern would be considered the only debridement, only suture or both. We have encountered 19 wrists of skip lesion in chronic wrist pain, and we are going to talk about our experiences.

Flavien Mauler, Thuan Ly, Claudia Meuli-Simmen, Itai Pasternak

Kantonsspital Aarau, Switzerland

Objective: Ulnar-sided wrist pain is a common complain, which is due to a multitude of entities. On its midcarpal side, two anatomical variant of the lunate have been described, with type II having an additional facet articulating with the hamate. The presence of this extra-joint can lead to hamato-lunate impingement. We describe the anatomical, biomechanical, and clinical features and implications of that morphological variant based on our literature review. Methods: We searched for literature in PubMed, but also Ovid SP, and Microsoft Academic, and looked for literature in English, German and French. All references about anatomy, demography, kinematics, biomechanics, and clinical data were reviewed. Results: Since its first description in the peer-reviewed literature in 1990, a total of 9 studies (1084 wrists) showed that type II lunate is predominant (46-73%) compared to type I. Specific kinetic features of the wrist are associated with the lunate type. Hamato-lunate impingement and erosion of the cartilage can be found in up to 80% of type II lunate, which in turn can lead to ulnar-sided wrist pain. Diagnostic tools from MRI to arthroscopy, and therapy options from infiltration to resection of the proximal pole of the hamate are discussed. Conclusions: This review highlights the importance to appreciate the lunate type when treating ulnar-sided wrist pain. Specific kinematic features of the wrist are associated to the lunate type, which seem to play a role in the pathogenesis. There is no consensus as to standard diagnostic and therapeutic algorithm.

Bong Cheol Kwon, Seon Jong Lee, Jae-Yeon Hwang

Hallym University Sacred Heart Hospital, Anyang, South Korea

Objective: Ulnocarpal griding test (UCGT) has been a widely used provocative test for TFCC tear. However, a paucity studies investigated diagnostic properties of the test. The purpose of this study was to determine the diagnostic accuracy of UCGT and compare them with those of ulnocarpal stress test (UCST) for the diagnosis of TFCC tear. Methods: UCGT and UCST were performed in 178 wrists of 178 consecutive patients. We assessed diagnostic properties of these tests using 3.0 T MRI or multi detector CT-arthrography and/or arthroscopy findings as the reference standard. Diagnostic values of each test were compared. Results: The UCGT was positive in 81 patients (66.9%) of 121 patients with TFCC tear and negative in 27 patients (47.4%) of 57 patients without TFCC tear, while the UCST was positive in 49 patients (40.5%) of 121 patients with TFCC tear and negative in 40 patients (70.2%) of 57 patients without TFCC tear. The UCGT showed a sensitivity of 66.9% (95% confidence interval (CI), 58.2–74.7%), a specificity of 47.4% (95% CI, 35–60.1%), a positive predictive value (PPV) of 73% (64–80.4%), a negative predictive value of 40.3% (95% CI, 29.4–52.3%), a positive likelihood ratio (LR) of 1.27, a negative LR of 0.7, and an overall diagnostic accuracy of 60.7% (95% CI, 53.1–67.8%). The UCST showed a sensitivity of 40.5% (95% CI, 32.2–49.4%), a specificity of 70.2% (95% CI, 57.3–80.5%), a PPV of 74.2% (62.6–83.6%), a negative predictive value of 35.7% (95% CI, 27.5–44.9%), a positive likelihood ratio (LR) of 1.36, a negative LR of 0.67, and an overall diagnostic accuracy of 50% (95% CI, 42.7–57.3%). The UCGT test showed a significantly better diagnostic accuracy than the UCST (P<0.001). Conclusion: The ulnocarpal grinding test is useful and significantly better than the ulnocarapal stress test for the diagnosis of TFCC tear.

Hee Seop Lee, Myung Jae Oh, Ilhoon Kwak, Jong Woo Kang, Min Jung Park, Hye Jin Park

Korea University Ansan Hospital, Ansan, South Korea

Ulnar variances after ulnar shortening osteotomy often were lengthened again. However, less is known about the changes of ulnar variance after ulnar shortening osteotomy though it can affect on clinical outcome of ulnar shortening osteotomy. The purpose of this study was to quantify the change of ulnar variance and evaluate its clinical effect after ulnar shortening osteotomy. We retrospectively reviewed 124 patients (139 wrists) who had undergone ulnar shortening osteotomy before 2 years from this study. Wrists which have other musculoskeletal disease or trauma in upper extremity were excluded. To quantify the lengthened ulnar variance, the immediate postoperative ulnar variances were compared with those at 1 and 2 years after surgery. To assess its clinical effect, wrists were divided into two groups (group A; ≥50% of lengthened ulnar variance, group B; < 50% of lengthened ulnar variance) and the preoperative DASH score and those at 1 and 2 years after surgery were compared. A logistic regression analysis was performed in order to detect predictors for the ulnar variance lengthening. The average ulnar variances were 0.24 mm at immediate postoperative day, 1.01 mm at 1 year and 1.22 mm at 2 years after ulnar shortening osteotomy. Ulnar shortening length and proximal osteotomy (from insertion of central band of interosseous membrane) were independent risk factors for postoperative ulnar variance change.The ulnar variances after ulnar shortening osteotomy were lengthened with time and effect the clinical result of ulnar shortening osteotomy. To prevent the lengthening of ulnar variance, osteotomy should be performed at distal to insertion of central band of interosseous membrane.

Hee Seop Lee, Myung Jae Oh, Ilhoon Kwak, Jong Woo Kang

South Korea University Ansan Hospital, Ansan, South Korea

The main pathophysiology of idiopathic ulnar impaction syndrome is degenerative changes which are induced by impingement between ulnar head and carpus, therefore it is commonly considered that longer ulnar variances tend to induce severer ulnar sided wrist pain. However, there are no studies about the relationship between ulnar variance and pain intensity in any kinds of literature. The purpose of this study is to investigate factors associated with pain intensity of ulnar sided wrist in idiopathic ulnar impaction syndrome.One hundred twenty-four patients (139 wrists) who underwent ulnar shortening osteotomy and arthroscopic TFCC debridement at our hospital between June 2005 and March 2016 were reviewed retrospectively. Wrists which have other musculoskeletal disease or history of trauma in upper extremity were excluded. Preoperative DASH score, VAS score, and length of ulnar variance were measured and duration of ulnar wrist pain, dominant hand or not, and the amount of physical work exposure were interviewed preoperatively. The amount of physical work exposure was estimated by the self-report for work-related exposures within 1 month. Patients reported average daily time for 6 physical exposures using a modified Nordstrom questionnaire: hand/wrist bending, forearm rotation, pinch grip, finger/thumb pushing/pressing, forceful grip, and lifting >1 kg. The degree of degeneration (stage in Palmar classification) and presence of degenerative triangular fibrocartilaginous complex tear was assessed with preoperative simple radiography and intraoperative arthroscopic findings. The relationship between wrist pain intensity and activity limitation and associated factors were statistically analyzed with multiple regression models. The presence of degenerative triangular fibrocartilaginous complex tear and amount of physical work exposure had strong positive correlations with the intensity of ulnar sided wrist and activity limitation, whereas other factors including especially length of ulnar variance were not associated with the intensity of ulnar-sided wrist pain and wrist activity limitation. Patients who have degenerative complex TFCC tear and jobs which needed excessive wrist use tended to have severer ulnar sided wrist pain and wrist activity limitations.

Min Kai Chang 1, Shian Chao Tay 1,2,3

1 Duke-NUS Medical School, Singapore; 2 Biomechanics Laboratory, Singapore General Hospital; 3 Department of Hand Surgery, Singapore General Hospital

Objective: Patients with ulnar-sided wrist pain and positive ulnar fovea sign are usually treated nonsurgically before surgical options are considered. However, the outcomes of nonsurgical management are unknown. Many of these patients also have unstable distal radioulnar joint, but there has been no comparison between the outcomes of these patients with stable and unstable distal radioulnar joint. The objectives of this study are to (1) determine the outcomes of nonsurgical and surgical treatment of patients with positive ulnar fovea sign, and (2) compare the outcomes of patients with stable and unstable distal radioulnar joint. Methods: A retrospective analysis of the outcomes of patients with ulnar sided wrist pain and positive fovea sign was performed from March 2009 to December 2014. Outcomes were measured based on patient-reported pain improvement, grip strength and range of motion of the affected wrist before and after treatment. Results: 54.4% of wrists managed nonsurgically experienced pain improvement. 83.3% of wrists managed after arthroscopic repair experienced pain improvement. The mean grip strength increased by 2.8kg and 2.7kg, while the range of motion decreased by 14o and 5o after nonsurgical and surgical treatment respectively. When comparing patients with stable and unstable distal radioulnar joint, there were statistically more wrists with unstable distal radioulnar joint that experienced pain improvement after treatment. Conclusions: The study showed that there is a role for nonsurgical treatment for nonsurgical treatment for wrists with positive ulnar fovea sign with more than half of the patients experiencing pain improvement. We also determined that there are better outcomes in patients with unstable distal radioulnar joint after treatment.

Wrist (12 abstracts)

Masahiro Tatebe 1, Akimasa Morita 2, Michiro Yamamoto 1, Shigeru Kurimoto 1, Katsuyuki Iwatsuki 1, Kozo Fujisawa 2, Hitoshi Hirata 1

1 Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2 Department of Orthopedic surgery, Suzuka Kaisei Hospital, Suzuka, Japan

Scapholunate dissociation (SLD) is the most frequent type of wrist instability, and if untreated, can lead to early wrist osteoarthritis (OA), known as scapholunate advanced collapse (SLAC). The primary stabilizer of the scapholunate joint is the scapholunate interosseous ligament (SLIL). Kienbock disease (KD) can also lead to wrist OA. Lunate resection and vascularized pisiform transfer (LRVP) is one treatment option for advanced KD. This procedure sacrifices the SLIL, but the long-term results are good and there is no progression of severe wrist OA. The purpose of this study was to examine the carpal alignment in these cases. We hypothesize the malalignment of SLD is different from KD. We retrospectively reviewed 17 patients with SLD and 14 patients with KD. All arthroscopic findings of SLD were classified as Geissler 4. Carpal alignments were evaluated from pre- and postoperative radiographs. We assessed the radio-lunate angle (RLA), radio-scaphoid angle (RSA), carpal height ratio (CHR), and the scaphoid and capitate locations by plain radiographs and CT/MRI. All assessed parameters on non-affected sides were similar in both groups. The pre-operative RSA showed no significant differences between groups, but the RLA was significantly lower in SLD and the CHR was significantly lower in KD. The scaphoid and capitate were located dorsally in SLD compared to KD. Eleven of 17 (65%) SLD cases and no KD cases showed scaphoid dorsal subluxation. No case of KD showed subluxation of the scaphoid before or after LRVP. Post-operative radiographs revealed a lower CHR/higher RSA in KD, but the CHR in KD showed no progression. There was no radiographic progression of OA in either group at final follow-up. The LRVP sacrificed the SLIL and preserved the dorsal capsule for KD, but it did not cause SLAC. KD showed no dorsal subluxation of the scaphoid. The carpal malalignment of SLD is definitely different from KD.

JuiTien Shih

Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan

Objective: Tears in the triangular fibrocartilage complex often appear in association with ulnar wrist pain and limited wrist function in work or sport. This study addressed the all arthroscopic repair of foveal tears in the TFCC with suture anchor, in a sample of 37 young adult patients . Methods : From July 2010 to February 2014, 37 patients underwent TFCC fovea repair with suture anchor by wrist arthroscopy. The mean follow-up period was 25.6 months (range, 22–28 months), and the patients’ average age was 21.4 years. The study included 27 men and 10 women. All patients had TFCC fovea tears and no wrist fractures. The 1.4mm suture anchor (Styker) was used to repair the tears and the wrist brace was applied for 6 weeks. After operation, patients were rehabilitated, reexamined, and followed up at the clinic. Complications were also recorded. Results : The results were graded with a Mayo Modified Wrist Score. Twenty-five of the 37 wrists were rated excellent, 10 were good, and 2 were fair. Overall, 35 of 37 patients (93.1%) rated satisfactorily and returned to sporting or work activities. Two patients experienced mild pain during work or exercise. Although motion remained normal for these patients, grip strength on the affected hand was at least 85% of that on the other hand. Conclusions : Arthroscopic repair of early foveal tears of the triangular fibrocartilage complex with suture anchor is a satisfactory method of repair. The procedure can enhance patients’ wrist function by relieving pain and increasing tolerance for work or sport.

Peter Axelsson 1, Christer Sollerman 2, Johan Kärrholm 3

1 Department of Hand Surgery, 2 Department of hand Surgery, 3 Department of Orthopaedics: Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Sweden

Objective Evaluation of treatments for distal radioulnar (DRUJ) disorders often include determination of grip strength and patient reported outcome measures (PROMs) such as disabilities of the arm, shoulder and hand (DASH) and Patient reported wrist evaluation (PRWE). Visual analogue scales (VAS) of pain and satisfaction are sometimes added. Grip strength is frequently used to determine DRUJ function even though rarely validated for DRUJ conditions. Forearm torque on the other hand is seldom assessed although facilitating forceful forearm rotation is an important feature of the DRUJ. We theorized that measurement of forearm torque could provide a more valid assessment than grip strength for DRUJ pathology. Method Eighteen patients treated with DRUJ implant arthroplasties were included. We compared preoperative and one-year follow-up recordings of grip strength, forearm torque, PRWE, DASH and VAS for pain and satisfaction. Responsiveness was analysed as standard response mean (SRM) and effect size (ES). Results Forearm torque was more sensitive to change (SRM 0.70-0.95, ES 0.75-0.78) after DRUJ arthroplasty than grip strength (SRM 0.39, ES 0.49). Change in forearm torque had a moderate to strong correlation to PRWE, VAS for satisfaction and VAS for pain during activity (r = -0.55-0.70) while grip strength was not significantly correlated to any outcome measures. Conclusions Forearm torque outperformed grip strength in detecting change after DRUJ arthroplasty. Improvement in forearm torque did more consistently mirror patient reported outcome than grip strength. Our findings suggest that the most relevant measures for the assessment of DRUJ dysfunction are forearm torque, PRWE and VAS for pain with activity.

S. Strafun, S. Tymoshenko, A. Lysak, S. Bezruchenko

State Institution "Institute of Traumatology and Orthopedics of NAMS of Ukraine", Kyiv, Ukraine

Objective. For such a complex area as wrist peculiar pattern of diagnostic and treatment mistakes are forming. That requires systematization and the ways of well-timed recognition, prevention and treatment determination. Methods: From more over 12,000 patients treated surgically in one hand surgery center for 8 years – 360 cases of wrist pathology, where the reason or result of surgical treatment were diagnostic or treatment mistakes has been selected. Both the structure of mistakes and the cause-and-effect mechanisms that determine their occurrence was analyzed. Results: Most represented nosologies were mis-treated fractures of distal radius, scaphoid, and perilunate dislocation. In addition, a number of more rare pathologies such as Kienbock's disease, osteod-osteoma, rare fractures, different types of instability or diseases and other pathologies had their distinctive, typical cause-and-error-effect characteristics. Some of mistakes have behavioral origin, some are related to beliefs or the influence of statistical data, and sometimes as a result of social distortions. Conclusions. Thoughtful review of typical mistakes and analysis of their origin will, perhaps, reduce their level. Obedience to the classical chrestomathy approach to patient examination, and practice of the most effective therapeutic options, critical approach to own work, combination of personal and others experience and constant education – will minimize the mistakes. However, they will always accompany any non-theoretic doctor.

Jihyeung Kim, Sang Hyun Park, Kee Jeong Bae, Hyun Sik Gong, Young Ho Lee, Goo Hyun Baek

Department of Orthopaedic Surgery, Seoul National University, College of Medicine, Seoul, South Korea

Background: The degeneration of the triangular fibrocartilage complex (TFCC) is usually combined in patients with ulnar impaction syndrome. Because ulnar shortening osteotomy can decrease the load-sharing through the ulnar carpus, there may be a possibility of indirect healing of TFCC degeneration after ulnar shortening. In this study, we focused on the changes of the TFCC degeneration after ulnar shortening osteotomy using 3D CT wrist arthrography. Methods: We retrospectively reviewed all patients who were diagnosed as ulnar impaction syndrome and underwent ulnar shortening osteotomy from January 2014 to December 2016. Of them, we enrolled 17 wrists of 14 patients who had checked 3D CT wrist arthrography preoperatively and checked postoperative CT wrist arthrography repeatedly one year after surgery. The average age at the time of surgery was 37 years. Results: In all patients, the degeneration of TFCC was observed in preoperative CT wrist arthrography. Six wrists were IIA, three were IIB, seven were IIC, and one was IID according to Palmer classification. One year after surgery, the degeneration of TFCC improved in three wrists, and worsened in two wrists. In the other twelve wrists, there were no changes in the degeneration of TFCC. The average visual analog scale (VAS) for pain was improved from 7 (range, 5~9) preoperatively to 3 (range, 0~6) one year after surgery. Conclusions: Although ulnar side wrist pain was much improved after ulnar shortening osteotomy, indirect healing of the TFCC degeneration was not observed in most of our cases one year after surgery. Therefore, we can conclude that indirect healing of the TFCC degeneration may need more time or may not occur after ulnar shortening osteotomy. The degeneration of the TFCC may not seem to be the main cause of the ulnar side wrist pain in patients with ulnar impaction syndrome.

Constantinos Kritiotis, Zaf Naqui, Lindsay Muir

Manchester Hand Centre, Salford Royal NHS Foundation Trust, Manchester, UK

Background : We present a retrospective series of 10 ulnar shortening osteotomies using the Medartis Ulnar Shortening Osteotomy system, with reference to ease of use, pitfalls as well as final results Methods : 10 patients underwent ulnar shortening osteotomy using this system between June 2017 and November 2017. The main indication was relative ulnar lengthening secondary to a prior distal radius fracture that healed in shortening. All patients had an ulnar positive variance ranging from 2mm to 7mm and had ulnar abutment syndrome with ulnar sided wrist pain as well as pain in pronosupination of the forearm. The procedure was done through a direct approach to the ulna and with volar plating. Nine of the patients had an oblique (45 degree) osteotomy, compressed with a lag screw and one had a 90 degree osteotomy. All patients were placed in a below elbow backslab for six weeks after the procedure Results : In three patients there was a problem with the extraction of the tension bolt resulting in added operating time. By the time of the writing of this abstract 7 osteotomies have united at an average of eight weeks. So far no loss of fixation has been noted or any other complication. In all but one of the patients good bony compression was achieved using this system. Conclusion : We have flagged up the problem with the tension bolt, both to the company HQ as well as to the local reps. The head of the tension bolt can become stripped extremely easily, making its removal extremely difficult. This could lead to significant intraoperative problems as without removing the tension bolt you cannot remove the jig from the plate. We have already suggested alternatives to the tension bolt. We are happy with the compression and the shortening that we can achieve using this system and we believe that is a reliable alternative for ulnar shortening osteotomies

Michel Chammas, Charline Garçon, Adeline Cambon-Binder, Bertrand Coulet, Cyril Lazerges

Hand and Upper Extremity Surgery Unit, Lapeyronie University Medical Center, Montpellier, France

Objective : The aim of this study was to evaluate carpal malalignment after distal scaphoid excision and tendon interposition in isolated scapho-trapezio-trapezoid arthritis (STT) and its clinical consequences. Methods : It was a retrospective, monocentric and single-operator study, including 16 patients, or 20 wrists, with an average age of 67.6 years (56-80). All patients had grade 2 or 3 STT osteoarthritis according to the Crosby classification. The distal part of the scaphoid (3 mm) was resected anteriorly with tendon interposition (palmaris longus or hemi flexor carpi radialis tendon when absent). The clinical evaluation criteria were pain (EVA), patient satisfaction, range of motion, Kapandji index, pinch and grasp strength, and QuickDASH functional score. Radiological evaluation included characterization of the carpus (Viegas type I or II),measurement of carpal angles (scapholunate (SL), radiolunate (RL), capitolunate (CL), radio-scaphoid (RS), radio-capitate (RC), the measurement of the height of the carpus, the search for midcarpal subluxation as well as signs of radio and / or mediocarpal arthritis. Results : The mean follow-up was 6.3 years (1 to 15 years). 85% of patients were satisfied with an average QuickDASH of 28.7 (0-77). The mean EVA at the last visit was 1.8. Postoperatively, there was no significant difference in mobility, grasp and pinch compared to the contralateral side. Radiologically, 90% of patients had DISI at last time with an average RL angle of -31 ° (-7 to -44). The mean CL angle was -14 °(0 to -26) and was significantly increased in postoperative, with a linear correlation between the increase of CL angle and the existence of midcarpal subluxation. The mean SL angle was normal in 90% of cases with an average of 58 ° (35 to 92 °). The Viegas type II lunate wrist have all presented midcarpal subluxation compared to 28% of Viegas the type I lunate wrist. The carpal height ratio was conserved. 35% of patients had midcarpal osteoarthritis and 15% radiocarpal and midcarpal osteoarthritis. Conclusion : The occurrence of a midcarpal subluxation, usually well tolerated clinically, is correlated with the increase of the capitolunate angle and appears to be favored by a Viegas type II lunate wrist. Distal scaphoid excision and tendon interposition in isolated scapho-trapezio-trapezoid osteoarthritis gives good long-term clinical results. However, in case of Viegas type II lunate wrist increasing the risk of midcarpal subluxation other surgical options can be discussed.

Luc Van Overstraeten 1,3, Emmanuel J Camus 2, Fabian Moungondo 3

1 Hand and Foot Surgery Unit Tournai, Belgium; 2 Chirurgie de la Main et du pied, Lesquin, France; 3 ULB Erasme University Hospital, Brussels, Belgium

Purpose Carpal instability begins generally with a scapholunate tear. Its repair is essential to preserve wrist function. Classical techniques, as Blatt's capsulodesis, or Brunelli's tenodesis don't reproduce wrist isometry and produce stiffness. Authors used a capsulodesis that seems to take in account dorsal wrist ligament isometry. Methods From 2006 to 2012 authors operated prospectively a continuous series. It's composed of 14 men and 12 women of age mean 38 years. Half were working accidents. All patients presented a pain, often a loss of strength, and a half part presented a loss of wrist motion or annoying crackings. The follow-up is 37 months. Viegas' technique consists of a dorsal capsulodesis, using a transverse strip coming from the dorsal intercarpal ligament. This strip is fixed with anchors, and protected with carpal pinning and wrist cast during 8 weeks. Results The post-operative data are compared with the preoperative data. The flexion-extension arc decreased of 2 °. The radio-ulnar tilt increased of 22 °. The grasp improved of 11 kgf, the pain on VAS improved of 3,3 points, the PRWE score of 60 points. Radiologically, the scapho-lunar gap decreased of 0,7 mm and the scapho-lunar angle passed from 57 to 45 °. We deplore four CPRS among which three with clinical signs, one abrasion of the EPL, one superficial sepsis. Two unfavourable evolutions were taken back, one by die-punch arthrodesis, one by luno-capitate arthrodesis. In one case the scapho-lunar gap reproduced without DISI. It's logical to propose a repair of the dorsal portion of the scapho-lunar ligament, which is mechanically the most efficient. By proposing a direct axial radio-carpal fixation, the Blatt capsulodesis, or Brunelli's tenodesis, both most used interventions, create an inextensible and not isometric dorsal reinforcement stiffing the wrist. Viegas proposed in 2000 a transverse dorsal scapho-lunar capsulodesis, which does not fix the radio-carpal joint and used a portion of the dorsal intercarpal ligament. Its mechanical resistance is superior to that of the dorsal scapho-lunar ligament. It can be used as reinforcement after a scapho-lunar suture. Its realization doesn't contain important technical difficulties. The results show not much change of the flexion-extension arc after the procedure. The radio-ulnar tilt, the grasp force, the pain and the score PRWE are improved. The results are good 26 times on 24. The Viegas capsulodesis doesn't destabilize the carpus and doesn't cut the bridges. The two bad cases were taken back with a partial arthrodesis. Conclusion This technique allows to stabilize a non directly repairable scapho-lunate tear, chronic, without fixed carpal instability, corresponding to arthroscopic EWAS stages 3 and 4.It’s suitable for Garcia-Elias grade 2-3 SL instabilities. Consequences are generally simple, but we must beware of a CRPS, or a pin complication. The dorsal scapho-lunar Viegas capsulodesis has specifications of a reliable non stiffing stabilization in case of dynamic instability. The results are satisfactory.

Torbjörn Vedung 1,2, Daniel Muder 1,2, Bertil Vinnars 1,2

1 Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; 2 Department of Orthopedic and Hand Surgery, Uppsala University Hospital, Uppsala, Sweden

Objectives Osteoarthritis in the distal radioulnar joint (DRUJ) is a challenging condition with few really reliable surgical options, particularly in young individuals. Traditional methods as hemiresection, the Darrach procedure, and the Sauvé-Kapandji procedure have less favorable results in the nonrheumatoid patient. An alternative method to treat osteoarthritic joints is surface replacement with free costal perichondrium. Methods Four female patients (38-47 y.o) with severe and painful osteoarthritis in the DRUJ underwent perichondrial transplantation at Uppsala University Hospital between 2011-2014. The DRUJ was opened both volarly and dorsally. All remnants of the eroded joint surfaces were resected down to bleeding subchondral cortex. The graft was harvested from the 6th or 7th rib. The perichondrium was peeled off the underlying cartilage with a blunt dissector, from the bone-cartilage rim to the sternum. Care was taken not to include any cartilage and not to damage the cambium (inner) layer of the perichondrium. Both joint surfaces were reconstructed with separate transplants. The grafts were osteo-sutured and glued to the recipient sites with the cambium layer facing towards the joint space and the outer fibrous layer facing the subchondral bone. A thin silastic sheet was temporarily placed in the joint to mold the transplants and prevent adherences between the joint surfaces. The silastic membrane was removed after two months. Results Preoperatively, the patients approximated the pain to be between 7-9 using the visual analog scale (VAS). At short-term follow-up (range 1-5 years) the patients were almost pain free both at rest (VAS 0.5, range 0-2) and at activity (VAS 1.5, range 0-5). The total range-of motion (TROM) in the DRUJ was preoperatively between 90-140 degrees. At follow-up, the TROM had increased to on average 156 (range 100-180 degrees). The preoperative Quick DASH score (60-77) decreased considerable to on average 14.4 (range 0-45) at follow-up. Conclusions Osteoarthritis in the DRUJ represents a challenging problem with limited surgical options, especially in the young individual. Our short-term results after reconstructing the DRUJ with rib perichondrium are gratifying. It may be a reasonable method in young patients with severe osteoarthritis in the DRUJ. The option for later implant surgery is preserved since most of the anatomy of the joint and all the soft tissue stabilizers are intact.

Hande Usta 1, Ali Kitiş 1, Merve Kalpak 1, Umut Eraslan 1, Ali Çağdaş Yörükoğlu 2, Ahmet Fahir Demirkan 2

1 Pamukkale University, School of Physical Therapy and Rehabilitation, Denizli, Turkey; 2 Pamukkale University, Medicine Faculty, Department of Orthopaedics and Traumatology, Denizli, Turkey

Objective The aim of this study was to evaluate early functional status and activity participation of the patients who diagnosed with carpal degeneration and lunatum avascular necrosis and treated by proximal row carpectomy procedure. Methods 15 patients (9 female, 6 male) whose age range was 19-67 years and followed in Pamukkale University Department of Physical Therapy and Rehabilitation/Hand Therapy Unit between April 2013 and July 2017 were included in this study. The mean age of the patients was 36,93±14,57 years. The surgical technique, dorsal approach, was used for all patients. Both groups started physiotherapy program within post-op 5 to 7 days by attending weekly sessions for 12 weeks. Therapy included wound care, edema control, active and active assistive exercises. Light activities of daily living were allowed. At eight weeks strengthening exercises were initiated. The body function and structure were evaluated with Visual Analogue Scale (VAS), Range of Motion (ROM), Grip and Pinch Strength. Activity participation assessments were done with Michigan Hand Outcomes Questionnaire (MHOQ) and Quick-The Disabilities of the Arm, Shoulder and Hand Score (Q-DASH). Also, Short Form-36 (SF-36) was used to evaluate Quality of Life and Beck Anxiety Inventory was done. All measurements were performed at 12th weeks. The comparisons between affected and non-affected extremity were done by using Two Related Sample Test. Results Patients were found to have minimal pain as well as during activity (4.23 ± 3.41) was more than sleeping and resting. When affected extremity compared to the contralateral, there was a significant difference in both ROM, grip and pinch strengths (p<0.05). Respectively in these measurements, the patients were reached approximately 60% and 30% of the contralateral extremity. MHOQ ADL and total scores were respectively 59,78±27,83 and 41,55±19,61 for affected extremity. Q-DASH results were found to be 51.20 ± 19.69 out of 100 points. SF-36 results, especially physical and mental roles subscores, have remained under the Turkish population norm for each subtitle. Beck Anxiety Inventory results (9,93 ± 10,69) showed mild anxiety symptoms. Conclusions As a result of this study, proximal row carpectomy surgery, a salvage procedure, appears to affect patients in every aspect of the biopsychosocial model in early term. Improvement of pain and ROM were provided with early physiotherapy however, recovery of grip and pinch strengths were insufficient. Based on functional outcomes daily life and activity participation were affected. Also, difficulties in the physical and mental roles/functions of the patients, leading to deterioration of the quality of life and mild anxiety. The 12th week has an important place in assessing participation, but it will be helpful to follow the patient until returning to the previous activity or job. The hand surgeon and hand therapist should maintain long-term follow-up in accordance with the methodological and biopsychosocial approach with the patient compliance. Key Words: proximal row carpectomy, rehabilitation, functional status

Olga Politikou, Christoph Erling, Lisa Reissner, Maurizio Calcagni

Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Switzerland

Objective: The technique of arthroscopic partial wrist arthrodesis has already been described in the literature, but a very limited number of studies are published. We present our experience of arthroscopic midcarpal arthrodesis. Methods: From January 2015 to October 2017, we performed 12 cases of arthroscopic midcarpal wrist fusion, including 7 cases of 3-corner fusion and 5 cases of lunocapitate fusion. The indication was mid-carpal arthritis related to post-traumatic carpal instability with SNAC or SLAC Wrist Grade II-III or to degenerative systemic diseases. In all cases the scaphoid was excised through a small palmar approach. The triquetrum was left in situ. Cancellous bone was harvested from the excised scaphoid and was inserted arthroscopically to the arthrodesis site before placing the K-wires. In all cases we used cannulated headless screws to fix the bones, inserted percutaneously through small incisions. We assessed the union rate, the complications and the range of motion and force after index surgery. Pre- and postoperative wrist assessments were systematically recorded through our hand therapy department. Results: The mean follow-up was 8 months (range 1.5-16). The union rate was 83% (ten out of twelve). The first signs of union were recorded in 1.7 month (1-2.5), while total union (concerning the ten cases) was achieved in 6.1 months (3-11,5). The wrist total range of motion was reduced 25% and the strength 27%. We observed complications in two cases; these concerned the distal migration of one screw in the carpometacarpal joint in both cases; we removed the screw 8 weeks and 12 weeks after fusion respectively. In one case, a total wrist fusion was necessary because of rapidly progressed arthritis in the lunate fossa. All patients reported important pain relief in active motion (post-op range VAS 0-3, pre-op 7-9) after surgery and all but one returned to work and usual daily activity in a mean time of 4,5 months (1,5-7). Conclusions: Dry arthroscopic mid-carpal arthrodesis seems to be a safe and efficient mini-invasive surgical option in cases of mid-carpal arthritis. The technique is reliable and in our study with an operative time comparable to the open technique. Moreover, the arthroscopic technique potentially is related to low risk of infections and to small surgical scars. The use of endomedullary compression screws reduces the complications related to the hardware. Long-term follow-up and bigger series are needed in order to draw a safe conclusion through quantitative research results.

keiji Fujio 1, Takumi Hashimura 2, Kazuaki Tsuyuguchi 1, Hyongyon Kan 1, Masayuki Matsuoka 1

1 Hand Center and Medical Institute, Kansai Electric Power Hospital, Osaka, Japan 2 Orthopaedic Department, Kobe Municipal Medical Center

(Objctive) Stage 3 or 4 according to 5 questions by Garacia is good candidate for reconstruction. How long should we need to keep K-wire after any ligament reconstruction? When can we achieve successful engraftment? Internal splint such as RASL or SwieveLock fixation are analyzed to maintain reduction and achieve engraftment. (Methods & Results) Berger’ s approach was applied for all cases. Partial DIC was transferred to dorsal portion of Scapholunate ( = SL) ligament. 12 patients were fixated by RASL using double thread screw, and 6 patients were fixed using fiber tape with SwieveLock system as internal fixation. 12 cases of RASL were analyzed averaged followed up for 32.4 months.10/12 patients returned to previous occupation. 2 cases were converted to Swieve Lock system. 1 case occurred breakage of double thread screw. There was no carpal collapse or progression to SLAC. 6 cases of SwieveLock system were analyzed averaged followed up for 15 months. There was no progression of SL gap except for 1 case. 3 dimensional kinematic analysis was performed after operation for each methods. Result showed almost normal motion during flexion and extension. Dorsal portion of SL was taut, and volar portion of SL remained laxity as same as normal motion established by Moritomo. (Discussion) According to 3D kinematic analysis, center axis of normal scaphoid motion is dorsal scaphoid. Distance between scaphoid apex and center motion axis are different among normal, RASL, and fiber tape with SwieveLock system. Fiber tape with Swievelock is closer to normal compared to RASL, and clinical result is better compared to RASL as internal splint..

Wrist arthritis (5 abstracts)

Marion Mühldorfer-Fodor, Mark Immler, Jörg van Schoonhoven, Karl Prommersberger

Clinic for Hand Surgery, Rhön-Klinikum AG, Bad Neustadt a.d. Saale, Germany

Study question: Does a carpal collapse lead to pisotriquetral (PT) subluxation and osteoarthritis? Methods: We identified 234 patients (83% men, mean age 50 (21-76) years) with an scaphoid nonunion or scapholunate advanced collapse (86 SNAC and 148 SLAC wrists stage 2° or 3°), who had an MRI (89) or CT scans (145) of the wrist prior to a salvage surgery. Those were retrospectively evaluated with regard to subluxation or osteoarthritis of the PT joint. The prevalence and degree of PT osteoarthritis was analyzed according to the cause and stage of the carpal collapse, age of the patients and a concomitant PT subluxation. Results: Among all patients, PT osteoarthritis was found in 76%, 71% of all SLAC wrists, and 85% of all SNAC wrists. In SLAC wrists, the prevalence was significantly higher in stage 3° (77%) than stage 2° (52%). In SNAC wrists, both stages were similar (83 and 85%) and significantly higher than in SLAC wrists. Severe Osteoarthritis was significantly more often observed in SLAC wrist 3° (53%) than in 2° (21%), SNAC wrists had a high 58% at both stages. The highest rate of PT osteoarthritis was found in patients younger than 30 years (88% of 17 patients) and patients older than 70 years (91% of 11 patients). 66% of all patients had a subluxation of the pisiforme, mainly a translation proximally, followed by a tilt into flexion, less patients had a widening of the joint gap. The rate was similar in SLAC- and SNAC wrists, except a higher rate of patients with palmar tilt among the SLAC wrists. With regard to the 154 patients with pisiforme subluxation, 80% of them had concomitantly a PT osteosarthritis, 49% a severe osteoarthritis. Vice versa, 69% of the patients with a severe PT osteoarthritis had simultaneously a pisiforme subluxation. Conclusion: Carpal collapse comes very often along with PT osteoarthritis, in SNAC wrist more often and earlier than in SLAC wrists. Clinical relevance: PT osteoarthritis might cause residual pain after denervation or partial wrist fusions, performed as salvage procedure for patients with carpal collapse.

David Eckerdal 1,2, Nina Vendel 3, Lars B. Dahlin 1,2, Marianne Nygaard 2, Niels Söe 4

1 Department of Translational Medicine – Hand Surgery, Lund University, Malmö, Sweden; 2 Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; 3 Department of Operation, Anaesthesiology and Day Care Surgery Q, Herlev and Gentofte, University Hospital, Denmark; 4 Handsection, Department of Orthopaedic, Herlev and Gentofte University Hospital, Denmark

Background Objectives: Representing only 10% of clinical isolated osteoarthritis in the wrist, isolated osteoarthritis in the STT-joints is rare, but may present with weakness, pain. The treatment for such a disorder is usually conservative, but a number of surgical treatments exist, like implant of a spacer, where the scaphoid trapezium pyrocarbon implant (STPI), made of pyrolytic carbon, being one of these. Previous follow up studies have reported a limited number of treated patients with a shorter follow up time. The purpose of our study was to evaluate the long-term outcome of surgical treatment of STT-osteoarthritis with the STPI implant. Patients and Methods In the prospective study, patients treated with a STPI 2003 - 2009 were followed over 72 months. Outcome was measured with VAS (Visual Analogue Scale), grip/ and pinch strength, range of motion, a modified version of the Mayo wrist score, as well as subjective patient satisfaction. Results Most patients were satisfied with the results of the procedure. The VAS score at rest decreased, but not at activity, and the grip and pinch strengths increased. The range of motion (ROM) and the Mayo wrist score did not change after the procedure. Conclusions Surgical treatment of STT osteoarthritis with implantation with a STPI implant results after six years in subjective patient satisfaction and a reduction of pain at rest, but not at activity, as well as an increase in grip and pinch strength, without any change in ROM. STPI can be considered as an option to treat STT osteoarthritis.

Onur Berber, Lorenzo Garagnani, Sam Gidwani

Guy's and St Thomas' Hospital, London, UK

Background: End-stage wrist arthritis caused by conditions such as inflammatory arthritis or osteoarthritis refractory to non-operative treatment has traditionally been treated with a total wrist fusion. There has been a recent trend towards motion preserving surgery of the wrist in the form of a total wrist replacement. Objectives: The broad of objective of this review is to assess clinical effectiveness in performing a total wrist arthroplasty or a total wrist arthrodesis in adult patients with wrist arthritis through a systematic review. Search Methods: The following databases were searched on the 2nd of June 2017: OVID Medline, OVID Embase, CINAHL and BNI. The Cochrane CENTRAL register, the WHO Clinical Trials portal and ClinicalTrials.gov were also searched. Selection Criteria: The studies to be included are at a minimum “case series” or higher level including cohort studies and randomised control trials investigating either total wrist arthrodesis or arthroplasty for end-stage wrist arthritis. Outcomes of interest are physical function, pain, range of motion, grip strength, quality of life and adverse events. Data Collection and Analysis: The studies identified through the initial search were systematically screened according to strict inclusion and exclusion criteria, assessed for risk of bias and quality, data was extracted and reviewed. 9 Main results: A total of 41 studies were included in the review, 17 arthrodesis studies, 22 arthroplasty studies and 2 matched cohort studies. This represented 668 arthrodesis index operations performed in 603 patients, and 1091 arthroplasty operations performed in 991 patients. A variety of arthrodesis techniques were employed. The number of wrist implants totalled 14, including 4 currently available designs. Generally, a significant improvement in functional outcome was seen with both interventions, although this was better reported in arthroplasty studies. Similar improvement was seen with pain scores and a modest improvement was seen in grip strength. Range of motion following arthroplasty also improved significantly in several studies but was in the functional range in only 1. Complications were higher with arthroplasty (range: 0.2-20.5%) compared to arthrodesis (range: 0.1-6.1%; p=0.07). Fourth-generation implants performed better than earlier designs (range: 0.2-11.4%; p<0.001). Implant revision rates ranged from 3.5%-52.6% and the rate of conversion to arthrodesis ranged from 0-42.1%. Implant survival was at best 95% at 8 years (Meastro wrist). Conclusions: The newer fourth generation wrist implants appear to be performing better then earlier designs. Generally, both wrist arthrodesis and wrist arthroplasty improve function, pain and grip strength. The complication profiles of wrist replacements are higher than wrist arthrodesis procedures. Ongoing close monitoring of wrist replacement surgery is still recommended.

Aleksandar Lovic Jazbec, Luis Landín Jarillo, Pedro Bolado Gutiérrez, María L Manzanares Retamosa, César Casado Pérez

Hospital Universitario La Paz, Madrid, Spain

Objetive: In the cases with advanced posttraumatic DRUJ arthritis especially in young patients with considerable functional demand the decision making is very difficult task. The deficiencies of so called “traditional” techniques are well known( instability, impingement, distal stump problems etc). On the other hand encouraging results of total prosthesis sometimes are “eclipsed”by the fears of being too aggressive in young patients, of making the treatment too “pricy” or simply of not having defined options of possible rescue in the case of failure. Using our experience in congenital and postoncologic reconstruction we were trying to find the solution that could provide good range of movement, enough strength and longlasting result without implantation of any foreign material. Our efforts finally resulted in new technique: perimetral ulnar shaving with interposition of the vascularized posterior interosseus fascial flap.The flap is distally based pedicled flap described initially by Angrigniani and Zancolli and widely used for skin coverage of the hand and forearm. The most important fact is that the flap that has its own vascularization and can resist moderate compression. The ulnar head is literally wrapped by the flap that permits the radius to pivot freely around it. Methods:We present 6 patients with advanced posttraumatic DRUJ arthritis treated by this technique with an average follow up of 16 months. Presented data: functional preoperative exam, range of motion, grip strength, pain (AVS) both pre and postoperatively. Results:Average range of pronation/supination postoperatively was 150° of pronation-supination or 47% of improvement. The increase of grip strength was 29% reaching the 87% of contralateral side and average decrease of of pain after the surgery was 6 points . 4 of 6 patients are completely incorporated to their previous professional and sports activities and 2 patients changed their job definitely prior to surgery. Conclusions: The technique that we present to be very efficient in improving the functionality in these advanced cases with considerable functional demand. The surgical morbidity is minimal, the ulnar length remains the same, diameter of the ulnar head is not reduced as in Bowers or Watson’s technique. In the case of failure of the technique could be salvaged by any of the traditional methods or by prosthesis.

Muhammad A Quolquela

Tanta University, Department of orthopaedics, Tanta, Egypt

Objective Traditional surgical treatment of DRUJ (distal radio-ulnar joint) arthritis entails resection of the arthritic ulnar head which ensures pain relief and improvement of prono-supination. Drawbacks of such ulnar head total resection is twofold. Firstly, loss of the ulnar head sharing of load transmission across the wrist results in weakness of hand gripping. Secondly, loss of the stabilizing effect of the triangular fibro-cartilage (TFC) results in springing and instability of the remaining ulnar stump. In an attempt to avoid complications of total ulnar head resection , partial (hemi) resection of only the articulating ulnar head was performed with preservation of the ulnar styloid together with the attached TFC to prevent springing of the ulna and preserve some ulnar sharing of load transmission across the wrist. Methods 23 hands in 13 patients with rheumatoid DRUJ arthritis were treated surgically after failure of non operative management. They were 11 females and 2 males with an average age of 25 years. Average dorsi-flexion was 20º (range 15º to 25º) and average palmar flexion 25º (range 20º to 35º). Average prono-supinaton range was 60º (range 55º to 75º). In all patients, ulnar head was prominent and painful but relatively stable. Grip strength had an average of 35 % of normal side. Through a direct approach along the distal ulna, the extensor retinaculum was opened in a Z-plasty fashion creating two flaps; a proximal flap based radially and a distal one based ulnarly. In all patients, extensor carpi ulnars (ECU) tendon was observed to subluxate volarly permitting the ulnar head to herniat dorsally between this tendon and extensor digiti minim one. The capsule was opened and the hypertrophied synovium together arthritic head were excised preserving the ulnar styloid with attached TFC. The ulnar head was divide obliquely so that the final cut surface would be inclined from distal to proximal and radially to be parallel to the ulnar border of the distal radius to minimize radio-ulnar impingement. Free Palmaris longus tendon graft was harvested and made as an anchovy and anchored in the void created after ulnar head resection. During closure of the wound the proximal extensor retinacular flap was reefed under ECU tendon with the latter relocated dorsally radial to the preserved ulnar styloid to stabilize the remaining distal ulna. RSULTS Patients were followed up for an average of 38 months. All patients were pain free. Average post-operative dorsi-flexion was 30º (range 25º to 45º) and average palmar flexion 45º (range 30º to 50º) .Grip strength had a mean of 75 % of contr-alateral side (range 65% to 85%). Mayo modified wrist score improved from an average of 50 points (range 40 to 60) preoperatively to 70 points (range 60 to 80) postoperatively (P=0.03). Coclusions Hemi-resection of the ulnar head with free tendon graft interposition and ECU subsheath reconstruction for DRUJ arthritis results in a improved pain free prono-supination with increased hand grip strength.

Wrist trauma (23 abstracts)

Karim Latrach Tlemsani, Sabeur Saadi, Khezami Mounira, Rafrafi Abderrazak, Lotfi Nouisri

The Main Training Military Hospital Tunis, Tunisia

Objective The management of scaphoid nonunion represents a challenge that leads to wrist functional impairment and radiologic degenerative changes if neglected. Several techniques have been proposed for scaphoid non-union, but the ideal treatment remains a controversy. The purpose of this study was to assess functional and radiological outcomes of scaphoid nonunion surgery in a series of 42 patients treated by 3 different procedures: between non-vascularized bone grafting from iliac crest, vascularized bone grafts from the distal radius and percutaneous pinning. Methods In a retrospective study between 2010 and 2015, 42 consecutive patients, all males, were operated for scaphoid nonunion. According to surgeon preference, the operative procedure was selected. Wrist motion was measured pre-and post-operatively. Wrist radiographs served to confirm and classify the nonunion and to evaluate the level of arthrosis and the carpe alignment. Final functional results were assessed using a modified Mayo wrist score at latest follow-up visit. Results The mean patient age at surgery was 29 years old. Twenty-five injuries involved the dominant wrist. The mean interval between fracture and surgery was 20 months and the mean follow-up period was 49 months. Twenty-seven cases of nonunion were located at the middle third of the scaphoid. We noted 11 cases of Dorsal Intercalated Segment Instability (DISI). Thirteen patients presented with advanced arthritic changes: 8 patients had stage I scaphoid nonunion advanced collapse (SNAC) wrist, 4 had stage II, and only one had stage III. We opted for non-vascularized bone grafting in 19 times, vascularized bone grafts in 10 times and percutaneous pinning in 13. 69% patients reported satisfaction with surgery. The mean modified Mayo Wrist Score was 81. The wrist motion improved significantly by 10° in flexion, 15° in extension, 6° in radial deviation and 9° in ulnar deviation. Bony union was achieved in 32 patients (76%) after 12 weeks with 100% rate with vascularized bone graft. The mean scapholunate angle decreased significantly from 62° to 55° (p<0,01). Conclusions Using an appropriate surgical technique, suitable fixation devices, and a careful immobilization protocol, successful outcomes can be achieved. According to our study, union likelihood seems to be enhanced in early diagnosed non-smoker patients, in the absence of advanced arthritis and instable nonunion and every time we used bone grafting.

Salamah Moamen, Wasrbrout Ziv, Luria Shai

Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Objective Scaphoid fractures with signs of associated carpal instability have been considered unstable fractures with elevated risk of nonunion. The mode of fracture displacement includes extension and supination of the proximal fragment with no significant motion of the distal fragment, differing from the rotatory instability of the scapholunate ligament (SLIL) injury. We aimed to examine the prevalence of radiographic signs of carpal instability, comparing fractures with ligament injuries. Our hypothesis was that there is a correlation between wrist position and the presence of these signs. Methods Wrist radiographs of the patients with scaphoid fractures and SLIL injuries were compared with a control group with no pathology. Measures of carpal instability included –scapholunate (SL), radioscaphoid (RS) and radiolunate (RL) angles on lateral radiographs and the cortical ring sign (CRS). An association was examined with measures of wrist position – radiocapitate (RC) and radius-3rd metacarpal (R3M) angles on PA views and radiocapitate (RC) angle on lateral views. Results We examined radiographs of 57 patients with fractures, 23 with SLIL injuries and 43 with no pathology. Measures of wrist instability differed between the three groups although the mere presence of a ring on the scaphoid PA view did not differ. The SL angle differed between the healthy and the displaced body fracture and static SLIL injury groups (p<0.001). The RS angle differed between the healthy and SLIL injury groups (p<0.001). In the study groups, wrist position was found to be in flexion (lateral view RC angle) and radial deviation (PA view R3M angle) in comparison with the healthy group (p<0.001 and p=0.18, respectively). A CRS could be seen with wrist radial deviation (PA view RC and R3M angles)(p=0.003 and p=0.003, respectively) and wrist flexion (lateral view RC)(p=0.024). A complete CRS was specifically associated with wrist radial deviation (measured with the PA view RC angle) in comparison with absent or incomplete CRS (p=0.004). The RS angle was correlated with the lateral RC and PA R3M angles (R=0.5). Conclusions Differentiating complete and incomplete CRS was found to be the more significant measure, then examining the mere presence of a ring on the scaphoid PA view. Wrist position was found to be a significant factor when examining measures of wrist instability and pathology. Wrists with pathology were found to be flexed and radially deviated, possibly a position that will alleviate pain. When utilizing different measures of carpal instability, the effect of wrist position should be considered.

Lionel Athlani, Nicolas Pauchard, Gilles Dautel

Department of Hand Surgery, Plastic and Reconstructive Surgery. Centre Chirurgical Emile Gallé CHU de Nancy, France

Objective : We performed a cadaveric study to evaluate radiological performance of a technique for scapholunate intercarpal ligamentoplasty designed for treating reducible scapholunate dissociation. Methods : We created scapholunate instability in 12 fresh adult cadaveric forearms by sectioning the dorsal scapholunate interosseous ligament and the dorsal intercarpal ligament. All wrists showed scapholunate diastasis, dorsal intercalated segmental instability and posterior scaphoid subluxation. We performed scapholunate intercarpal ligamentoplasty in six wrists and Garcia-Elias three- ligament tenodesis in another six. Wrists were examined radiographically both after ligament sectioning and after ligamentoplasty to compare static and dynamic scapholunate gaps and scapholunate and capitolunate angles. Results : Improvement was statistically significant in all wrists, reflecting a return to normal values. Posterior scaphoid subluxation was also corrected. There was no significant difference between the two treatment groups. Conclusion : Our findings suggest that ligamentoplasty can restore scapholunate joint stability and normal carpal anatomy. It is similar to 3LT in terms of restoration of carpal alignment.

Lionel Athlani, Nicolas Pauchard, Gilles Dautel

Department of Hand Surgery, Plastic and Reconstructive Surgery. Centre Chirurgical Emile Gallé CHU de Nancy, France

Objective : We report the preliminary results of the ScaphoLunate InterCarpal Ligamentoplasty with a minimum follow-up of 12 months. A preconstrained palmaris longus graft is used to reconstruct the dorsal scapholunate interosseous ligament and the dorsal intercarpal ligament, thus countering dissociative scapholunate instability and preventing ligamentous loosening. The procedure takes into account recent biomechanical conceptions involving the stabilizing role of the dorsal intercarpal ligament. Methods : 26 patients (20 men, 6 female) with a mean age of 40 year-old (22 – 57) were operated on in a single center by senior hand surgeons. Indications were symptomatic chronic reducible scapholunate dissociation in the absence of chondral lesion. There were 15 static instabilities and 11 dynamic. All the patients were operated on with the same procedure and were evaluated (pain, motion, strength, function, X-rays) with a mean follow-up of 36 months (12 – 54). Results : Pain decreased from 4.5 (rest) and 6.7 (load) to 0.4 and 1.9 on VAS scale (/10). At the follow-up, the average wrist motion was 55° extension, 56° flexion, 17° radial deviation, and 32° ulnar deviation. Grip Strength was 89% compared with the contralateral side. Function measured with the DASH score (/100) and the PRWE (/100) had improved respectively from 57 and 56 to 20 and 18. There was a significant decrease in the scapholunate angle from 76° to 62°, and in the scapholunate gap. Static gap was reduced from 3.2 mm to 2.3 mm and dynamic from 4.6 mm to 3.0 mm. Posterior scaphoid subluxation was systematically corrected with the exception of 4 cases of rapid recurrence (3 months) of static instability by ligament loosening. Conclusion : ScaphoLunate and InterCarpal ligamentoplasty showed satisfactory clinical and radiological results in this study. This procedure reduces scapholunate dissociation and restores normal carpal anatomy. Extended studies are needed to determine the long-term benefits of this reconstructive procedure. It is very important scaphoid can be « easily » reduced during surgery.

Nicolas Balagué, Konstantinos Vakalopoulos, Philippe Vostrel, Sana Boudabbous Jean-Yves Beaulieu

Geneva University Hospitals, Department of Traumatic and Orthopedic Surgery, Hand and Peripheral Nerves Surgery Unit, Geneva, Switzerland

Introduction: Scaphoid non-union remains a major problem in hand surgery. The 1,2 intercompartimental supraretinacular artery flap, as first described by Zaidemberg, is widely used with a union-rate of about 80%, however limited in case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse. Methods: 9 patients with scaphoid non-or-delayed-union with carpal collapse were treated with a vascularized bone graft based on the 1,2 intercompartimental supraretinacular artery using a combined volar and dorsal approach between 2006 and 2015. Immobilization by a short arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity as well as clinical endpoints were noted, and scapho-lunate (SL) angles were measured using two accepted techniques. Results: Union rate was 100% with a median time to bone consolidation of 4 months. Depending on the SL measurement technique used, four or eight patients had pre-operative DISI which was corrected in all patients. Humpback deformity was seen in five patients and corrected in all cases. No major complications were observed in this series. Conclusion: The 1,2 intercompartimental supraretinacular artery bone flap is a reliable treatment of scaphoid non-union associated with carpal collapse. Our combined volar and dorsal approach permits the correction of DISI and Humpback deformity without precluding scaphoid vascular supply, eliminating the need for the use of free bone flaps from other sites. In this series, we observed a 100% union rate without major complications.

Konstantinos Tolis, Aliki Kotsilini, Panagiotis Kanellos, Markos Liontos, Sophia Syggouna, Sarantis Spyridonos

Hand Surgery, Upper Limb and Microsurgery Department, General Hospital KAT, Athens, Greece

Objective: Closed carpal dislocations are complex rare injuries, usually a result of a fall on the outstretched hand. Active youngsters are mostly affected, amongst which adolescents are rarely mentioned in the literature. We present a rare case of a fracture dislocation in a 14 year old female adolescent, treated with primary lunocapitate arthrodesis. Methods: A 14 year old female patient was evaluated at the emergency department after sustained a fall in a motorcycle accident, 6 hours before administration. The patient reported pain and inability to complete any motion of the left carpus, immediately after the fall. During clinical examination extended edema of the carpus and weak grip was documented. No neurovascular deficit was documented. On plain radiographs a perilunate volar dislocation was demonstrated. Computed Tomography (CT) was unavailable at the time and the young patient was moved to the operation room. Under tourniquet and brachial block anesthesia a dorsal incision through the 3rd and 4th extensor compartment was performed. Lunate was identified volarly and reduced. A fracture of the dorsal pole was noted, creating a deficit of almost 30% of the articular surface. Also an osteochondral fracture of the capitate was identified, as well as complete disruption of the dorsal scapholunate and lunocapitate ligaments. Due to extensive bone loss of the lunate, it was decided to perform a primary lunacapitate arthrodesis, with the use of K-wires. Ligaments were reconstructed using absorbable sutures and anchors. A volar plaster cast was used for rest and immobilization. Results: K-wires and the plaster cast were removed 6 weeks after surgical operation. The young patient started intense, but gradual physiotherapy. At 2 years follow up the patient had regained a painless wrist, with 450 volar flexion and 450 dorsal flexion. Conclusion: A closed volar perilunate fracture dislocation is a rare and complex injury. Anatomical reduction and partial fusion of the wrist is an option, when the reduced lunate is anatomical unaffected. In cases where bone loss is adequate, a primary lunocapitate arthrodesis is a satisfying treatment, so as to prevent against future collapse of the wrist. Although bibliography lucks treatment options in adolescents, we believe it can be performed with safety, minimal chances for pseudarthrosis and good results, as far as wrist kinematics are concerned.

Robert Gvozdenovic

Herlev and Gentofte Hospital, University of Copenhagen, Department of Orthopedic Surgery, Hand Surgery Unit, Copenhagen, Denmark

TFCC foveal re-attachment by ulnar tunnel technique Objective Triangular fibrocartilage complex (TFCC) injury is present in up to 80 % of patients with displaced distal radius fractures (DRF). TFCC usually heals well along with the fracture treatment. Thought, the commonest cause of prolonged pain and disability after DRF is ulnar-sided wrist pain and instability caused by the foveal injury of the TFCC. Only few series have investigated treatment of the foveal TFCC injuries. We report the short-term results of our preferred arthroscopic method of foveal TFCC repair. Methods Between April 2013 and May 2017, 15 patients have been operated by modified Iwasaki technique (ulnar tunnel technique) for foveal re-attachment of TFCC injury. All patients had ulnar sided wrist pain and mild instability of the Distal Radioulnar Joint (DRUJ). Average time from the initial injury to the reconstruction procedure was 18 months (range 3 – 96 months). All the patients had undergone X-ray and MR scan investigations of the wrist, prior to the TFCC surgical treatment. There were 6 men and 9 women, and their mean age was 27 years (range 16 – 40). All patients were immobilized post-operatively for 3 weeks in a sugar tongue splint, whereupon they all received the removable orthosis with limited rotation for further 3 weeks. Then, hand therapy with light weight-bearing exercises started. Full weight-bearing activity was allowed at 3 months follow-up. Mean follow-up was 18 months (range 6 – 48 months). Retrospective evaluation included assessment of pain (VAS score), satisfaction, DRUJ instability, range of motion (ROM), grip strength and Disabilities of the Arm, Shoulder and Hand (quick-DASH) Score. Results There were no complications during the operative procedures or the recovery / hand therapy. All patients, except one achieved full stability and improvement in the measured values at the evaluation as well as full satisfaction of their treatment. Both pain in rest/activity, grip strength and q-DASH values improved significantly (p<0.05). Mean pre-operative pain was 17/66 in rest/activity on the VAS score scale 1 – 100, improved to 6/18, post-operatively. Mean grip strength was 29 Kilogram-Forces (KgF), pre-operatively improved to 36 KgF, post-operatively - a 24 % increase (91 % strength of the contralateral side). q-DASH value was measured 40, pre-operatively and 16, post-operatively. ROM improved non-significantly, especially in rotation. In one case, we observed recurrent pain despite full stability. Conclusions Short-term results of the modified Iwasaki ulnar tunnel technique for foveal repair of the TFCC injury provided satisfactory results with a few observed complications. The presented knotless technique simplifies the procedure. A larger study with a longer follow up is desirable.

Hannah Ng Jia Hui 1, Sellakkuddy Selvaganesh 1, Bosco Jie 2, Jane Sim 3, Vaikunthan Rajaratnam 1

1 Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore; 2 Department of Radiology, Khoo Teck Puat Hospital, Singapore; 3 Department of Occupational Therapy, Khoo Teck Puat Hospital, Singapore

Objectives - Assessment of the outcome of scaphoid fractures in a single hand unit. Methods - Scaphoid fractures are not common hand fractures which will be missed in 10% of the time during the first clinical visit. Majority can be managed with non-operative treatment, if the patient understands the seriousness and necessity for the compliance with the cast and splint. The data was filtered from the electronic database of our department (OTSys). It is a retrospective study. The data was collected with an interviewer administered Google based questionnaire. The results were analyzed using excel spreadsheet. Results - We had 38 surgical procedures during the period of study and all patients were males with health insurance. Majority were involved in road traffic accidents. Three quarters of patients were Singaporeans. One-fifth of patients were smokers, of which, majority (75%) were smoking for more than 2 years. There were 13.2% of patients with scaphoid fractures due to job-related risk. None had open fractures. Commonest upper limb fracture associated with the scaphoid fracture was distal radius fracture in 21.1% of the patients. There were 76.3% right-handed patients. Fracture was right-sided in 55.3%, left-sided in 42.1% and bilateral in one patient. The fracture of the waist of scaphoid was the commonest type in 65.8%. There were 55.3% of patients who had bone grafting, with the commonest site from radius (71.4%). Vascularized bone grafting was performed in 19.0% of patients. The time to return work was 8.71 weeks. Dependence on strong analgesics was for < 1.5 weeks on average. Range of movement was not compromised secondary to the surgical management. Uneventful recovery was seen in 76.3% of patients. Commonest complication was non-union (18.4%). Outcome - Our outcomes were comparable to the available literature with regard to pain free period, time to return to work and post-operative range of movement. Conclusion – Scaphoid fractures commonly occur in the young productive age group and had good outcomes in our units’ care.

Gonzalo Luengo Alonso, Miguel Angel Porras Moreno, Veronica Jimenez Diaz, Lorena Garcia Lamas, David Cecilia Lopez

Hospital 12 de Octubre Madrid, Spain

Introduction: Scaphoid fractures B1 or B2 according to Herbert´s classification, could be treated whether with surgery or orthopedic treatment. Objectives: The aim of the present study is to analyze results and complications of scaphoid waist fractures treated with percutaneous fixation using a volar approach. Study Design & Methods: 92 patients with scaphoid waist fractures, which were treated in our institution from 2006 to 2016 using a volar percutaneous fixation, were retrospectively reviewed. The average follow-up was 16 months (range 12–48). Injuries were classified using Hebert´s classification, including types B1 and B2; the rest of fracture types following this classification system were excluded. Politrauma patients, dorsal approach, fractures associated with distal radius injuries, patients treated using another surgical technique and patients transferred to other centers for treatment or follow-up were also excluded. Demographic data, mechanism of injury, associated injuries and postoperative complications were collected in all patients. Clinical and radiological assessments were performed at the outpatient clinics. Functional results were evaluated using the DASH questionnaire. Consolidation was considered as presence of bony bridges crossing fracture site in all x-rays projections performed, associated with absence of pain in physical examination. Results: The average time to fracture healing was 6.6 weeks (range 5-11). After 12 months of follow-up, the average wrist range of motion was 70º of extension (range 58-80) and 75º of flexion (range 72-86). Regarding functional evaluation, the average score of The DASH questionnaire was 75 in patients that had associated injuries, decreasing to 42 in patients without it. Only two patients could not return to their daily activity due to other fractures. Complications were present in 1.08% patients during the surgical intervention; 9.78% patients referred any kind of complication during follow-up. The most frequent complication was non-union in 5 cases. The average timing of surgical intervention was 20-25 minutes Conclusions: Volar percutaneous fixation is a simple and quick technique for a specialized surgeon characterized by low morbidity and complications rates compared to ORIF, which accelerates patient´s functional recovery. Keywords: Percutaneous Fixation, Scaphoid Fracture, Volar Approach, Osteosynthesis

Stefan Quadlbauer 1,2,3, Christoph Pezzei 1, Josef Jurkowitsch 1, Thomas Beer 1, Thomas Hausner 1,2,3, Martin Leixnering 1

1 AUVA Trauma Hospital Lorenz Böhler - European Hand Trauma Center, Vienna, Austria; 2 Ludwig Boltzmann Institute for Experimental und Clinical Traumatology, AUVA Research Center, Vienna, Austria; 3 Austrian Cluster for Tissue Regeneration, Austria

Objective: Non-union of the scaphoid is even today a challenge for the treating hand surgeon and does if occurs, present notable consequences in hand function for the patients. Several methods for treating scaphoid nonunion are available, like sole bone graft in the technique according to Matti – Russe, with or without additional stabilization by a headless compression screw (HCS) or plate. In the last decades, Extracorporeal Shockwave Therapy (ESWT) has become an established procedure for nonunion treatment. However, the mechanism of shockwave therapy is poorly understood, but it´s considered verified, that it leads to an angio- and vasculogenesis in the treated tissue, which causes a persisting increase of blood supply. Main aim of this study was to investigate union rate and clinical outcome of a combined treatment of scaphoid nonunion by surgery and ESWT and to compare union rates after stabilization by one HCS, two HCS or plate. Material und Methods 42 patients with a scaphoid nonunion treated by non-vascularized bone graft from the iliac crest and a interval between injury and surgery of at least 6 months were investigated. 26 patients were treated with an additional ESWT within two weeks after surgery and 16 without. A scaphoid plate was used in 20 patients, a double HCS in 12 patients, and one HCS in 10 patients. Age, gender, range of motion (ROM), date of surgery, the last follow-up examination were included in the statistical analysis. DASH scores, PRWE, the Green O´Brien Score, and the Michigan Hand Questionnaire score were determined for all patients. A CT was performed in each patient to analyze union and signs of osteoarthritis. Results: In total 74% (31/42) of the scaphoid nonunion showed bone healing at the follow-up investigation. Mean range of motion in extension/flexion was 144 (SD 33)°, in supination/pronation 172 (SD 23)° and in radial/ulnar deviation 48 (SD 9)°. DASH Score was in mean 12.6 (SD 15.4) points, PRWE Score 15.6 (SD 19.4) points and the MHQ 83.8 (SD 16.7) points. The Mayo Wrist Score showed totally with a mean of 83 (SD 16.0) points a “good” clinical outcome. Patients in the ESWT group showed in 21/26 (81%) and in the group without ESWT 12/16 (75%) bony healing. No significant differences could be found between the groups in ROM, grip strength, DASH score, PRWE score or MHQ. Patients stabilized by one HCS showed in 6/10 (60 %), by two HCS 10/12 (83 %) and by scaphoid plate 17/20 (85 %) union. No significant differences could be found between the groups in respect of VAS, ROM, grip strength, PRWE Score, DASH Score and MHQ. Conclusion: The results of this retrospective study suggest that a combination of ESWT and surgery is reasonable in treating scaphoid nonunions and a stabilization by two HCS or scaphoid plate provide higher unions rates than a stabilization by one HCS.

Fidel Cayon 1,2,3, Luis LaTorre 1, Daniel Saavedra 1

1 Clinica El Bosque, Bogotá, Colombia; 2 Centro de Especialidades Ortopedicas, Quito, Ecuador; 3 Hospital Metropolitano, Quito, Ecuador

Naviculocapitate fracture syndrome is a fracture of the Capitate bone associated to a fracture of the medial third of the scaphoid bone, the different injuries presented in the Naviculocapitate fracture syndrome are produced when the radial stiloid process impacts to the scaphoid bone generating a fracture of this bone at the moment when the scaphoid is located between the stiloid process and the capitate bone, if the deforming force continues then the capitate bone will fracture too. A patient who suffers multiple trauma from falling down receiving impact over his hand, wrist in extension, generates a mechanism of trauma that coincide with this pathology. We present a case report of a male patient 29 years old falling down from approximately 12 meters high, receiving the trauma with his right wrist extended, immediately present pain and difficult with wrist function, imaging studies confirmate the diagnose of Naviculocapitate fracture syndrome, we decide to perform a closed reduction and percutaneous fixation with canulated Screws, we present the postoperative evolution in the 3 months after the surgical procedure. Key Words: Scaphoides, Capitate, Naviculocapitate fracture syndrome, Trauma

Pier Paolo Borelli

Casa di Cura San Camillo, Brescia, Italy

Objective Evaluate an alternative treatment to Vascularized Bone Grafts (VBGs) in Avascular Proximal Pole Nonunions (APPN). There is a general consensus about the indications of a VBG, but up to now there is no evidence for technique superiority between VBGs and NVBGs. There is still no consensus on definition of avascular necrosis of the PP: x-ray, CT scan, MRI, histology, or bleeding points at surgery, even if the absence of proximal pole bleeding points seems to be the main diagnostic element for vascular impairment. Since some years, arthroscopy has been proposed for proximal pole nonunion, even with vascular impairment, using a spongious NVBG to fill the emptied PP, with very good results, proving once again that it is stability of fixation, by means of screw or Kirschner wires, which creates the conditions for the revascularization of the proximal pole. It is well known that the metaphyseal core decompression of the distal radius can incite hyperaemia and, more recently underlined, can stimulate regional bone regeneration factors, such as the Bone Morphogenetic Protein-2 BMP-2 to accelerate revascularization of a necrotic lunate. Even the biophysical treatment has been recognized to be able to stimulate BMP-2. Methods: 13 patients, between 18 and 30 years, with APPN confirmed at surgery by the absence of bleeding points, with obvious need for volar grafting detected by CTCB, has been treated through a mini-invasive volar approach, characterized by: -a volar NVBG, spongious or corticospongious only in case of shortening of the bone, harvested from distal radius, producing a metaphyseal core decompression. - a stable fixation by means of an headless screw with a short leading thread, or 2 Kirschner wires, when the proximal pole, after debridment in nearly emptied, making impossible a volar screw fixation. Technical details of Kirschner wires stable application in order to be left in situ even for many years without any functional limitation, are shown. - an early biophysical treatment (CCEF) therapy, for at least 2 months. Results Radiological union was obtained in all patients with obvious proximal pole revascularization, detected by CBCT or MRI, with gadolinium when need, with respect of the morphology of the scaphoid. Optimal ROM recovery was observed, without any functional limitation, even when Kirschner wires is still in place after many years. Conclusions The technical aspects of this approach are similar to the increasingly popular Arthroscopic Bone Graft in APPNs. Performing a stable fixation is easier with open surgery, even with the “evergreen " Kirschner wires, but they must be inserted correctly in order to obtain just as stable fixation as that obtained with the headless screw. In practice, as long as the proximal pole is intact and the cartilage is good it is possible to have its revascularization. Considering the literature concerning this controversial topic, VBG still remains a correct indication in APPN and in secondary reconstruction after failed fixation with NVBG, but it is not an absolute indication.

Lorena García-Lamas, Veronica Jiménez-Díaz, Miguel Angel Porras, David Cecilia-López

12 de Octubre University Hospital, Madrid, Spain

OBJECTIVE: We present the clinical case of a patient with an asymptomatic hereditary bilateral trapezoscaphoid coalition diagnosed incidentally after a distal radius fracture. METHODS: The patient is a 17-year-old man, healthy, with an adequate level of development for his age. No family or personal history of known hereditary syndromes. He was seen on the Emergency Department of our center diagnosed of a left distal radius fracture produced after casual fall two weeks before. Simple radiographs were made with standard antero-posterior and lateral views in which the following findings were observed: Extra-articular distal radius fracture with dorsal angulation of 12º, 18º of radial tilt , open physis and increase of the space between lunate and scaphoid bones .We did a CT Scan to visualize if there were consolidation of the fracture. CT Scan confirmed the diagnosis of type II epiphyolisis, without signs of consolidation, with a scapholunate space of 3 mm, 11º of dorsal inclination and 17º of radial tilt with deviation of the lunate in DISI. . With this information the patient was proposed for surgical treatment. However, when we review the images for surgical planning, we objectified a coalition between the scaphoid and trapezius bones. Taking this finding into account, we did a comparative radiograph of the right wrist to the patient and the same findings were found. The patient was completely asymptomatic of the contralaral wrist. Due to these findings and the non-improvement of the radiological parameters after the fracture reduction, we decided to perform conservative treatment of the fracture and proceeded to remove the plaster at 5 weeks after the fracture. RESULTS: Two months after the fracture the patien was painfree and complete active motion was achieved without apparent deformity despite of dorsal radius angulation. We performed x-rays of both hands to the patient's mother objectifying the same type of coalition in different degrees, being on the right side a synchondrosis and the left one a synostosis but in this case without an increase in the scapholunate space , and also asymptomatic from the clinical point of view. CONCLUSIONS: The coalition that occurs between the scaphoid and trapezius is of the intercarpal type, since it occurs between bones of the two rows of the carpus, much more infrequent than those that occur between bones of the same row.

Lorena García-Lamas, David Cecilia-López, Miguel Angel Porras-Moreno, Verónica Jimenez-Díaz

12 de Octubre University Hospital, Madrid, Spain

Objective: Radiocarpal fracture-dislocations are uncommon high energy fractures of the wrist. We present our experience and treatment results of this complex injury pattern performing an integral repair of all affected bone and ligament structures. Methods: Eight patients with a minimum follow-up of 2 years were included. Epidemiological data regarding age, sex, dominance, profession and type of trauma were collected. Surgical data referring to surgical approach,associated injuries observed, type of treatment performed and surgical complications were analyzed. Functional results were mesured using the Quick DASH and Mayo Wrist Score (MWS) scales. The average age was 28 years. Sex and dominance were distributed at 50%. Volar aproach was made in 6 cases and a combined volar and dorsal approach was made in the other two cases. Osteosynthesis of the radius fracture and volar ligaments repair was performed. Results: There were no immediate or short-term complications related to surgery. Final functional result was 40 points according to the Quick DASH scale and 60 points according to the MWS. Conclusions: Radiocarpal fracture-dislocation are uncommon and complex wirst injuries. They are often misdiagnosed as a radial fractures. In this kind of lesion is mandatory a well understanding of anatomy and ligamentous involved to try to make a repair as anatomical as possible. The correct treatment is not established due to the low frequency of this kind of injury.

Ajmal Ikram, Dirk Vander Spuy, Karl Strauss, Martin Wells

University of Stellenbosch, Tygerberg Hospital Cape Town, South Africa

Aims of study: Assess the functional, radiological results of scapho-lunate reconstruction with SLAM (Scapho-Lunate Axis Method) Method: All patients who presented to our institution with chronic scapho-lunate ligament injury and where primary repair was not possible underwent the scapho-lunate biologic reconstruction with two tailed palmaris longus tendon autograft was used to create tether between the scaphoid and lunate, by placing the graft along the axis of motion of scaphoid and lunate with tendon graft anchor. This was coupled with reconstruction of dorsal portion of SLIL and DIC with securing of the two limbs of the graft dorsally with anchors to the lunate and capitate respectively. The patients were follow up at 6 weeks, 3 months, 6 months,1 year,2 year and 3 years The radiological parameters, i.e. scapholunate angle and scapholnate gap were compared as well as the functional outcomes by means of DASH score. Results: We currently have done 10 patients with SLAM procedure and early radiological results shows the scapholunate gap which was reduced post reconstruction has gradually increased scapholuante angle reduction maintained in most cases. Conclusion: SLAM procedure is biologic reconstruction of scapholunate ligament reconstruction and early results shows favourable radiological outcome.

Britt Siesing-Mejer 1, Niels Søe Nielsen 2, David Eckerdal 3, Lars B. Dahlin 3

1 Hand section, Department of Orthopaedic Surgery, Nordsjællands Hospital Hillerød, Denmark; 2 Hand Section, Department of Orthopaedic Surgery, Herlev and Gentofte Hospital, Gentofte, Denmark; 3 Department of Translational Medicine – Hand Surgery, Lund University, Malmö, Sweden / Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden

Surgery for non-union of proximal pole fractures of the scaphoid with an APSI-prosthesis - a five year follow up Objective: Long term follow up studies regarding non-union of the proximal pole of the scaphoid after fracture, treated with APSI-prosthesis, are rare in the literature. One study from 2013 by Daruwalla et. al. described 12 patients who were operated with APSI prosthesis due to non-union of the scaphoid after a proximal pole fracture. The results were encouraging regarding the use of the APSI prosthesis with a follow up of 3 years. Our aim was to perform a 5 year follow up of 25 patients operated due to a non-union of a proximal pole fracture with necrosis of the proximal pole of the scaphoid bone. Methods: Over a period of 10 years, the patients were included and operated after being diagnosed with a necrotic proximal pole of the scaphoid with MRI scan. The patients consisted of 5 women and 20 men (in total 25 operated hands). At least 12 of these had hard manual labor work. The median age of the patients was 35 years (ranging from 18 to 57 years) at the time of the operation. All, but one, of the patients were operated through a dorsal approach; the remaining patient was operated through a volar approach and a prosthesis was placed in the proximal pole of the scaphoid. The follow up was performed with assessments of pain, range of motion and grip- and pinch-strength measurements at 1, 2, 3 and 5 years post-surgery Results: All prosthesis, but in one female patient, remained in place during the follow up of 5 years. In the patient, where the prosthesis was dislocated after surgery, the patient was re-operated and the problem was solved with a larger prosthesis. The results showed that treatment with an APSI prosthesis relieved the patients of a great deal of pain, ranging from VAS scores 10-70/100 before surgery and resulting in a VAS score around 0-42/100 postoperatively. Range of motion in the wrist joint was not changed after the procedure; with a range of motion extending from 65 - 145 degrees preoperatively to 65-125 degrees postoperatively. Many patients were able to return to work; even though 12 of them had hard labor occupations that we normally would believe were not possible after this kind of injury. Conclusion: We suggest that the use of APSI prosthesis is a useful technique to treat patients with a proximal scaphoid pole fracture with necrosis, which does not heal, and the treatment has a good long-term outcome. Daruwalla ZJ et. al.: An alternative treatment option for scaphoid nonunion advanced collapse (SNAC) and radioscaphoid osteoarthritis: early results of a prospective study on the pyrocarbon adaptive proximal scaphoid implant. Ann Acad Med Singapore, 2013, june; 42(6): 278-84.

Ergys Gjika 1, Swenn Krahenbuhl 2, Kostantinos Vakalopoulos 1, Sebastien Durand 2

1 Geneva University Hospitals, Switzerland; 2 Lausanne University Hospitals, Switzerland

Introduction The treatment of Scaphoid non-unions with vascularized 2nd metacarpal bone flaps has shown promising results in recent literature. It is widely accepted that a dorsal approach to the Scaphoid may limit damage to its perfusion by sparing the anterior vessels. However, the dorsal approach may not be sufficient in the case of concomitant carpal collapse or to correct humpback deformity. In this original study, we present a novel technique for the treatment of Scaphoid non-union which enables the subsequent correction of humpback deformity using a vascularized bone flap from the 2nd metacarpal bone, through a single dorsal approach. M&M This pilot study includes 4 patients with Scaphoid non-union associated with humpback deformity. Osteoarthritis of the wrist was a contraindication for inclusion. The technique used consists of correction of the Scaphoid humpback deformity by placing 2 Kirschner wires dorsally into the distal Scaphoid fragment, through the non-union site and out on the anterior wrist surface. After harvest of the M2 bone flap through a single dorsal longitudinal incision, one of the two K-wires is used as a lever to reduce the humpback deformity under direct vision. After correction of the humpback deformity, the second K-wire is used to fixate the bone flap. Patients were immobilized in a short-arm spica cast until union was achieved, as monitored by CT scanning. Results Mean age at time of inclusion was 30 years. Humpback deformity was corrected in all patients, as seen on postoperative CT scans. All included patients achieved union, with a median time to bone consolidation of 8.2 weeks. No postoperative complications were noted and all patients were able to return to their previous work, with a median leave of absence of 14.2 weeks. Median follow-up time was 6.3 months. Conclusion This novel technique enabled correction of humpback deformity and treatment of Scaphoid non-union through a single dorsal approach with a 100% union rate. Importantly, this approach did not jeopardize the fragile anterior perfusion of the Scaphoid, which we believe to be vital for Scaphoid consolidation.

Claudia Lamas-Gómez, Ariadna Da Ponte-Prieto, Aranzazu González-Osuna, MC Pulido-Garcia, Laura Velasco-González, Xavier Aguilera-Roig

Hand Unit and Upper Extremity. Department of Orthopaedic Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain

Objetives: Diagnosis of acute hamate hook fracture is difficult and rarely made at the time of the initial injury. Hook excision remains the operation of choice. The effects of hamate hook excision lead to 4 to 5 mm of ulnar displacement of the little finger profundus tendon. Flexor tendon force decreases between 11% and 15%. However, alternatives are available, one of which is open reduction and internal fixation (ORIF). ORIF constitutes the logical treatment of hamate hook fracture, because it restores the native anatomy and function of the carpal bone. The purpose of this study was to analyze the grip strength and outcomes of ORIF in hamate hook fractures. Methods: In a retrospective study over a period of 12 years (2003 to 2015), we identified 13 patients with a hamate hook fracture who were surgically treated with ORIF. All patients had a minimum follow-up of 1 year after surgery and completed the study follow-up examination.In eight patients (61%) the fracture was associated with ulnar nerve neuritis in Guyon’s canal. We assessed the following clinical data: age, sex, mechanism of injury, side of the injured hand and associated lesions, fracture classification, average time from injury to correct diagnosis, surgical technique and complications. A headless bone compression screw (Micro Acutrak screw, Acumed, Hillsboro, OR) was used in all patients. Functional outcomes evaluated were pain, range of motion, grip strength, Disabilities of the arm, shoulder and hand (DASH) and Mayo wrist score. Data were analysed using SPSS computer software system, version 21 (Chicago, IL, USA). The paired “t” test was used to evaluate differences in grip strength between hands treated by ORIF and unaffected hands. Results: There were 12 male and 1 female, with mean age of 32 years (range, 22 to 48 years). The mean follow-up was 36 months (range, 12 to 144 months). The etiology was 3 motorcycle accidents, 3 falls on the outstretched hand during a basketball game, 2 bicycle accidents, 2 direct hits by a golf club, 2 tennis racket traumas, and 1 unspecific accident while diving. The right hand was affected in eleven cases. All patients returned to their pre-injury level of functioning after 10-12 weeks and there were no complications. Analysis of grip strength revealed values comparable with the unaffected hand. 
Eight patients complained of numbness, tingling and/or paresthesia in the ulnar nerve. Mean VAS pain score was 5 preoperatively (4-9) and 1 (0-2) postoperatively. Mean grip strength in the hand with the hook fracture was 58 Kg. compared with 53 Kg in the unaffected hand. However, this difference was not statistically significant. Preoperative modified Mayo Wrist Score was 51 and the postoperative value was 94. The patients who participated in sports postoperatively were able to do so at or near pre-injury levels. Conclusions: ORIF of hamate hook fractures is a safe and effective technique to restore normal grip strength and return to pre-injury level. In cases of ulnar nerve neuritis, neurolysis of the deep palmar branch is mandatory.

Carla Nunes, Andreia Nunes, Ana Ângelo, Joaquim Rodeia, Pedro Fernandes, Raquel Teixeira Carla Nunes 1,2, Andreia Nunes 1, Ana Ângelo 1, Joaquim Rodeia 1, Pedro Fernandes 1, Raquel Teixeira 1

1 Hospital de São Francisco Xavier, Lisbon, Portugal; 2 Hospital da Cruz Vermelha Portuguesa, Lisbon, Portugal

Objective Perilunate Injuries, Not Dislocated (PLIND) are the equivalent lesions of Perilunate Dislocation (PLDs) and Perilunate Fracture-dislocation (PLFDs), where there was no dislocation of the capitate form the lunate on initial images. These injuries require a high level of suspicion do be diagnosed and are more severe than their early images let us know. High energy wrist injuries, with marked clinical changes and images that suggest more than only a ligament rupture or carpal fracture are candidates to be identified as PLIND lesions. Methods We reviewed all our cases of acute perilunate injuries and displaced carpal fractures over a period of one year (September 2016 to September 2017). We used the initial x-rays to evaluate the cases and excluded the ones where there was dislocation of the capitate from the lunate. All other images (CT scan and MRI) were reviewed when available. Results There were 16 cases that met the criteria, 3 cases considered as PLIND. One was a pure ligament injury, the others were dislocated scaphoid fractures. There was one male and two females, ages 22 to 46. The mechanism was a forceful twist on the pure ligament injury and a fall from height on the scaphoid fractures. Their treatment, once diagnosed as PLIND, followed the principles used for their dislocations equivalents. The pure dislocation was treated by arthroscopic repair and K wire fixation. The fractures had open reduction, scaphoid fixation and ligament repair. The average follow up was 10 months. In all injuries was obtained correct carpal alignment and bone healing. The final range of motion was within functional levels. Conclusion PLIND injuries are challenging to diagnose and treat. Our approach was similar to the one for PLDs and PLFDs, the final results were overlapping.

Panagiotis Kanellos, Dimitrios Flevas, Konstantinos Tolis, Maria Ladogianni, Sarantis Spyridonos

"KAT" Hospital, Athens, Greece

OBJECTIVE To prospectively evaluate patient related outcomes of surgically treating perilunate fracture dislocations with a single dorsal approach METHODS We present 26 patients (23 males, 3 females; mean age 41 years; range, 24-68 years) that were surgically treated for perilunate fracture dislocations in our institution. The dominant wrist was involved in 17 patients. Surgery was performed within 5 days after injury. A dorsal wrist approach was performed in all patients. All fractures, when present, were treated with internal fixation with screws and ruptured ligaments were anatomically reconstructed when possible. PIN neurectomy is routinely perfomed. Anatomical provisional scapholunate, scaphocapitate lunotriquetrum and triquetrumcapitate fixation with Kirschner wires was, always, applied for two months. During this period, wrist immobilization in a cast was also applied in all cases. Thereafter, all patients followed the same rehabilitation protocol for, at least, 3 months. Mean follow-up was 45 months (range, 28-65 months). Clinical outcomes were evaluated on the basis of Mayo wrist score and Dash score. Results At the last follow-up, the mean grip strength was 63 % of the uninjured side (range 40%-88%) and the mean range of flexion was 53% and extension was 71%. Eighty-eight percent (88%) of patients returned to their previous occupation after six months. The mean Mayo wrist score was 81, accounting for excellent results in 5 cases, good in 14 and satisfactory in 7. Mean Dash score was 25.2 (range 7.5-91.7). 3 patients developed complex regional pain syndrome type I. One patient underwent secondary procedure to remove a scaphoid screw. No case of infection, wrist or finger neuropathy or tendon rupture was recorded in this series of patients. Conclusion Anatomic reduction is essential in perilunate fracture-dislocations and is typically obtained by open-reduction, screw and percutaneous pin fixation. Dorsal approach provides adequate visualization of the radiocarpal and midcarpal joints allowing effective reduction and stabilization. In most patients good clinical outcome is expected, with low complication rates.

Robert Gvozdenovic

Herlev and Gentofte Hospital, University of Copenhagen, Department of Orthopaedic Surgery, Hand Surgery Unit, Copenhagen, Denmark

Objective Scaphoid waist- or proximal pole fractures have been related to high rates of late- or nonunion after conservative treatment. Fixing the fracture with the compression screw by the open- or the percutaneous technique has been the method of choice to treat these conditions, resulting in good heeling, though, needing long heeling-time and compromising the function. Arthroscopic treatment has been winning in recently as a minimal invasive technique, not interruptive to the patient’s blood supply and proprioception, thus giving possibility for faster recovery. Few studies enlightened the union rate and the exact heeling speed of the arthroscopic / arthroscopically assisted procedures in the scaphoid nonunion treatment. Our study shows the results of the arthroscopically assisted, scaphoid nonunion treatment. Methods From December 2015 to September 2017, 8 consecutive patients have been treated for the nonunion of the scaphoid arthroscopically with a bone grafting from the distal radius. Mean time from the injury to the operative treatment has been 18 months (range 3 months – 10 years). All the patients were men, with the mean age of 23 years (range 17 – 35). Only 1 patient received conservative treatment with an immobilization time of 6 weeks, before the surgery. 7 patients received no treatment for their condition. All patients were investigated with the CT scan prior to surgery in order to distinguish any hump-back deformity of the scaphoid bone which was the relative exclusion criteria. The Mini Acutrak headless compression screw system of Acumed, (Hillsboro, Oregon, USA) has been used in all cases. All the patients were immobilized with a thumb/wrist splint after the arthroscopic treatment for 2 weeks, allowing the hand therapy with non-weight-bearing exercises begin. The removable splint was used for the four further weeks where X-ray investigation discovered the level of bony union. Full weight-bearing activity was allowed after the bony union was determined by the X-ray follow-up studies. Mean follow-up was 7 months (range 3 – 12 months). The evaluation included assessment of pain (VAS score), union time, range of motion (ROM), grip strength and Disabilities of the Arm, Shoulder and Hand (quick-DASH) Score. Results No complication during surgery or postoperative treatment has been discovered. All patients achieved full bony heeling at the 6 – 10 weeks follow-up established by the x-ray investigation. All patients achieved improvement in the measured values at the evaluation as well as full satisfaction of their treatment at the follow-up. Pain, ROM, grip-strength and quick-DASH showed statistical significance (p<0,05). Conclusions Our study showed that arthroscopically assisted compression screw fixation and bone-grafting of established scaphoid nonunion yielded fast heeling and recovery. A larger, comparative study between different treatment methods is desirable.

Tariq Aboelmagd 1, Karim Aboelmagd 1, Jennifer Lane 1,2, Neville Davies 1, Claire Middleton 1, John Morley 1

1 Royal Berkshire Hospital, Reading, UK; 2 University of Oxford, UK

Objectives Virtual fracture clinics (VFC) enable regional hospitals to prioritise trauma services, especially to local minor injury units without surgical facilities. VFCs have been shown to streamline care for other injuries, expediting management and reducing the need for repeated hospital visits, which can be distressing for children. Wrist pain without radiographic signs of injury is a common presentation, and mismanagement of an occult scaphoid fracture is a significant concern. This study aimed to investigate whether VFCs could improve efficiency of care and be a cost effective process for managing suspected scaphoid fractures in children. Methods This study evaluated 19 months of managing suspected scaphoid fractures in children through a VFC pathway, and compared costs to conventional treatment. A VFC protocol was established for patients presenting in the Emergency Department and 4 community minor injury units. The child was given a splint and an ‘appointment’ allocation. As soon as possible, the child’s radiographs and notes were reviewed by a consultant orthopaedic surgeon at the regional secondary care hospital without the patient present. For children over 12 years, if no obvious fracture was seen, the family was phoned requesting they present to their local unit for an x-ray at 10-14 days post injury. The radiograph was then reviewed remotely by the consultant. If no fracture was seen, the patient was told to remove splint and begin mobilizaton, preventing the need for face-to-face consultation. They were advised to contact the clinic if they continued to have pain after 4 weeks post injury. All children under 12 years were reviewed in VFC and then once in person in the regional orthopaedic department. Results 184 children presented with a suspected scaphoid fracture between 01/08/2015-01/03/2017, 4 cases were bilateral. Mean age was 13 years (SD 2.2; range 9-17 years). The average time of VFC review from injury was 1.6 days (1.2; 1-10). The most common mechanisms were fall on outstretched hand (70%); fall off bike (15%), direct blow (6%). The VFC nursing staff were able to contact 97.2% by phone; 35% were referred directly to fracture clinic. Of those 102 requested to only present for a second x ray, 80% were discharged without further consultation. 49% of the total cohort did not require a face-to-face appointment, saving a minimum of £116 per patient. The minimum follow up time was 9.4 months; mean was 19.6 months (SD 5.7, range 9.4-29). 42 patients sustained scaphoid fractures (0.22 incidence rate); 1 with a first presentation of a scaphoid non-union. A further 4 forearm and 1 metacarpal fractures were identified. 3.7% required surgery. 1.6% patients represented for review following discharge, the mean time to representation was 12 weeks. No patients returned in the follow up period with a missed injury. Conclusions VFC is a safe and efficient method of managing children presenting with suspected scaphoid fractures. It allowed expedited senior review and increased efficiency of care across a wide geographical area. This cohort presents a low incidence of ‘missed’ injuries, and significantly reduced costs compared to conventional treatment pathways.

Karim Aboelmagd 1, Tariq Aboelmagd 1, Jennifer Lane 1,2, Claire Middleton 1, John Morley 1

1 Royal Berkshire Hospital, Reading, UK; 2 University of Oxford, UK

Objectives Virtual fracture clinics (VFC) enable regional hospitals to prioritise trauma services, especially to local minor injury units without surgical facilities. VFCs have been shown to streamline care for other injuries, expediting management and reducing the need for repeated hospital visits, which can be inconvenient for patients. Wrist pain without radiographic signs of injury is a common presentation, and mismanagement of an occult scaphoid fracture is a significant concern. This study aimed to investigate whether VFCs could improve efficiency of care and be a cost effective process for managing suspected scaphoid fractures in adults. Methods This study evaluated 19 months of managing suspected scaphoid fractures in adults through a VFC pathway, and compared costs to conventional treatment. A VFC protocol was established for patients presenting in the Emergency Department and 4 community minor injury units. Patients were given a splint and an ‘appointment’ allocation. As soon as possible, the patients’s radiographs and notes were reviewed by a consultant orthopaedic surgeon at the regional secondary care hospital without the patient present. If no obvious fracture was seen, the patient was phoned requesting they present to their local unit for an x-ray at 10-14 days post injury. The radiograph was then reviewed remotely by the consultant. If no fracture was seen, the patient was told to remove splint and begin mobilization, preventing the need for face-to-face consultation. The patient was advised to contact the clinic if they continued to have pain after 4 weeks post injury. Results 652 patients presented with a suspected scaphoid fracture between 01/08/2015- 01/03/2017. Mean age was 42 years (SD 17.6; range 18-87 years). The average time of VFC review from injury was 1.4 days (SD 1 0-10). The most common mechanisms of injury were fall on outstretched hand (74.23%); fall off bicycle (7.82%), direct blow (5.83%). VFC nursing staff were able to contact 97.35% of patients by phone. Of those 414 requested to present for a second x-ray 85.5% (354) attended, 81.4% (288) were discharged after the 2nd x ray without further consultation. Overall, 53.4% of the total cohort did not require a face-to-face consultation, saving a minimum of £116 per patient compared to conventional treatment. The minimum follow up time was 9 months, mean was 18.8 months (SD 6, range 9-30). 131 patients sustained scaphoid fractures (0.20 incidence rate) including 21 first presentations of a scaphoid non-union. 1.9% required percutaneous fixation, 2.2% requiring ORIF + bone graft. 0.61% patients represented for review following discharge, the mean time to representation was 30 weeks (SD 29; 3-104); 1 patient managed non operatively developed a scaphoid non-union requiring operative fixation. Conclusions VFC is a safe and efficient method of managing patients presenting with suspected scaphoid fractures. It allows expedited senior review and increased efficiency of referrals across a wide geographical area. This cohort presents a low incidence of missed injuries, and significantly reduced costs compared to conventional treatment pathways.